Medicare in West Virginia

Medicare provides health insurance to older adults aged 65 and over. This federally run program also covers individuals with specific disabilities. In West Virginia, a total of 441,852 people have Medicare coverage as of 2020. This includes 294,946 people enrolled in Original Medicare and an additional 146,906 enrolled in Medicare Advantage plans. That is around 25% of the total population of just under 1.8 million people.

Original Medicare has two parts. The first is Part A, which covers inpatient care at hospital, nursing home care, some home health care services and hospice care. If a senior has paid Medicare payroll taxes, or had a spouse who did for a certain amount of time, this coverage costs nothing. Part B covers other medical services, including preventative care and outpatient services, as well as medical supplies. In 2022, the standard premium for Part B is $170.10.

Medicare Advantage plans, also known as Part C, provide Medicare-compliant plans through health insurance companies. These plans provide the same coverage as Original Medicare, except hospice care which Medicare Part A covers. The Advantage Plans have the option to add additional coverage options, such as coverage for prescription drugs, dental or vision care. 

Part D is the prescription drug option that beneficiaries can add to Medicare plans, especially those who use Original Medicare. Most Medicare Advantage plans cover prescription drugs (Part D). 

Medigap refers to Medicare supplement plans that private health insurance companies offer. These plans cover what Original Medicare doesn’t to reduce out-of-pocket costs.

Medicare in West Virginia can be confusing, but this guide breaks down coverage options, costs and personalization choices for health insurance providers. It also has resources seniors can use to make the best decisions about health insurance coverage.

Options for Medicare Coverage in West Virginia

For many older adults, Original Medicare’s basic coverage is exactly what they need. For some, it is not sufficient. Thankfully, West Virginia offers a number of programs that will help those who qualify for Medicare find coverage that works well for their needs. The primary program, which the federal government runs, is one option, but additional alternatives from private health insurance providers can also work well.

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 beneficiaries who need more control over medical expenses or additional coverage than what Original Medicare offers may opt for Medicare Advantage plans, also known as Part C. These plans come from traditional insurance providers and often provide additional coverage like dental or prescription drug coverage. They also often have out-of-pocket limits, making it easier to budget for medical costs each year.

Medicare Advantage plans fall into one of four main categories: Preferred Provider Organization (PPO), Health Maintenance Organization (HMO), Private Fee For Service (PFFS) and Special Needs Plans (SNPs). All Medicare Advantage plans provide the same benefits as Original Medicare, except for hospice care which is part of Medicare Part A, but add additional coverage options. Eligibility rules, deductibles, networks and other potential costs will vary from one plan to the next.

Who Should Consider Medicare Advantage 

Seniors may benefit from Medicare Advantage plans if they:

• Need to control their out-of-pocket costs
• Like the idea of a managed care planning
• Need additional coverage options, such as prescription drug coverage or vision
• Who are generally healthy and can benefit from low premiums 

The Top 10 Medicare Advantage Plans in West Virginia

Many providers in West Virginia offer Medicare Advantage plans. The table below highlights the top options based on how many people are enrolled. It shows the costs for these plans as of April 2022, the type of plan offered and the Medicare star rating. The Medicare Advantage Plans in West Virginia page has more information about these options.

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.

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 West Virginia

Applying for Medicare is complicated, and many seniors find themselves wondering how to go about the process properly. The state of West Virginia has a number of resources seniors and their caregivers can tap to help with the application process. From assistance with appeals to help with the actual applications, here are some resources that provide assistance to those seeking Medicare coverage.