In Virginia around 1.5 million residents are enrolled in Medicare as of late 2019. Around 15% of these residents are under 65 years of age and qualify due to disability. Beneficiaries in Virginia have several options in Medicare to receive coverage as per their needs. Beneficiaries can receive Medicare coverage either through Original Medicare which is Medicare Part A and Part B or can also avail Medicare benefits through Medicare Advantage plan. Medicare is a social health insurance program, which is managed, administered and partially funded by the federal government. This healthcare plan was initiated in the year 1966 and was conceptualized to ensure guaranteed health insurance benefits to seniors residents of the U.S. who are 65 years of age or older. This plan was specifically designed for seniors because after retirement seniors didn’t have employer-sponsored coverage and health insurance for the elderly was highly expensive. Thus, to provide them with medical benefits Medicare plan was launched by the government.
Some of the Medicare plan options available in Virginia include:
Original Medicare is a federal government administered plan that works same in all the states of America including Virginia. Even the benefits and eligibility for Original Medicare are same throughout the Unites States. This plan is offered to the U.S. citizens and and to the permanent legal residents living for at least five continuous years. Original Medicare comprises of Medicare Part A, Hospital Insurance and Part B, Medical Insurance.
People qualify for this plan either through age or disability. People of age 65 or older become eligible for Original Medicare and some people under 65 years of age also qualify for Original Medicare through certain disabilities or if they have end-stage renal disease or amyotrophic lateral sclerosis. People who qualify by age are automatically enrolled in Original Medicare. Most of the Medicare beneficiaries get automatically enrolled into Original Medicare as soon as they become eligible and are already receiving retirement benefits or have been receiving disability benefits for at least two years.
Medicare Part A or hospital insurance coverage include inpatient hospital and skilled nursing facility care, some home health care and hospice care. It also covers prescription medications that are given to insured as a part of their inpatient treatment in a hospital. Complimenting Part A coverage Medicare Part B or medical insurance coverage include outpatient services such as doctor visits, preventive screenings, lab tests, durable medical equipment along with ambulance transportation. It also includes physical therapy, some home health services and may also cover medications that are administered to the insured as an outpatient in an office setting. However the medications taken at home are not covered. Original Medicare also doesn’t include costs of routine dental or vision care, hearing, long-term care or health coverage received outside the country.
Medicare beneficiaries may get Medicare Part A coverage without paying any premium if they have worked for at least 10 years and have paid their Medicare taxes. Other than this they may owe a premium for their Part A coverage. However, Medicare beneficiaries have to pay a premium for Part B coverage, in addition to deductibles, co-payments, and coinsurance costs.
Medicare Advantage or Part C Plan
Medicare Part C or Advantage plan is another way of getting Original Medicare benefits along with some additional benefits like routine vision, dental benefits, wellness programs, and prescription drug benefits. Medicare Part C plans are offered through private, Medicare approved insurance companies and as per law these plans should offer at least the same level of coverage as Original Medicare except for the hospice care. Medicare Advantage plans are available in all 95 counties and 38 independent cities of Virginia, though plan availability ranges from one county to another. In 2019 around 20 percent of Medicare beneficiaries in Virginia were enrolled in a Medicare Advantage plan.
Medicare beneficiaries must have medicare Part A and Pat B in order to be eligible for Medicare Part C and able to enroll in Medicare Advantage plan. Beneficiaries in order to qualify for this plan should also live in the plan’s service area. Enrollees of Medicare Advantage plan need to keep paying their Medicare Part B premium along with the premium amount of their Medicare Advantage plan.
Medicare Advantage plans limit insured out-of-pocket costs like co-payments, deductibles and coinsurance for the covered services. It means that once insured have spent up to the annual cap then their Medicare Part C plan pays 100% for covered services of Original medicare for the rest of the benefit year. Second advantage is that besides Original Medicare coverage, Part C also includes additional coverage.
Average premium for a Medicare Advantage plan in Virginia in 2019 was $43 per month, whereas out-of-pocket spending limits like deductibles, premiums and other costs generally vary from one area to another.
Medicare beneficiaries can enroll in Medicare Part C plan during their Medicare Initial Enrollment Period, which begins three month prior to the month of their birth and extends three months after the birth month. Beneficiaries must enroll in this plan when they first become eligible to avoid a late-enrollment penalty. Individuals who fail to sign up during the Initial enrollment period can still enroll during the General Enrollment Period though they may have to pay the late-enrollment penalty.
Types of Medicare Advantage Plans
Medicare beneficiaries in Virginia are offered with different types of Medicare Advantage plans in their area and they can select the best Advantage plan that best suits their individual health needs. Some of the advantage plans available are:
- Private Fee-for-Service Plan
- Medicare Special Needs Plan
- Medical Savings Account
Medicare Advantage Prescription Drug Plan
Some of the Medicare Advantage plans comes with the combine benefits of prescription drug coverage as well as health insurance. A Medicare Advantage Prescription Drug Plan is a Medicare Advantage plan that includes prescription drug coverage. These plans are offered by private insurance companies having contract with Medicare to provide Part A, Part B and Part D benefits.
Medicare Advantage Prescription Drug plans just like any other Medicare Part C plans are required to cover everything that are covered under Original Medicare except the hospice care. In addition to prescription drug coverage, most of these plans include additional benefits like dental, routine vision hearing, and access to wellness programs.
Every Medicare Advantage Prescription Drug plan covers a documented list of prescription medications, which is called plan’s formulary. This plan must cover two or more medications within each category such as two drugs from antidepressant, and two drugs from antibiotic categories. Therefore, before enrolling in a Medicare Advantage Prescription Drug plan, beneficiaries are recommended to make sure that all their prescriptions are included in the plan’s formulary, since medications covered vary from one plan to other.
Medicare Prescription or Part D Plan
Medicare Part D plans are used in conjunction with Original Medicare to exclusively provide coverage for prescription drugs. These plans are sold by private insurance companies, thus each Part D plan will have its own premiums, deductibles, co-payment, coinsurance and drug formulary. Medicare beneficiaries, who wish to have prescription drug coverage, can enroll in Medicare Part D plans, also known as prescription drug plans that help cover the cost of prescription medications but do not include medical coverage. Since Original Medicare plan do not cover the cost of prescription drugs therefore people enrolled in Original Medicare choose Medicare Part D plan so that they do not have to pay all their prescription drug costs out of pocket.
Individuals having Original Medicare or a Medicare Advantage plan are eligible to enroll in a Medicare Part D plan. Besides, the enrollees should live in the service area of the plan that provides prescription drug coverage. Individuals meeting these two criteria are eligible to enroll for the Medicare Part D plan.
Beneficiaries in Virginia can enroll in Medicare Part D plan when they first become eligible for the Medicare plan which is the Initial Enrollment Period for Part D. Initial Enrollment Period is the seven month duration that start three months prior the beneficiaries become eligible for Medicare, include the month in which beneficiary become eligible and continues for three months after it. If the individuals do not enroll during their Initial Enrollment Period, then they can enroll for Part D coverage during the Annual Election Period also called Open Enrollment Period for Medicare Part D plan, which occurs from October 15 to December 7 every year.
Medicare Part D plans comprise of a formulary, which is simply a list of covered prescription drugs and vaccines. The Medicare Part D plan covers at least two drugs from each category like Antidepressants, Antipsychotics, Immunosuppressants, Anticonvulsants, Antiiretrovirals and Antineoplastics. Medicare Part D plans also cover all commercially available vaccines, if the vaccine is reasonable and essential for preventing illness.
Medicare Supplement or Medigap Plans
Medicare beneficiaries who have health issues that require ongoing treatment may have to pay huge bills for out-of-pocket expenses. Since, out-of-pocket expenses like co-payments and deductibles are not covered under Original Medicare, beneficiaries look out for some other options like Medicare Supplement insurance plans that cover some of the costs not included under Original Medicare. Medicare Supplement or Medigap Plans help beneficiaries with co-payments, coinsurance, deductibles and other out-of-pocket expenses and these plans also provide coverage for the first three pints of blood along with emergency medical services received outside the United States.
Types of Medigap Plan
The federal government in Virginia has authorized ten standardized Medicare Supplement insurance plans, where each plan is labeled with a letter. The ten standardized Medigap plans are A, B, C, D, F, G, K,L, M, and N. Every same letter plan offers the same set of standard benefits irrespective of the insurance company offering this plan and the area where the plan is available.
Medicare Supplement insurance plans work alongside Original Medicare coverage and beneficiaries need to remain enrolled in Medicare Part A and Part B for their hospital and medical coverage. Residents of Virginia like any other states become eligible for Medicare Supplement insurance plan once they are enrolled in Medicare Part A and Part B. Medigap plans are also available to beneficiaries who are under 65 and qualify because of disability or due to certain medical conditions.
Best time to enroll in Medicare Supplement plans for beneficiaries in Virginia is during their six-month Medigap Open Enrollment Period. This period starts automatically once the beneficiaries attain the age of 65 or older and they are enrolled in Medicare Part B. Enrollees during this period have guaranteed-issue rights, which means that they can’t be turned down for Medigap plan due to any pre-existing conditions or health problems. Besides, health insurance companies cannot even charge higher premiums from enrollees having health issues or require medical underwriting. After this period beneficiaries do not have guaranteed-issue rights and they may even find difficulty enrolling in Medigap coverage, especially if they have health problems.