Medicare Advantage, also known as Part C, is an alternative way for many Virginia seniors to get their Medicare benefits. Unlike Original Medicare, Medicare Advantage plans are provided through private insurance companies, which are approved by the federal government. Medicare Advantage plans provide all of the same benefits as Medicare Parts A and B, and many also offer extra coverage for dental, vision and prescription drugs. While Original Medicare provides blanket coverage for every beneficiary, Medicare Advantage plans offer Virginia seniors a degree of customization in how their care is delivered.
Medicare Advantage is somewhat less popular in Virginia than it is across the rest of the nation. According to the Kaiser Family Foundation, Medicare Advantage participation in Virginia represents just 20% of eligible beneficiaries, while the national participation rate is 34%. Virginia ranks 38th in Part C membership, tied with Oklahoma, Montana and North Dakota. Medicare Advantage participation is far higher in Minnesota, where 54% of eligible seniors take part in the program, while only 3% and 1% of Wyoming and Alaska seniors opt into Medicare Advantage, respectively.
Medicare-eligible seniors in Virginia have a choice between HMO, PPO, PFFS and SNP Part C plans. Multiple resources in the commonwealth also help out with prescription drug plans for total coverage of seniors’ needs. In this guide, we go over the plan types available to seniors in Virginia, as well as details about enrollment and the prescription drug benefits they may be eligible for. We also provide a list of state and local resources for seniors who need help managing their Medicare Advantage benefits and get the coverage they need.
Medicare Advantage plans are issued by private companies, which are allowed to craft specific policy options to serve different beneficiaries’ needs. In Virginia, seniors have three main options for how they want to receive their Part C benefits, HMOs, PPOs and SNPs. Seniors who are eligible for Original Medicare in Virginia are free to choose a plan with the services and costs that best suits their need for coverage.
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations are unified health care organizations, in which the same company provides insurance coverage and delivery of health services under one umbrella. Members often pay relatively low premiums for HMO coverage, and large networks tend to have all common specialties within the network. Members of HMOs usually need approval from a primary care physician before getting advanced diagnostic services or specialist care, and going outside the network usually requires prior approval from the insurer.
Preferred Provider Options (PPOs)
Preferred Provider Options provide greater flexibility for plan participants than a typical HMO. Under a PPO, members can seek care from any health care provider inside the network of preferred practitioners. Costs within the network are paid at plan rates, and coverage may be reduced or denied for nonemergency services delivered by non-plan providers. Monthly premiums for PPOs tend to be higher than premiums for HMOs, though beneficiaries are usually free to seek specialist care without the approval of a primary care physician.
Private Fee-For-Service Plans (PFFS)
Private Fee-For-Service plans operate much like private insurance plans. Beneficiaries with PFFS plans are generally free to seek care from any provider that accepts the plan’s payment system, though benefits may not be available for services rendered by non-participant care providers. PFFS members commonly pay high monthly premiums, but this type of plan can be ideal for beneficiaries who have difficult-to-predict health care needs or who frequently travel outside of their local area and might need care in other states.
Special Needs Plans (SNPs)
Special Needs Plans are a specially designed option that can work for seniors with permanent disabilities or chronic medical conditions. SNPs provide coverage that is optimized to care for people with the specific condition the plan is intended to treat, while sacrificing some flexibility and other care options that are less likely to be needed. Seniors with diabetes, for example, may opt into an SNP that provides excellent nutrition services and affordable prescription care, but which may limit orthopedics and home health services. Seniors with Alzheimer’s disease may benefit from an SNP that includes memory care services and residential care coverage, but with more expensive emergency department visits. Premiums for SNPs can be high, though co-payments for selected services tend to be low or free.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
Medicare-eligible seniors in Virginia have several choices for getting standalone Part D coverage to help pay for prescription drugs. The state has 11 insurance providers that offer 29 authorized Part D plans. Monthly premiums for these plans range from as low as $13.20 to a maximum of $75.20. Co-payments range from $0 to $47, with coinsurance limits for some that average 25%.
Prescription drug coverage in Virginia is available through Part D to both Original Medicare and Medicare Advantage beneficiaries. Among Virginia seniors with any form of Medicare, however, only 32% also have at least some coverage through a Part D plan. Prescription coverage may cost Medicare Advantage beneficiaries a higher monthly premium, and costs at the point of sale can be higher, depending on the details of the seniors’ specific Medicare Advantage managed care plan. Another option for Medicare-eligible seniors in Virginia, who may face higher-than-average prescription costs, is to choose a Part C plan that sacrifices some benefits for comprehensive prescription coverage. Some of these operate as standalone supplements specifically for Medicare and Medicare Advantage prescription coverage.
Making sense of the Medicare options available in Virginia can be a challenge for many seniors. Fortunately, many resources exist in Virginia to help seniors find and apply for adequate Medicare Advantage and prescription drug coverage on their own.
The Virginia Insurance Counseling and Assistance Program (VICAP) is a state program that operates as part of a nationwide network of certified benefits counselors and senior advisers. Offering free, unbiased advice and counseling services, VICAP helps Medicare-eligible seniors and their loved ones clarify the insurance options they have and better understand how benefits plans work together for full coverage. Program staff offer case worker support and can assist in filling out applications for assistance programs seniors may be eligible for. Counselors can assist seniors who have been denied coverage with their appeals, as well as with planning ahead to meet program income and asset eligibility criteria. Programs and topics VICAP counselors can assist seniors with include:
Contact the VICAP support team by calling the main helpline at 1-800-552-3402. Email inquiries from the public go through the program’s main account at [email protected]. VICAP receives mail at the head office mailing address at the Division for Community Living Office for Aging Services, in Henrico.Email
Seniors in Virginia who have enrolled in the Virginia AIDS Drug Assistance Program, and who meet income and asset limits, may be eligible for financial assistance with their prescription drug costs. Benefits are provided through the State Pharmaceutical Assistance Program (SPAP), which pays Medicare Part D costs for people with an income less than 400% of the federal poverty limit. Some senior beneficiaries of the SPAP program get assistance managing their co-payment and coinsurance requirements, in addition to help with the monthly premiums charged by their Part D provider. SPAP benefits can also help close the gap in benefits, known as the “donut hole” between co-payment amounts and the coinsurance threshold.
The Virginia Drug Card is a statewide prescription assistance program that seniors can use to help cover the costs left unpaid by their Medicare Part D coverage. No personal information is required to sign up for benefits, and the card is available to all Virginia residents. Using the card at the time of purchase, seniors can save up to 75% of the cost of both generic and prescription drugs at over 56,000 locations around the state. Average savings at the point of sale are 30% off of list price for most drugs.
Rappahannock Rapidan Community Services (RRCS) serves the communities of Culpeper, Fauquier, Madison, Orange and Rappahannock counties with prescription coverage and Medicare assistance for low-income seniors. Benefits include referrals to prescription drug plans and private sector assistance programs, as well as Medicare and Medicare Advantage counseling. Case workers at RRCS can assist seniors aged 60 and over who meet the program’s income and asset guidelines with signing up for services and managing appeals and denials of service. Advice is unbiased and given by certified staff to help seniors understand and maximize the benefits they are eligible to receive.
RRCS counselors can be reached over the phone by calling 540-825-3100. Email inquiries may be sent through the online contact form here. Application packets should be directed to the program’s mailing address, as should all other mail inquiries, at: Rappahannock Rapidan Community Services (RRCS)
15361 Bradford Road
P.O. Box 1568, Culpeper, VA 22701
Care Coordination at AASC works with partner agencies in and around the Cedar Bluff area to maximize the benefit coverage and social support seniors get in the community. Care coordinators can provide advice and planning assistance for managing Original Medicare, Medicare Advantage, Medigap and Part D plans for eligible Virginians aged 60 and over. Outreach, assessment and planning services are offered free of charge. AASC offers seniors insurance counseling (VICAP), health education and screening, emergency interventions and My Medicare Matters computer training in-home or at a training center.
Seniors in the Cedar Bluff area, or their caregivers and loved ones, may reach out to Care Coordination at AASC by phone at 1-800-656-2272, or by email at [email protected]. Mailed correspondence can be sent to the program’s Cedar Bluff mailing address at the Appalachian Agency for Senior Citizens (AASC).Email
The Carilion Medication Assistance Program (MAP) at Pearisburg offers services to low-income seniors in the Pearisburg, Princeton and Blacksburg areas who need help paying for prescription drugs. Many seniors who participate in the program have primary care physicians through Original Medicare or Medicare Advantage programs, but little or no Part D coverage. Seniors who do have Part D insurance but who struggle to meet the co-payment or coinsurance requirements are also eligible for direct aid through the MAP benefit program. Technically, all program participants are asked to contribute $10 quarterly to support the program, but no senior is turned away for lack of payment and the fee is voluntary. The Carilion Medication Assistance Program at Pearisburg offers extra program assistance for seniors with additional needs. Case managers at the MAP office can assist seniors with the signup process for MAP and various other state and federal programs they might be eligible for. Counseling is available to help seniors plan their benefit profile during Medicare’s annual open enrollment periods, and program staff can personally follow up with seniors who need prescription refill reminders.
Call the program office at 540-922-4282 for information about local areas served, senior eligibility information and other requirements of care. Seniors, caregivers and their loved ones may contact the program via email through the online contact form here. Application packets and other correspondence can be mailed into program headquarters at:Carilion Medication Assistance Program
c/o Carilion Giles Community Hospital
159 Hartley Way, Pearisburg VA 24134