Medicare in Virginia

Medicare is a federal health insurance program available to seniors aged 65 and older and certain adults who have complex medical needs. It provides comprehensive medical care and a number of value-added benefits. Primary and specialty care are covered by Medicare Part B, which has its own premium that’s typically taken out of the beneficiary’s Social Security check. Part A covers inpatient hospital care, hospice and a limited amount of skilled nursing in certain situations. Medicare may also cover prescription drugs through Part D, and this benefit is included in most Medicare Advantage plans.

According to the Kaiser Family Foundation, more than 1,535,000 Virginians were covered by Medicare in 2020. Although 1.1 million residents depend on Original Medicare, about 24% of beneficiaries obtain their coverage through a Medicare Advantage (Part C) provider in the same year. Medicare Advantage plans are an increasingly popular option because they include many additional benefits, such as vision, hearing and dental, that aren’t covered by Original Medicare. Private insurance companies also offer a variety of supplemental Medigap policies for individuals using Original Medicare. Medigap can reduce or eliminate most out-of-pocket costs, and there are financial assistance programs for seniors who have a limited income.

This guide takes a look at Medicare coverage in Virginia, including 10 of the state’s most popular Medicare Advantage providers. It also includes a directory of Medicare-related resources that provide free insurance counseling and other valuable services at no cost.

Options for Medicare Coverage in Virginia

Seniors who are eligible for Medicare can stick with Part A and Part B, which is known as Original Medicare. The government also contracts with private insurance companies that offer Part C Advantage Plans. The Advantage Plans include almost all the benefits that come with Original Medicare, along with some additional benefits. The best option depends on a variety of factors, as well as each beneficiary’s individual needs.

Original Medicare (Parts A & B)

Original Medicare is administered by the Centers for Medicare & Medicaid Services (CMS) and is open to seniors aged 65 and over, along with those under 65 years old, but with certain disabilities or end-stage kidney disease. It includes two parts. Part A covers inpatient hospital care, nursing home and skilled nursing care, hospice and home health care. Part B, or medical coverage, pays for medically necessary goods and services such as durable medical equipment, mental health services and emergency medical transportation. 

Unlike most private Medicare plans, Original Medicare’s provider network isn’t limited to the beneficiary’s geographic region, making it easier to obtain services while traveling within the country. In most cases, Medicare doesn’t pay for health services the individual receives outside the United States. 

Under this program, seniors pay for services as they receive them. They must pay an annual deductible, which is $1,556 for Part A and $233 for Part B in 2022. After they’ve paid this amount, Medicare covers all eligible services at 80%. Beneficiaries pay the remaining 20% out of pocket.

Who Should Consider Original Medicare

Original Medicare may be a good option for those who:

• Travel frequently within the United States
• Don’t need extra benefits such as home-delivered meals and coverage for over-the-counter medication
• Want to choose their own prescription drug coverage

Medicare Advantage (Part C)

Medicare Advantage, also called MA or Part C, is a great option for seniors who want to receive all their health care benefits through a single provider. These health insurance companies operate traditional managed care networks, such as Health Maintenance Organization(HMOs) and Preferred Provider Organization( PPOs). There are also Private Fee-For-Service (PFFS) networks that have fixed pricing arrangements and Special Needs Plans (SNPs) that target individuals who have certain medical conditions.

In Virginia, available Medicare Advantage plans vary by metropolitan area. Some of the major providers include Aetna, Anthem, Cigna, Clear Spring Health, Humana, Kaiser Permanente, Mary Washington, Optima and UnitedHealthcare. Each MA plan has an out-of-pocket maximum. Monthly premiums start at $0, but beneficiaries must keep paying for Part B. With some plans, there’s no cost to see a primary care provider. Most MA plans include prescription drug coverage. Many plans also include dental, vision and wellness coverage. 

Who Should Consider Medicare Advantage?

Medicare Advantage plans are a great option for seniors who:

• Want extra benefits, such as vision and dental
• Prefer receiving their prescription drug coverage through the same company
• Don’t mind staying in-network or paying more for out-of-network care
• Are looking for a plan with low monthly premiums

The Top 10 Medicare Advantage Plans in Virginia

The following table highlights the top 10 Medicare Advantage providers in Virginia based on total enrollment as of April 2022. It also provides an overview of possible costs. While not all plans are available statewide or in all metropolitan areas, most providers offer multiple options. For more information about Medicare Part C plans, visit our Medicare Advantage Plans in Virginia page. 

Medicare Prescription Drug Coverage (Part D)

Original Medicare doesn’t pay for most prescription drugs through Part A or B coverage. Instead, seniors purchase separate prescription drug policies, also called Part D coverage. Medicare contracts with private health insurance companies to provide this coverage. There are multiple plans to choose from with varying monthly premiums, which beneficiaries pay in addition to their Original Medicare premiums. While seniors don’t have to purchase prescription drug coverage when they’re first eligible for Medicare, not obtaining this coverage at this time may result in late enrollment penalties they pay for as long as they have Medicare if they enroll later. 

Each prescription drug plan has its own formulary, or list of covered drugs. Formularies are typically split up into tiers. The tier a medication is in determines how much the insurance company pays and how much the beneficiary pays for it. Lower-level tiers are usually made up of generic and low-cost brand name drugs, while higher tiers are composed of more expensive brand name and specialty drugs. In most cases, the lower the tier, the lower the policyholder’s cost-sharing responsibility.

Who Should Consider Medicare Prescription Drug Coverage

Seniors who may benefit from prescription drug coverage include those who:

• Currently take prescription medication or expect to in the future
• Want to avoid late enrollment penalties
• Want to reduce out-of-pocket prescription drug expenses

Medicare Supplement Insurance (Medigap)

While Original Medicare provides coverage for many medical costs, seniors may still have significant out-of-pocket expenses. These may include copays, coinsurance and deductibles. Seniors may be able to reduce their cost-sharing obligations by purchasing a Medigap plan. These plans can only be used with Original Medicare. It’s illegal for private insurance companies to sell Medigap plans to those with Medicare Advantage plans.

In Virginia, there are 10 types of Medigap plans, eight of which are available to new enrollees. Plans are standardized, meaning policyholders get the exact same coverage from a given plan regardless of the health insurance provider they buy it from. For more information on Medigap plans, seniors can refer to the Best Medicare Supplement Companies of 2022 page.

Who Should Consider Medicare Supplement Insurance

Good candidates for Medigap may be those who:

• Have ongoing health issues and expenses
• Travel overseas often
• Want to access an expanded network of health care providers
• Expect to need health services not covered by Original Medicare

Medicare Resources in Virginia

Medicare is a complex health insurance system. It doesn’t matter whether seniors are new to Medicare or have been through a few seasons of open enrollment. Coverage options and prices can change year after year. Fortunately, the state offers numerous resources to help seniors and their families learn more about their options and maximize their benefits.