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Overview of Medicare in Virginia

Whether you are already a Medicare beneficiary in Virginia or planning for the future, Medicare coverage may be a matter of interest to you. We would like to help you understand your options and the resources available to you in Virginia, so that you can make informed decisions about the Medicare coverage option that best meets your lifestyle and health coverage needs.

To begin, it is helpful to understand the components or “parts” of the Medicare program, what each covers, and how they can work together.

Medicare Part A is sometimes referred to as hospital-care coverage. Medicare Part A coverage is one part of the Original Medicare program, which is administered by the federal government.

Medicare Part B is sometimes referred to as physician-care coverage. Together with Medicare Part A, Part B coverage is part of the federal government’s Original Medicare program.

Medicare Part C is available through Medicare Advantage plans. Private insurance companies approved by the Centers for Medicare & Medicaid Services (CMS) offer Medicare Part C (Medicare Advantage), which includes at least the same level of benefits of Original Medicare (Part A and Part B) and may also include additional coverage.

Medicare Part D is Medicare prescription drug coverage that helps cover prescription drug costs and lower your out-of-pocket expenses for medications. Private insurance companies approved by the Centers for Medicare & Medicaid Services (CMS) offer prescription drug coverage. These insurance companies may offer either Medicare Advantage plans that include prescription drug coverage, called Medicare Advantage Prescription Drug (MA-PD) plans, or stand-alone Medicare Prescription Drug Plans (PDPs).

Some of the decisions you will need to make about your Medicare coverage involve the following choices:

  • Remain solely in Original Medicare, Part A and/or Part B.
  • Apply for a Medigap (Medicare Supplement) plan that works alongside Original Medicare.
  • Enroll in a Medicare Prescription Drug Plan (PDP) that works with your Original Medicare coverage.
  • Enroll in a Medicare Advantage plan as an alternative way to receive your Original Medicare benefits.

To help you along the decision-making path, let’s look at each option and what it has to offer in more detail.

Original Medicare is available to United States citizens and permanent legal residents of at least five continuous years. You’re eligible if you’re at age 65 and older, or some younger people may qualify through certain disabilities, or if they have a health condition called end stage renal disease (permanent kidney failure requiring a kidney transplant or continuous dialysis treatments) or amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease. If you qualify by age, typically you are automatically enrolled in Part A and Part B if you’re already receiving retirement benefits before you turn 65, and you must disenroll from Part B to avoid paying the Part B premium if you don’t want it. Eligibility and benefits under Original Medicare are the same throughout the United States.

Medicare Part A covers inpatient hospital care, inpatient skilled nursing care (for circumstances such as nursing care in transition from inpatient hospital care to home), some home health care and hospice care. As a complement to Part A coverage, Medicare Part B covers outpatient services, including lab tests, doctor visits for diagnosis and treatment of illnesses, injuries, and some preventive screenings and exams. Medicare Part B also covers durable medical equipment, physical therapy, and some home health-care services.

Original Medicare doesn’t cover costs like routine vision or dental care, hearing, long-term care, or health coverage outside of the country.

Medicare beneficiaries get Medicare Part A without a premium if they’ve worked at least 10 years (40 quarters) and paid Medicare taxes; otherwise, they may owe a premium for their Part A coverage. Most Medicare beneficiaries pay a premium for Part B coverage, along with the deductibles, copayments, and coinsurance costs that apply to Medicare Part A and Part B coverage.Medigap (Medicare Supplement) insurance plans are offered by private insurance companies and can help you pay your out-of-pocket costs for services covered under Original Medicare. You might want to learn more about Medigap insurance plans if you decide to stay with Original Medicare.

You may opt to enroll in a Medicare Advantage plan in Virginia as an alternative way to receive your Original Medicare benefits. Medicare Advantage plans are offered by private insurance companies that contract with the Centers for Medicare & Medicaid Services (CMS). Also known as Medicare Part C coverage, these plans must provide at least the same level of Medicare coverage as Original Medicare, Part A and Part B, with the exception of hospice care. (Hospice care continues to be covered under Medicare Part A even if you enroll in a Medicare Advantage plan.)

Among the attractive features of Medicare Advantage plans, two stand out.

  • First, Medicare Advantage plans are required to limit your out-of-pocket costs (including deductibles, copayments and coinsurance amounts) for covered services. In other words, once you have spent up to the annual cap, your Medicare Advantage plan pays 100% for Part A- and Part B-covered services for the rest of the benefit year. Original Medicare does not have this cap protecting how much you have to spend out of pocket for covered services.
  • Second, most Medicare Advantage plans cover benefits beyond Medicare Part A and Part B, such as routine dental and vision care, hearing, and wellness programs. Some of these plans, called Medicare Advantage Prescription Drug (MA-PD) plans, also include Medicare Part D prescription drug coverage. Medicare Advantage Prescription Drug plans cover your Medicare medical and prescription drug benefits through a single plan-a convenience many people find very attractive.

To be eligible for Medicare Part C and enroll in a Medicare Advantage plan, you must have Medicare Part A and Part B, and live in the Medicare Advantage plan’s service area. Most beneficiaries who have permanent kidney failure, or end-stage renal disease, requiring dialysis or a transplant must remain in Original Medicare, but there are exceptions. Typically, you’ll need to keep paying your Medicare Part B premium in addition to any premium that may be required by your Medicare Advantage plan. For information about the specific Medicare Advantage plans available in your community, use the eHealth plan finder tool on this page and enter your zip code.

To obtain Medicare Part D prescription drug coverage, you also have the option of enrolling in a stand-alone Medicare Part D Prescription Drug Plan (PDP), which can work alongside your Original Medicare, if you decide to keep Original Medicare, Part A and Part B. If you enroll in a Medicare Prescription Drug Plan, you will be responsible for paying the plan’s premium and any applicable deductible, copayments, and coinsurance costs of the prescription drug benefit plan. As mentioned, another option for getting Medicare Part D coverage is through a Medicare Advantage Prescription Drug (MA-PD) plan. Typically, if you have Medicare Part C and want prescription drug benefits, you should enroll in a Medicare Advantage plan that includes this coverage, unless your plan type doesn’t offer prescription drug benefits. For example, Medicare Savings Account (MSA) plans and Private-Fee-for-Service (PFFS) are types of Medicare Advantage plans that don’t cover prescription drugs, and you’ll need to enroll in a Medicare Prescription Drug Plan (PDP) if you want prescription drug coverage. .

Some people, however, may have the costs associated with Medicare Part D prescription drug coverage reduced if they are eligible for Extra Help, which is a government-sponsored subsidy available to Medicare beneficiaries who have low incomes. State agency counselors identified below can assist you in determining if you are eligible for Extra Help.

Medicare resources in Virginia

The Office for Aging Services of the Division for Community Living – This Commonwealth office provides a wide range of services for seniors, including housekeeping, transportation, and meals. The office also provides insurance counseling for Virginia Medicare beneficiaries through the State Health Insurance Assistance Program (SHIP). Offices are staffed with trained volunteers who can provide unbiased, accurate counseling to Virginia residents. The website also offers a number of links to additional Medicare resources, both through Commonwealth and federal government offices.

Virginia Department of Social Services – Virginia Medicare beneficiaries who need help with paying for their health-care coverage can check their eligibility for assistance through the Department of Social Services for the Commonwealth. This office provides information and oversight of the Commonwealth’s Medicaid program, for which some Virginia Medicare beneficiaries may also qualify. Eligibility for Medicaid is based on income, and those that qualify for assistance may get help paying for their Medicare premiums, deductibles, and/or coinsurance costs.

Virginia Association of Area Agencies on Aging – This non-profit organization was established in 1976 to provide seniors living in Virginia with localized services through a network of Commonwealth offices. This office is home to Virginia’s Senior Medicare Patrol (SMP), which works to prevent Medicare fraud through awareness and education. The SMP is a federal program that operates on a state level. Trained volunteers of the SMP program provide education through public events and one-on-one counseling on fraud detection and what to do if they suspect it has occurred.

Medicare statistical trends in Virginia

In 2018–

  • More than 1.4 million Virginians received Medicare coverage, according to CMS.
  • 1,146,632 Virginians were enrolled in Original Medicare, Part A and/or Part B
  • 300,291 Medicare beneficiaries enrolled in Medicare Advantage plans and other health plans.
  • Approximately 64% of Medicare beneficiaries in Virginia included Medicare prescription drug coverage in their choice.
  • More than 691,000 people enrolled in a stand-alone Medicare Prescription Drug Plan.
  • 238,511 beneficiaries received their Medicare prescription drug coverage from a Medicare Advantage plan.
  • 96 Medicare Advantage plans are available in Virginia.
  • 100% of Medicare beneficiaries living in Virginia have access to a Medicare Advantage plan.
  • 24 Medicare Prescription Drug Plans are available in Virginia.
  • 79% of the Medicare beneficiaries in Virginia with Medicare Part D prescription drug coverage have access to a plan with a lower premium than they paid in 2015.
  • The lowest monthly premium for a Prescription Drug Plan is $16.70 (excludes those who qualify for low-income subsidies and late-enrollment penalties). .
  • 27% of Virginians with Medicare Part D get Extra Help (also called the Low-Income Subsidy, or LIS).

*Sources Used:
Statistical data from the Centers for Medicare & Medicaid Services, “Medicare Enrollment Dashboard ”; and “2018 MA Part D Landscape State-by-State Fact Sheet”.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply.

Benefits, premiums and/or copayments/co-insurance] may change on January 1 of each year.

This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

The product and service descriptions, if any, provided on these Web pages are not intended to constitute offers to sell or solicitations in connection with any product or service. All products are not available in all areas and are subject to applicable laws, rules, and regulations.

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