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Medicare Advantage Plans in West Virginia

October 6, 2016

As a Medicare beneficiary in West Virginia, you may have the option of Medicare Advantage (Medicare Part C), an alternative way to receive your Original Medicare Part A and Part B coverage.  Medicare Advantage plans are offered by Medicare-approved private insurance companies in defined service areas.  The following information provides a general overview of Medicare Advantage plans to assist you in evaluating the plans available where you live.

How Medicare Advantage works in West Virginia

Medicare Advantage plans in West Virginia are required by the United States government to offer the same level of coverage as Original Medicare, Part A (hospital insurance) and Part B (medical insurance), with the exception of hospice care which remains covered by Part A. Medicare Advantage plans in West Virginia may also offer extra benefits, like routine vision services and prescription drug coverage.

If you want to enroll in a Medicare Advantage plan in West Virginia, you’ll need to be aware of the eligibility requirements and enrollment periods:

  1. You must have Medicare Part A and Part B;
  2. You must live in the Medicare Advantage plan’s service area; and
  3. In most cases, you cannot enroll in a Medicare Advantage plan if you have end-stage renal disease (kidney failure), the treatment for which is covered through Original Medicare.

You may enroll in a Medicare Advantage plan during one of several periods.

You are first eligible to enroll during your Initial Coverage Election Period (ICEP). The Initial Coverage Election Period is usually the same as the Initial Enrollment Period (the period of time during which you first become eligible for Medicare Part A and Part B).  The Initial Coverage Election Period is the seven-month period that starts three months before the month you turn 65. The ICEP then runs through your birth month and for the three months after.

Each year after your first year of Medicare coverage you can enroll in a Medicare Advantage plan, or change to a different Medicare Advantage plan, during the Medicare Advantage and Prescription Drug Annual Election Period, also called the Fall Open Enrollment season, which runs from October 15 to December 7 of each year. The new coverage goes into effect on January 1 of the following year.

In some cases, you may be able to enroll in or switch Medicare Advantage plans during a Special Election Period.  A Special Election Period occurs when a change in your life or in your health plan coverage occurs. Some examples of these types of changes include, but are not limited to, your move to a new residence that is outside the service area of your Medicare Advantage plan, or moving into or out of a nursing home.

If you decide to disenroll from your Medicare Advantage plan and switch back to Original Medicare Part A and Part B, you can do this during the annual Medicare Advantage Disenrollment Period, which runs from January 1 to February 14 in West Virginia and the rest of the United States. You can also add a stand-alone Medicare Part D plan for prescription coverage during that time.

Types of Medicare Advantage plans in West Virginia

If you’re interested in signing up with a Medicare Advantage plan, you may want to familiarize yourself with the various types of Medicare Advantage plans that may be available where you live in West Virginia before making your selection. Here’s a look at the various types of Medicare Advantage plans that may be available to you in West Virginia and a brief description of how you access covered health-care services and receive benefits under each plan type.

A Health Maintenance Organization (HMO) plan is a type of Medicare Advantage plan that requires you to use doctors, health-care providers, and hospitals included in your plan’s network to receive benefits for covered services unless you needed emergency care or received pre-approval from the plan to receive treatment outside the network. An HMO Point-of-Service plan, on the other hand, is a more flexible option, allowing you to go out of network for some health services and receive benefits, but generally you pay higher out-of-pocket costs for these covered services than you would pay if you received the services from providers in the plan’s network.

If you prefer a Medicare Advantage plan with more flexibility, you may be able to choose a Preferred Provider Organization (PPO)* plan. In a Medicare Advantage PPO plan, you may choose doctors, health-care providers, and hospitals in or outside of your plan’s network.  Your out-of-pocket costs are typically lower when you receive covered services from providers in the plan’s network.

You may be able to select a Private Fee-for-Service (PFFS) plan, which reserves the right to decide how much it will pay for your doctor, health-care provider, and hospital visits, and also determines your share of each expense. Any provider you use must agree to accept the plan’s terms and conditions on a case-by-case scenario and agree to treat you. The PFFS plan may include a partial or full network of participating providers.  Keep in mind you should check with the provider to make sure they accept the plan before getting any services.

Another option may be Medicare Advantage Medical Savings Account (MSA) plan, which combines a high deductible with a savings account that you can use to pay for your health care expenses until you have reached your deductible.

If you have specific health conditions, you may want to consider a Medicare Advantage Special Needs Plan (SNP). There are Medicare SNPs for people with certain chronic diseases such as congestive heart failure and HIV/AIDS, those living in nursing homes or other institutions, and people who qualify for both Medicare and Medicaid. A Medicare SNP can offer coverage tailored to an individual’s personal health-care needs.

And if you’re seeking both health and prescription drug coverage, you may want to choose a Medicare Advantage Prescription Drug (MAPD) plan, which combines into a single plan health and prescription drug coverage. If one is not available where you live, you may still be able to enroll in a stand-alone Medicare Part D Prescription Drug Plan to complement your Medicare Advantage plan.

Remember that even if you enroll in a Medicare Advantage plan in West Virginia, you have to continue paying your Medicare Part A (if you are not entitled to premium-free coverage) and Medicare Part B premiums in order to keep your health coverage.

Comparing Medicare Advantage plans available in West Virginia

As a Medicare beneficiary living in West Virginia, you may find it useful to compare all the Medicare Advantage plans available in your area.

The availability and cost of Medicare Advantage plans generally varies depending on where you live and which plan you enroll in. You may find that some Medicare Advantage plans in West Virginia offer premiums as low as $0, but no matter what premium the plan charges, you must continue paying your Medicare Part B premium.

Some Medicare Advantage plans may offer additional benefits beyond what is included in Original Medicare, Part A and Part B, so you might want to consider what benefits are important to you, plus whether or not you want prescription drug coverage with your Medicare Advantage plan. With all these options available in West Virginia, you can see why it may be wise to compare plans and look for one suited to your personal health and budget needs.

The Medicare Advantage plans available where you live may include networks of participating providers in West Virginia. 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 in it.

To start comparing Medicare Advantage plans in West Virginia, enter your zip code above for a customized list of plans available in your area. You can also enter your prescription drug needs to further customize your search and cost estimates.

Access the following resources to get more information about Medicare in West Virginia:

* 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.