Medicare Advantage Plans in West Virginia

checkmark Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: May 7, 2021


Medicare Advantage, also known as Medicare Part C, is managed by private insurance companies. By law, these companies are required to provide the exact same coverage that you would receive under Original Medicare, specifically Medicare Part A and Part B. Unlike Original Medicare, however, these Medicare Advantage plans may offer additional benefits such as dental, hearing, and vision, usually at an additional cost. Many of these Medicare Advantage plans also cover prescription drugs (or Part D Medicare) but not all of them.

Key Points

  • 1 In 2019, there were 33 Medicare Advantage plans available in West Virginia.
  • 2 26% of the total Medicare population in West Virginia is enrolled in Medicare Advantage plans as of 2018.
  • 3 In 2018, Original Medicare spent an average of $9,852 per beneficiary in West Virginia, which is 2% lower than the national average.
  • 4 Available Medicare Advantage plans range from 17to 28 across West Virginia’s 55 counties.

Residents of West Virginia who are eligible to select a Medicare Advantage plan may choose from one of four plan categories. To anyone who has been covered by workplace healthcare plans, these options may seem familiar. In some cases, you’ll need to use in-network providers. For other types of policies, you’ll be able to choose doctors outside the network, but it will cost more. Many of these plans offer prescription drug coverage, but others do not.

In West Virginia, seniors can enroll in a Medicare Advantage plan, move between Medicare Advantage plans, or move from Original Medicare to a Medicare Advantage plan (or vice versa) during specific periods.

Medicare Advantage Plans in West Virginia

Types of Medicare Advantage Plans

There are four categories of Medicare plans from which Medicare-eligible West Virginia residents can select. Before doing so, however, it’s important to consider some key questions.

  • Do I want to plan that offers the choice of using out-of-network providers?
  • Do I want a plan that includes Medicare prescription drug coverage?
  • How much of a premium do I want to pay?

Remember that West Virginia’s Medicare Advantage program varies in the type and number of plans available from county to county. Therefore, where you live in West Virginia will impact which plans you can choose.

Health Maintenance Organizations (HMO)

These plans require you to use in-network healthcare providers, and you must name a primary care physician. You’ll also need to get a referral to see most specialists. Emergencies and out-of-area urgent care or dialysis are not subject to these limitations. Many HMO Medicare Advantage plans in West Virginia are inexpensive and may not require a premium. Additional benefits may be available but at an added cost. You will need to select a specific HMO medical advantage plan that provides prescription drug coverage if that is important. Medicare Advantage HMO plans still require its members to pay Original Medicare’s Part B premium and, if applicable, the Part A premium.

Preferred Provider Organizations (PPO)

Instead of restricting its members to in-network healthcare providers, Medicare Advantage PPO plans allow members to use out-of-network resources. However, the PPO will not cover the additional cost of seeing an out-of-network healthcare provider if there is one. Plan members are not required to name a primary care physician or get referrals to see most specialists. Medicare Advantage PPO plans can also offer additional benefits like vision, dental, and hearing. Most of these plans also provide Medicare prescription drug coverage.

Private Fee-For-Service Plans (PFFS)

Medicare Advantage PFFS plans offer flexibility not seen in the other plans. They do, however, set limits on what they will pay healthcare providers in West Virginia. Many PFFS plans contract with a network of healthcare providers who promise to treat the plan’s members. However, members may visit out-of-network providers, but these healthcare suppliers may refuse service based on how much the member’s original PFFS plan is willing to pay. All PFFS plans must provide emergency coverage. Members of these plans do not need to choose a primary care physician or obtain referrals for most specialists. The plan may cover prescription drug costs, but members can sign up for a Medicare Part D plan if it does not.

Special Needs Plans (SNP)

Individuals who have specific medical issues or diseases can select an SNP plan. These plans provide coverage for specific medical conditions or situations, such as skilled nursing care or chronic diabetes. Members must use in-network healthcare providers and are required to name a primary care physician and obtain referrals for specialists. Exceptions are made for emergency care and out-of-network dialysis for End Stage Renal Disease (ESRD). Medicare Advantage SNP’s are legally required to provide prescription drug care coverage. 

Enrollment & Eligibility for Medicare Advantage Plans in West Virginia

The guidelines for enrollment and eligibility in a Medicare Advantage plan in West Virginia are as follows:

  • The senior must be at least 65 years old or currently receiving Social Security disability benefits
  • The individual must be an American citizen or a permanent resident for at least five years
  • Anyone wishing to enroll in a Medicare Advantage plan must already be enrolled in Original Medicare’s Part A and Part B
  • Anyone who wishes to enroll in a Medicare Advantage plan must select a plan available in the county where they live in West Virginia
  • Most Medicare Advantage plans will not accept anyone suffering from ESRD, although some SNPs may be an option

Senior residents of West Virginia who wish to enroll in a Medicare Advantage plan may do so at specific times:

  • The first opportunity to enroll, or the initial enrollment period, comes three months before an individual’s 65th birthday, the month of their birthday, and the three months following their 65th birthday
  • A yearly Medicare open enrollment period is available from October 15-December 7. Seniors can move from Original Medicare to a Medicare Advantage plan (or back to Original Medicare). They may also move from one Medicare Advantage plan to another plan
  • Medicare Advantage open enrollment lasts from January 1-March 31. Only seniors currently on Medicare Advantage plans can select a different plan or return to Original Medicare may do so during this timeframe
  • Finally, another general enrollment lasts from April 1-June 30, which impacts individuals who have recently enrolled in a Part B plan and want to join a Medicare Advantage plan

Medicare Advantage Resources in West Virginia

Determining if you want to remain on Original Medicare or select a Medicare Advantage program can be a frustrating process. Original Medicare presents you with one option while there are many Medicare Advantage programs in West Virginia, depending upon which county you live in. Fortunately, there are resources for senior residents of West Virginia to find help. These organizations will answer questions about Medicare and Medicare Advantage and other important issues like prescription drug coverage, legal aid for seniors, and any other special needs.

Area Agencies on Aging

These agencies cover four different areas of West Virginia. They’re part of a group of organizations that were created by the Older Americans Act. They help provide seniors with information on Medicare and Medicare Advantage, meals, transportation, and other services. State Health Insurance Assistance Program (SHIP) counselors are available through the various AAAs. These trained professionals provide unbiased advice on choosing Medicare plans and also coordinate area Medicare education events.

Contact information: Website | 304-558-3317

West Virginia RX card

West Virginia’s free statewide prescription assistance plan is open to all residents of the state. It’s designed to help the uninsured and under-insured with prescription drug costs, so it’s ideal for seniors who may have selected a plan that doesn’t cover prescription drug costs. The card is accepted at 56,000 pharmacies nationwide, including CVS, Target, and Walgreens.

Contact information: Website | 888-808-0099

West Virginia Bureau of Senior Services

West Virginia’s Bureau provides information to seniors and their family members about available programs and services, including Medicare and Medicare Advantage. It also helps residents of West Virginia connect to various senior-related services throughout the state.

Contact information: Website | 877-987-3646

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Contributing Expert:

Roseann Birch, Medicare Consultant

With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.

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Reviewed by:

Leron Moore, Medicare Consultant

With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.