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Medicare in Virginia

October 6, 2016

As a Medicare beneficiary in Virginia, you might have several options when it comes to how you want to receive your coverage. You can get your Medicare coverage through Original Medicare, Part A and Part B, or you may be able to get your Medicare benefits through a Medicare Advantage plan. Read below about the various Medicare plan options.

Original Medicare for Virginia beneficiaries

Original Medicare is the traditional, fee-for-service program that provides health coverage for adults over 65 and those who qualify due to disability. Beneficiaries with Original Medicare can see any provider that accepts Medicare assignment (a payment agreement with Medicare). Because Original Medicare is administered by the federal government, it works the same in all 50 states, including Virginia.

Most U.S. citizens and permanent legal residents of at least five years in a row qualify for Medicare when they turn 65. However, you can get Medicare before age 65 if you’ve received Social Security or Railroad Retirement Board disability benefits for at least two years (24 months) in a row. You might also qualify for Medicare before age 65 if you have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease).

Original Medicare consists of two parts, Part A and Part B. Medicare Part A is hospital insurance and generally covers inpatient hospital and skilled nursing facility care, limited home health care, and hospice care. Medicare Part B is medical insurance and may cover outpatient services, including doctor visits, preventive screenings, lab tests, durable medical equipment, and ambulance transportation.

Original Medicare typically doesn’t cover long-term care, routine vision and dental care, or personal care (for example, help with getting dressed and bathing). It also doesn’t include most prescription drug coverage. Medicare Part A covers prescription medications given to you as part of your inpatient treatment in a hospital. Medicare Part B may cover medications administered to you as an outpatient in an office setting, but generally doesn’t cover most prescriptions that you take at home. You can sign up for a stand-alone Medicare Part D Prescription Drug Plan.

In Virginia, as in the rest of the country, most beneficiaries get Medicare Part A without paying a monthly premium if they have worked at least 10 years and paid Medicare taxes. If you don’t qualify for premium-free Part A, you can still enroll in Part A and pay a monthly premium. Part B always comes with a monthly premium.

If you’re not automatically enrolled, you can enroll in Part A and/or Part B during the following enrollment periods:

  • Initial Enrollment Period(IEP): This is the seven-month period that begins three months before the month you turn 65, includes the month you turn 65, and ends three months after that month. If you qualify for Medicare due to disability, your IEP usually begins three months before your 24th month of receiving disability benefits, and ends three months after that month, for a total of seven months. General Enrollment Period (GEP): This annual enrollment period occurs from January 1 to March 31 every year. You may have to pay a late-enrollment penalty for Part A and/or Part B if you didn’t sign up when you were first eligible.
  • Special Enrollment Period(SEP): If you have health coverage through an employer, you may choose to delay enrolling in Part B. You can sign up through an SEP when your group coverage or employment ends, whichever comes first. You won’t have to pay a late-enrollment penalty if you qualify for an SEP. There may be other situations that qualify you for an SEP.

Virginia residents can enroll in Original Medicare through Social Security (or the Railroad Retirement Board, if applicable). There are several ways to apply:

  • Online at the Social Security website. If you aren’t ready or eligible to retire, you can apply for Medicare only.
  • By phone at 1-800-772-1213. If you are a TTY user, call 1-800-325-0778. Social Security representatives can be reached Monday through Friday, from 7AM to 7PM. If you worked for a railroad, you can apply through the Railroad Retirement Board (RRB) at 1-877-772-5772 (TTY users call 1-312-751-4701). RRB representatives are available Monday through Friday, 9AM to 3:30PM.
  • In person at a Social Security office. To find a list of offices in Virginia, use the Social Security Office Locator.

Medicare plan options in Virginia

You may have other Medicare coverage options in Virginia, beyond Original Medicare (Part A and Part B). These options are summarized below.

Medicare Part C

The Medicare Advantage (Medicare Part C) program offers you a way to get your Original Medicare (Part A and Part B) benefits through private, Medicare-approved insurance companies. By law, Medicare Advantage plans must offer at least the same level of coverage as Original Medicare (except for hospice care, which Part A covers), but may offer additional benefits. For example, some Medicare Advantage plans offer routine vision or dental benefits, which aren’t covered under Original Medicare. Many of these plans limit the providers you can use to a specific network or charge higher costs if you go out of this network.

Because Medicare Advantage plans are available through private insurers that contract with Medicare, plan costs may vary. Some Medicare Advantage plans offer premiums as low as $0. Regardless of whether your Medicare Advantage plan includes a premium, you must continue to pay the Part B premium.

Most Medicare Advantage plans include prescription drug coverage. With a Medicare Advantage Prescription Drug plan, you get your health and drug benefits all in one plan.

Medicare Part D

The Medicare Part D program provides optional prescription drug coverage. Beneficiaries with Original Medicare can enroll in a stand-alone Medicare Part D Prescription Drug Plan. These stand-alone plans come with separate plan premiums and cost-sharing expenses, on top of Original Medicare costs. Beneficiaries with Medicare Advantage Prescription Drug plans get this coverage through their health plans.

 Medicare Supplement (Medigap)

If you decide to stay with Original Medicare, another option you may have in Virginia, as in other states, is to sign up for a Medicare Supplement (Medigap) plan to help pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.

Virginia resources for Medicare beneficiaries

Medicare beneficiaries in Virginia may refer to the following list of resources from Medicare.gov for additional information:

  • Virginia Department for Aging and Rehabilitative Services: Find information on state programs for older adults, including the Virginia Insurance Counseling and Assistance Program (VICAP). If you have a question about health insurance or Medicare, contact a VICAP counselorin your area for free counseling.
  • Virginia Easy Access: Find resources for seniors, disabled individuals, and caregivers. Easy Access provides information on getting help with health costs, housing, community programs, and veterans’ services. Call toll-free 1-800-552-3402 (voice or TTY), Monday through Friday from 8:30AM to 5PM.
  • Virginia Medicaid: Find information on health coverage for low-income individuals and families, including disabled adults, children, and Medicare beneficiaries.

Learn more about how Medicare plans work in Virginia including:

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