Medicare health insurance is available in West Virginia when you turn 65 years old. It’s also available for some people who are under age 65 and meet certain eligibility criteria. When you’re ready to enroll in Medicare, it’s important to understand the different plans available.
There are a few different parts that make up the Medicare program. These include:
- original Medicare: Part A and Part B
- Medicare Advantage: Part C
- prescription drug plans: Part D
- supplemental insurance: Medigap
Next, we’ll go over the services that each part covers.
Part A (hospital insurance) covers:
- treatments and care in a hospital
- hospice care
- limited home health care
- limited stays in a skilled nursing facility
Part B (outpatient medical insurance) covers:
- doctors’ visits
- preventive care (annual wellness visits, screenings)
- counseling services
- lab tests and imaging
- some durable medical equipment
With original Medicare, you can choose any provider or facility that is enrolled in Medicare.
Part A costs
There is no monthly premium for Part A if you or a spouse worked for 10 years and paid Medicare taxes. If you don’t meet this requirement, you can also purchase coverage. Your costs will also include a deductible for each benefit period and additional daily coinsurance costs for stays over 60 days.
Fees for original Medicare are set by the Centers for Medicare & Medicaid Services (CMS).
Part B costs
If you have Medicare Part B, you may expect to pay monthly premiums, an annual deductible, coinsurance on covered items and services after you meet the deductible. Part B has no out-of-pocket maximum.
Medicare Advantage, or Part C, bundles Part A and Part B coverage into a single plan. Many Medicare Advantage plans include Part D (prescription drug) coverage.
Many Medicare Advantage plans have an out-of-pocket maximum for the year that is set by the provider. Most plans require that you visit providers within the plan’s network.
Prescription drug coverage
Part D plans are optional and can be purchased through private insurance carriers to cover prescription drug costs. Costs vary by plan, and if you don’t sign up for Part D when you’re eligible for Medicare, you will pay a lifetime late enrollment penalty.
Medicare supplemental insurance (also known as Medigap) is available through private companies to help pay out-of-pocket costs under original Medicare. Costs vary depending on which plan you choose.
You can not purchase a Medigap plan if you have Medicare Advantage.
There are many different carriers that offer Medicare Advantage plans in West Virginia, including:
- Lasso Healthcare
- The Health Plan
Keep in mind, not every carrier offers plans throughout all areas of West Virginia. Your choices will vary depending on the county where you live.
In West Virginia, Medicare Advantage plans fall into four categories, which we’ll describe in detail below.
Health Maintenance Organization (HMO)
- Your primary care physician (PCP) from the HMO network coordinates your care.
- Out-of-network care is usually not covered, except in emergencies, such as urgent care or out-of-network dialysis.
- Most HMO plans require a referral from your PCP to see a specialist.
- You must follow plan rules to have certain items and services covered.
Preferred Provider Organization (PPO)
- Most care from the plan’s network of doctors and facilities is covered.
- Receiving care from a doctor or hospital outside the network may cost more or may not be covered.
- You normally don’t need a referral from your PCP to see a specialist.
- Some PPO plans in West Virginia are regional PPOs, which may offer care in surrounding states.
Private Fee-For-Service (PFFS)
- PFFS plans negotiate directly with providers and facilities. The plan determines how much you will owe for your care.
- There are no networks – you can choose any provider or facility that accepts your plan.
- Not everyone accepts PFFS plans, so check before you receive care.
Special Needs Plans (SNPs)
SNPs are available if you need a higher level of coordinated care and meet certain criteria:
Medicare plans in West Virginia are available when you turn age 65 if you are one of the following:
- citizen of the United States, or
- legal resident for 5 or more years
You may be eligible before age 65 if you:
- have received Social Security Disability or Railroad Retirement benefits for 24 months
- have amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)
- have received a kidney transplant or have ESRD
Not sure if you qualify? Use Medicare’s online eligibility tool to check.
There are certain times that you can enroll in Medicare and Medicare Advantage plans. We’ll discuss these different enrollment periods next.
Initial enrollment period (IEP)
Your IEP starts three months before your 65th birthday, extends through your birthday month, and continues three months after you turn 65 years old. If you wait until your birthday month or later, the start date for your coverage will be later.
Annual enrollment periods
- Medicare open enrollment (October 15 to December 7) is when you can make changes to your original Medicare coverage or switch between Medicare Advantage and original Medicare plans. You can also sign up for Part D.
- Medicare Advantage open enrollment (January 1 to March 31) is when you can make changes to your plan if you are already enrolled in Medicare Advantage. You can also drop your Medicare Advantage plan and switch back to original Medicare (and sign up for Part D) during this time.
- General enrollment period (January 1 to March 31) is when you can sign up for Part A, Part B, or Part D if you didn’t sign up during your IEP. You may have to pay a late enrollment penalty if you missed your IEP.
Special enrollment periods
Special enrollment periods allow you to enroll in Medicare outside of the usual enrollment periods if you lose coverage for a qualifying reason. Some examples of qualifying events may be if you lose an employer-sponsored plan when you retire after age 65 or you move out of your existing plan’s coverage area. You may have up to 8 months to enroll in coverage after the qualifying event.
The many choices for Medicare coverage can be overwhelming. Before you sign up it’s important to think about:
- plan costs and what each one covers
- whether the plan’s network includes your preferred doctors and hospitals
- if the plan is highly rated for quality and patient satisfaction using the CMS star ratings system (for Part C and Part D plans)
These resources can help you get more information about Medicare in West Viriginia:
West Virginia Bureau of Senior Services (877-987-4463)
- information on Medicare, Medicare supplement, and other resources
State Health Insurance Assistance Program (SHIP) (877) 987-3646)
- free counseling for Medicare questions
WV Aging & Disability Resource Network (877-987-3646)
- local offices to connect seniors with services
WV Department of Health & Human Services (800-642-8589)
- provides a wide range of vital services to West Virginia residents
- helps connect you with programs to help pay for Medicare
Visit the Medicare website to speak to someone who is trained to help you navigate Medicare.
When you’re ready to sign up for Medicare in West Virginia, follow these steps:
- decide between original Medicare or a Medicare Advantage plan
- contact SHIP with any questions about plans, coverage, and enrollment
- identify your enrollment period
This article was updated on November 20, 2020, to reflect 2021 Medicare information.
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