Medicare Advantage is a type of health insurance for seniors age 65 and older. Also called MA or Medicare Part C, Medicare Advantage is offered through private insurance companies that have been government-approved. MA is an alternative to Original Medicare Parts A and B; however, there are some major differences between Original Medicare and Medicare Advantage. MA plans often include extras not offered through the government Medicare plan, such as vision and dental care and prescription drug coverage. Another notable difference between Original Medicare and Medicare Advantage plans is the fact that costs and coverage vary with MA plans, and plan availability is different in each county.
Participation in a Medicare Advantage plan is optional, and MA adoption varies widely throughout the country. Nationwide, Medicare Advantage enrollment rose by 9% between 2019 and 2020, and just over one-third of Medicare beneficiaries now participate in a private MA plan. In West Virginia, 31% of eligible seniors and people with disabilities are covered by a private Medicare Advantage plan. Statewide enrollment in neighboring Virginia is significantly lower at 21%, while enrollment is at 41% in Pennsylvania and 39% in Ohio. Overall, the highest Medicare Advantage enrollment rates are in Minnesota (43%), Hawaii (44%) and Puerto Rico (70%), and lowest in Alaska (1%) and Wyoming (3%).
Seniors in West Virginia have hundreds of unique Medicare Advantage plans to choose from, and availability varies between counties. HMO, PPO and SNP plans are offered, and some HMO and PPO plans include prescription drug benefits. In this guide you’ll find in-depth information about the various types of MA plans in West Virginia, along with details about eligibility and enrollment. We’ve also included a number of statewide and local Medicare Advantage resources that seniors and their families can use to access information and guidance about their MA plan options.
West Virginia seniors who are interested in purchasing a Medicare Advantage plan can choose between a local Health Maintenance Organization (HMO), Health Maintenance Organization-Point of Service (HMO-POS), or local Preferred Provider Organization (PPO). Institutionalized seniors and people with chronic disabilities may also be eligible for enrollment in a Special Needs Plan, (SNP).
Health Maintenance Organizations (HMO)
HMO plans usually limit coverage to services that are provided directly through in-network doctors, specialists and affiliated health care professionals, and members must choose a primary care physician from within the plan’s network. In order to access covered specialist services, seniors with an HMO Medicare Advantage plan usually need a referral from their primary physician.
Although HMOs do not prevent their members from seeing an out-of-network doctor or other provider, MA members are not eligible for any coverage or reimbursement through their HMO for out-of-network services.
Health Maintenance Organization-Point of Service (HMO-POS)
Health Maintenance Organization-Point of Service plans include all of the coverage offered through HMO plans, plus the option to access some out-of-network services for a higher co-pay. In general, HMO-POS plans let members self-refer to specialists, and the cost of these plans is usually higher than regular HMO plans.
Preferred Provider Organizations (PPO)
Preferred Provider Organizations are another type of Medicare Advantage health insurance plan. Often called simply PPO, these plans tend to cost more than HMO plans, however, PPO benefits are generally more extensive. One important distinction is that PPO plans provide maximum coverage for members who utilize in-network providers, but members can also see out-of-network providers while maintaining a portion of their MA coverage. Another thing that differentiates PPO plans from HMO plans is that PPOs usually let their members see specialists without first seeking a referral from their primary care physician.
Special Needs Plans (SNP)
Special Needs Plans (SNP) are Medicare Advantage plans for people who either: reside in a nursing home or similar institutional setting; are eligible for both Medicaid and Medicare, or; have been diagnosed with a qualifying chronic disease, illness or permanent disability, such as end-stage kidney disease or advanced diabetes. In accordance with federal law, all SNPs must include Medicare Part D prescription drug coverage.
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.
In West Virginia, seniors who want Medicare Advantage coverage combined with prescription drug benefits need to choose an MA plan that includes coverage for prescription medications. It’s important to understand that enrolling in a MA plan eliminates the option to purchase a stand-alone Medicare Part D plan. Medicare Advantage members who opt to enroll in a Medicare Part D Prescription Drug Plan are automatically terminated from their MA plan. The exception to this rule is Medicare Advantage Special Needs Plans (SNPs), which by law must include Medicare Part D benefits.
With close to 1,000 plans to choose from in West Virginia, finding the best Medicare Advantage plan can be overwhelming for seniors. We’ve compiled a list of statewide and local resources that provide Medicare counseling, advocacy and related services. These services offer free and low-cost assistance to seniors, their families and caregivers.
West Virginia’s State Health Insurance Assistance Program, WV SHIP, is a free, federally regulated service that helps seniors navigate their Medicare options. A statewide network of trained volunteer SHIP counselors offer one-on-one counseling appointments with seniors, caregivers and family members who need unbiased information and guidance about Medicare Advantage plans. SHIP counselors can also help seniors understand the various Medicare Part D/prescription drug coverage options, and provide information on medication discount programs that Medicare members can use to reduce out-of-pocket costs. SHIP counselors are often based in local senior centers, and some services are delivered over the phone and through group information sessions.
West Virginia’s Senior Medicare Patrol is a volunteer-based, federally funded organization that works to raise awareness about Medicare fraud, misuse and billing errors. SMP volunteers work in conjunction with SHIP counselors to deliver information to seniors through one-on-one sessions, public events and community-based workshops. Medicare Advantage members who have concerns about their plan are encouraged to contact their insurance provider. If the concerns remain unresolved, SMP volunteers may be able to advocate on behalf of the Medicare beneficiary. Seniors who believe they have been affected by MA billing errors or misuse can contact their local SMP branch. Cases that are suspected to involve criminal activities such as fraud are referred to the appropriate local, state or federal agency.
West Virginia Legal Aid provides low-income and marginalized seniors aged 60 and older with access to free civil legal advice on issues including Medicare health care coverage. The statewide organization maintains a network of participating lawyers who can assist seniors, and also maintains a current library of plain-language resources that provide in-depth information on Medicare and other legal issues related to seniors.
To contact West Virginia Senior Legal Aid, call 1-800-229-5068.
Seniors and qualified adults with disabilities who have difficulty paying their Medicare Part A and Part B premiums, co-pays and deductibles may qualify for financial assistance through one of two West Virginia Medicare Premium Assistance Programs. Open to applicants with incomes up to 120% of the federal poverty level who have few countable assets, these programs are administered by the Department of Health and Human Resources, Bureau for Children and Families. Applicants may qualify for either the Qualified Medicare Beneficiary (QMB), or the Specified Low-Income Medicare Beneficiary (SLIMB) program.
For more information about the QMB and SLIMB Medicare Premium Assistance Programs, contact the Bureau for Children and Families at 304-558-0628.
Located in the City of Philippi, the Barbour County Senior Center offers a range of educational, support and advocacy services to older adults. Seniors can access State Health Insurance Assistance Program counselors at the center, speak with a social worker about local resources and get referrals to low-cost legal services that specialize in Medicare Advantage issues. The center also hosts information workshops that help seniors understand their rights and responsibilities related to Medicare and Medicare Advantage plans.
Seniors in Charleston and the surrounding areas can contact Kanawha Valley Senior Services for help with Medicare Advantage plan selection and obtaining prescription drug coverage. Five KVSS representatives are available to provide seniors with unbiased information about Medicare, Medicare Advantage and Medicare Part D prescription drug plans. KVSS Medicare counselors can also answer questions about plan selection, and provide information about financial aid programs for those who have difficulty covering their Medicare costs.
To book an appointment with a Medicare counselor at KVSS or learn more about KVSS services and programs, call 304-348-0707.