Medicare in Virginia

Medicare is a federal health insurance program designed for seniors aged 65 and up, as well as certain adults with complex medical needs. It’s a comprehensive package which covers a wide range of medical services, with a few value-added benefits. Of the 8.7 million members of the Virginia population, 1.6 million are seniors and eligible for Medicare. Although 1.1 million opted for the traditional Medicare plan, as of 2023, about 36% of eligible seniors were covered by a Medicare Advantage Plan, which is lower than the national average of 48% but shows a higher growth rate from the previous year.

Part A is responsible for covering inpatient hospital care, hospice and a bit of skilled nursing at home when needed. Part B takes care of preventative care and specialty care needs, along with medical equipment, and comes with a separate premium of $164.90 per month that’s usually deducted from Social Security. If prescription drugs are needed, Part D is available to cover those.

As shown by the trends in Medicare plans, there has been an increase in the selection of Medicare Advantage (more commonly known as Part C). Seniors prefer these plans because they come with a lot of the extra services and options Part A and Part B don’t provide. Some of these include vision, hearing and dental coverage, but they might also offer exercise programs and non-prescription medications. Private insurance companies partner with the government to offer more options to seniors. For those who choose to remain with Original Medicare, though, there are Medigap policies to help control and limit most of the out-of-pocket expenses.

This guide aims to be a comprehensive source for all things Medicare in Virginia, especially looking at the ten most popular Medicare Advantage providers in the state. There are also multiple resources offering free insurance advice and other useful services to assist in answering any questions seniors may have about their medical coverage. Ensuring seniors have what they need is the primary goal.

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 adequately covers a substantial number of mature individuals in Virginia and frequently remains the preferred choice. However, it doesn’t always cover everything seniors prefer, and the appeal is becoming less and less universal. Fortunately, seniors who qualify for Medicare have the option to personalize their coverage according to their distinct circumstances and health care needs. Apart from government-offered policies, beneficiaries have the flexible options of choosing a supplementary plan or privately offered Medicare Advantage Plans from insurance providers.

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 known as Part C, offers seniors in Virginia the same benefits as Original Medicare — except hospice care, which remains with Part A — but is controlled by private insurance companies and typically has annual out-of-pocket limits. To enroll in Medicare Advantage, seniors can’t be enrolled in Medigap but must already be enrolled in Parts A and B. There are four types of plans: preferred provider organization (PPO), health maintenance organization (HMO), private fee-for-service (PFFS), and special needs plan (SNP), each with their own varying costs and levels of flexibility, with some requiring referrals for specialist treatments.

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 August 2023. 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 2023 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.