If you’re a Medicare beneficiary living in Virginia and enrolled in Original Medicare, Part A and Part B, you may have the option of signing up for a Medicare Advantage plan offered by a Medicare-approved private insurance company.  The Medicare Part C (Medicare Advantage) program makes this option available to Medicare beneficiaries as an alternative way to receive Medicare benefits. If you choose the Medicare Advantage option, you still have Medicare, and continue paying your Medicare Part B premiums, but you receive your Medicare benefits from the Medicare Advantage plan.  You may also receive additional benefits offered by the Medicare Advantage plan. The benefits of a Medicare Advantage plan in Virginia depend on the plan you select and the county or zip code where you reside.

How Medicare Advantage works in Virginia

Medicare Advantage plans are required by law to offer at least the same coverage as Original Medicare, including hospitalization (Part A) and medical (Part B) benefits. Hospice care, however, continues to be covered by Part A.  Many Medicare Advantage plans offer additional benefits such as prescription drug coverage, routine vision, dental and hearing coverage, including hearing aids. As a Virginia resident, you can enroll in a Medicare Advantage plan offered by a private insurance company contracted with Medicare to provide Medicare Advantage plan(s) in Virginia.

When to enroll in a Medicare Advantage plan

You can enroll in a Medicare Advantage plan when you are first eligible for Original Medicare Part A and Part B.  To avoid a late-enrollment penalty, which translates into higher premiums for as long as you remain enrolled in Medicare, most individuals sign up for Original Medicare Part A and Part B or a Medicare Advantage plan during the Initial Enrollment Period. If you are one of the many Virginia residents qualifying for Medicare at age 65, your Initial Enrollment Period begins three months before the month you turn age 65, includes the month you turn 65, and includes the three months after you turn 65. If you fail to sign up for Original Medicare during your seven-month Initial Enrollment Period, you can still enroll during the General Enrollment Period, which runs from January 1 through March 31 each year. However, you may have to pay the late-enrollment penalty.

Medicare beneficiaries who have already enrolled in a Medicare Advantage plan and wish to switch plans can do so during the Medicare Advantage and Prescription Drug Plan Annual Election Period. Also known as the Fall Open Enrollment Period for Medicare Advantage and prescription drug coverage, the Annual Election Period runs from October 15 to December 7 each year. If you switch Medicare Advantage plans during this time, your new coverage begins on January 1 of the following year.

There are a few other scenarios in which you may change Medicare Advantage plans:

  • You move outside the service area of the Medicare Advantage Plan in which you are enrolled;
  • Your Medicare Advantage plan experiences changes that affect your health benefits (such as a significant change in its participating provider network); or
  • You are enrolled in a Medicare Advantage Special Needs plan and you experience changes in your health condition or your Medicaid status that the plan is designed to assist.

In the event that one of the fore-mentioned situations occurs, you have a Special Enrollment Period, which provides you the opportunity to change to another Medicare Advantage plan or return to Original Medicare.

You may also enroll in a Medicare Advantage plan during a Special Enrollment Period if you have certain changes in the status of your insurance.  For instance, if you are eligible for Medicare Part A and Part B, but you elected not to enroll in Medicare Part B because you had coverage from an employer-sponsored health plan, you can enroll in Medicare Advantage plan when you lose the employer-sponsored plan and enroll in Medicare B.

If, for any reason, you want to disenroll from your Medicare Advantage plan and go back to Original Medicare, Part A and Part B, you may do so during the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31 each year in Virginia, as it does in the rest of the country. During this period you can also enroll in a stand-alone Part D Prescription Drug Plan since Original Medicare generally doesn’t cover prescription drugs.

Types of Medicare Advantage plans in Virginia

As a Virginia Medicare Advantage beneficiary, it’s important to understand the various types of Medicare Advantage plans that may be available where you live so you can select the plan that best suits your individual health needs.

When signing up for a Medicare Advantage plan, it’s important to take into consideration your prescription drug needs. There are a number of Medicare Advantage plans in Virginia that combine health coverage and prescription drug coverage (Medicare Part D) into a single plan, known as Medicare Advantage Prescription Drug plans.

Medicare Advantage plan types available in Virginia include Health Maintenance Organization (HMOs) and HMO Point-of-Service (HMO-POS) plans. Under an HMO plan, beneficiaries are required to visit doctors, health care providers, and hospitals in the health plan’s HMO network in order to receive benefits, except in the instances of emergency/urgent care or the plan’s prior approval. Some HMOs may also require a referral from the beneficiary’s primary doctor in order to receive certain health services. HMO-POS plans are similar to standard HMO plans, but they generally cost a bit more because they offer greater flexibility, allowing beneficiaries to choose health-care providers who do not participate in the plan’s network for certain health services and usually at a higher out-of-pocket cost.

Another type of Medicare Advantage plan available in Virginia is the Preferred Provider Organization (PPO) plan.* PPOs allow Medicare beneficiaries to choose doctors, health-care providers, and hospitals inside and outside of the plan’s network, but generally beneficiaries have lower out-of-network costs when they use health-care providers who participate in the plan’s preferred network. PPOs generally do not require referrals to specialists, nor are beneficiaries required to select a primary care physician to coordinate their care.

There are Medicare Advantage plans called Medicare Special Needs Plan (SNP).  Beneficiaries who have certain chronic health conditions such congestive heart failure, diabetes, or HIV/ADS may have access to a Special Needs Plan that tailors benefits and support programs to assist plan members to manage their condition effectively.  Other Special Needs plans are focused on assisting Medicare Advantage beneficiaries who reside in a nursing home.  Still others may focus on the coverage and health care needs of individuals who receive Medicare and Medicaid benefits.

In a Medicare Advantage Private Fee-for-Service (PFFS) plan, the plan itself decides how much it will pay for your doctor, health care provider, and hospital visits, and also determines your share of each expense. Keep in mind that not all providers accept this plan. It is always a good idea to make sure you check with the provider before receiving services even if you have been seen by the provider in the past.

You may also have the option of enrolling in a Medical Savings Account (MSA) plan in Virginia. This type of Medicare Advantage health plan generally combines a high deductible plan with a savings account into which Medicare contributes some money that beneficiaries can use to pay for their health care expenses tax-free.

Once again, keep in mind that even if you enroll in a Medicare Advantage or Medicare Advantage Prescription Drug plan, you remain enrolled in Original Medicare and continue paying your Medicare Part B premiums.

Comparing Medicare Advantage plans in Virginia

The availability in Virginia and costs of Medicare Advantage plans generally vary depending on where you live in Virginia, the insurance company offering the plan, and specific plan details. You may find that some Medicare Advantage plans in Virginia offer premiums as low as $0.  Be sure you consider other costs as well, such as copayments and deductibles, and that you continue paying your Medicare Part B premium no matter which Medicare Advantage plan you choose.

The Medicare Advantage plans may include networks of participating providers. If so, your use of the doctors, hospitals and other health-care providers who participate in the plan’s network has a significant impact on your ability to receive the full benefits of the Medicare Advantage plan.  If you currently have doctors and other health-care providers you want to retain, check to see if they participate in the Medicare Advantage plan before you make a final decision to enroll.

Some Medicare Advantage plans may offer additional benefits beyond what is included in Original Medicare, Part A and Part B.  Consider whether a Medicare Advantage Prescription Drug plan would be a good choice to meet your medical and prescription drug coverage needs. If a Medicare Advantage plan offers other extra benefits, such as preventive vision or dental care, consider whether these are important to your coverage needs. With these options available in Virginia, you can see why it’s a good idea to compare plans.

To start comparing Medicare Advantage plans in Virginia, you may enter your zip code above for a customized list of plans available in your area.

For more information about Medicare in Virginia, see the following articles:

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.