Medicare in West Virginia

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West Virginia Medicare Plans

Medicare beneficiaries have few great options in West Virginia and they should be completely aware of all the options in order to pick the best coverage for them. Permanent and legal American residents qualify for Medicare, who are 65 years or older. However, residents either qualify by age or due to certain medical conditions like Lou Gehrig’s disease or end-stage renal disease. People having these disease can qualify for Medicare at any age, provided they have legally and permanently resided in the U.S. for at least five continuous years. Nearly 25% of West Virginia residents are enrolled in Medicare, though 21% of beneficiaries in the state were eligible due to a disability. The state is known to have nations highest percentage of elderly residents along with the high rate of disability, thereby making sense that great number of West Virginia residents are enrolled in Medicare.

Medicare Options for West Virginia Residents

Original Medicare

Original Medicare is a health insurance program offered and regulated by the federal government. Original medicare comprises of Medicare Part A, hospital insurance, and Part B, medical insurance. Medicare Part A coverage includes inpatient services in hospitals and skilled nursing facilities, hospice care and limited home health services in some situations. Medicare Part B covers services like doctor visits, diabetic supplies, preventive services along with other medically necessary services and items.


To be eligible for Original Medicare, individual should be a U.S. citizen or a permanent legal resident for at least five continuous years. Individuals get automatically enrolled in Part A upon reaching the age 65 and becoming eligible for Social Security. If individuals are receiving benefits from the Social Security or the Railroad Retirement Board then they automatically get Original Medicare benefits starting the first day of the month when they turn 65. Besides these, all other people need to sign up for Medicare Part B upon first meeting the age requirement, as their enrollment is not automatic. Individuals who get disability benefits from Social Security for 24 months or certain disability benefits from the Railroad Retirement Board for 24 months get automatically enrolled in Original Medicare.


Medicare Part A coverage include hospital stays, hospice care along with some skilled nursing care, which insured might need after being hospitalized for a stroke, heart-attack, fractures or other medical problems that require rehabilitation in a nursing home or other facility. Enrollees of the Medicare Part A plan do not have to pay a premium, as they have already paid the system in the form of the Medicare Tax deductions on their paycheck. However, Medicare Part A is not completely free, as hefty deductibles are charged by Medicare every time the enrollees are admitted into the hospital. Medicare covers for virtually all hospital services for the first 60 days of the hospitalization, though there are some exceptions like it won’t pay for a private room in the hospital. U.S. citizen or permanent resident who have not worked for ten years to qualify for Medicare then such residents need to pay a premium for Medicare Part A.

Medicare Part B coverage include doctor visit, lab tests, diagnostic screenings, ambulance transportation, medical equipment along with other outpatient services. Medicare Part B involves more costs compared to Part A. Due to the hefty cost, individuals often delay signing up for Part B if they are having coverage through their employer or if they are covered under their spouse’s health plan. However, if the individuals don’t have other insurance and they don’t sign up for Part B when they first enroll in Medicare, then they are likely to pay a higher premium. Enrollees of Medicare Part B have to pay a monthly premium set by the federal government and they are subject to an annual deductible that are set every year. Besides these, the enrollees of this plan also have to pay 20% of the bills for doctor visits and other outpatient services.

Medicare Advantage Plans in West Virginia

Around 26% of the Medicare beneficiaries in West Virginia opt for the Medicare Advantage plans and they have the option to select from between 17 and 26 Medicare Advantage plans in 2020, depending on the county in which they live. Medicare beneficiaries have the option to enroll in Medicare Advantage plans instead of Original Medicare. Medicare Advantage plans combine Medicare Part A and Part B into one plan that usually also incorporate prescription drug coverage along with additional benefits like dental and vision coverage. Medicare Advantage plans are offered by the private insurance carriers. However, enrollees of the Medicare Advantage plan do not have access to doctors and hospitals all across the country and they are confined to their plan’s provider network. This is the prime reason why most of the Medicare beneficiaries prefer Original Medicare but with time the number of enrollees in Medicare Advantage plan is increasing.


Eligibility for Medicare Advantage plan is based on the eligibility for Original Medicare. It means that enrollees of Original Medicare are eligible for Medicare Advantage plan. In addition to this, individuals looking to enroll in a Medicare Advantage plan should live in the service area of the plan, which they are considering to choose.


Medicare Advantage plan generally cover everything including emergency and urgent care that are covered under Original Medicare except for the hospice care. Beside these, Medicare Advantage plans also include coverage for routine vision and dental care and wellness programs. Some of the Medicare Advantage plans also include prescription drug coverage.


Since Medicare Advantage plans are offered by private insurance companies, every company has the flexibility of setting their pricing. Therefore, right from premiums, deductibles, co-payments and coinsurance vary from plan to plan. Some of the Medicare Advantage plans’ premiums in West Virginia have premiums as low as $0. However, enrollees of the Medicare Advantage plans will need to continue to pay for their Medicare Part B premium along with the Medicare Advantage plan premium.

Types of Medicare Advantage Plans in West Virginia

Some of the best types of Medicare Advantage Plans available in West Virginia in 2020 include:

  • PPO
  • HMO
  • Private Fee-for-Service Plans
  • Special Needs Plans
  • Medicare Savings Account

Medicare Advantage Prescription Drug Plans

Medicare Advantage Prescription Drug plan is a type of Advantage plan that includes prescription drug coverage. This is a comprehensive Medicare plans having combined benefits of Medicare Part A, Part B and Part D, which means this plan combines health insurance benefits and prescription drug coverage into a comprehensive package. This plan is offered by private insurance companies having contract with Medicare and is considered as an alternative way to avail Medicare coverage.


Medicare Advantage Prescription Drug plans just like Medicare Advantage plans cover everything that are covered under Original Medicare (Part A and Part B), with the exception of hospice care, which is only covered by Part A of Original Medicare. Besides prescription drug coverage, this plan include some additional benefits like routine vision and dental check ups, hearing care, and access to wellness programs.

Plan Formulary

Each Medicare Advantage Prescription Drug plan has its own formulary, which is a list of covered prescription medications. This plan usually have to offer two or more medications in the most commonly prescribed categories and classes such as antibiotic, antidepressant, immunosuppressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics.etc. This ensures that individuals with different medical conditions get the prescription drugs as per their requirements. Medicare Advantage Prescription Drug plan can choose the specific drugs they wish to cover. Enrollees of the Medicare Advantage Prescription Drug plan are recommended to make sure that their current prescriptions are included in the plan’s formulary, since covered medications and costs vary from plan to plan.

Medicare Prescription Drug Plans or Part D Plan

People having chronic illness need to take regular prescription drugs in order to maintain their health. Since, Original Medicare coverage doesn’t include prescription drugs that are taken at home, Medicare beneficiaries opt for Medicare Part D or prescription drug plan offered by private insurance companies. Medicare Part plan helps pay for a variety of prescription drugs such as outpatient prescription drugs, vaccines, biologicals, some medical supplies not covered by Part A or Part B.


In order to be eligible for Medicare Part D plans individuals should be enrolled in Medicare Part A and Part B plan and they should live in the service area of the plan.

Plan Formulary

Each Medicare Prescription Drug Plan has its own list of covered prescription drugs called a formulary. Medicare Part D plan place covered medications into different tiers, and the drugs on higher tiers have higher co-payment and co-insurance costs compared to medications on lower tiers. The Part D plan’s formulary may change at any time of the year, though enrollees are notified by their Medicare plan if needed. Medicare prescription drug plans cover at least two drugs in the six protected categories such as Immunosuppresants, Antiretrovirals, Antineoplastic, Antidepressants, Antipsychotics, Anticonvulsants and Antiretroviral (HIV) drugs.

Enrollment Period

Medicare beneficiaries of Virginia can enroll in prescription drug plan upon first becoming eligible for the plan, which is the Initial Enrollment Period for Part D. The seven month duration is the Initial Enrollment Period that begin three month before the beneficiaries become eligible for Medicare, include the month and continues three months after it. Medicare beneficiaries failing to enroll during this period can enroll for Part D coverage during the Annual Election Period that start from October 15 and ends on December 7 every year.

Medicare Supplement or Medigap Plans in West Virginia

Medicare beneficiaries in West Virginia have an option to enroll in Medicare Supplement plans that help them pay for the out-of-pocket expenses that are included with Original Medicare. Thus, medicare Supplement plans are usually opted by the individuals enrolled in Original Medicare. Generally there are ten standardized Medigap plans available in most of the states but one benefit included in some Supplement plans has changed in West Virginia in 2020. Medigap Plan C and Plan F that offer coverage for Part B deductible have phased out in West Virginia from January 2020. Therefore, individuals who have become eligible for Medicare on or after January 1,2020 will not be able to enroll in Plan C or Plan F. However, those who already have one of these plans will be able to keep their coverage.


Medicare Supplement plans offers coverage for some of the out-of-pocket costs like deductibles, co-insurance and co-payment associated with Original Medicare. Some of the Medicare Supplement plans also help cover emergency medical costs at the time when insured are traveling outside the United States and some Medigap plans also cover co-payments for hospice care.


Individuals can enroll in Medicare Supplement plans during their Medigap Open Enrollment Period, as this is the best time to enroll in this plan. Medigap Open Enrollment Period is the six-month, which start from the month in which individuals attain age of 65 or over and they enroll in Medicare Part B. This is the best time to enroll because they can select the Medigap plan of their choice and the plan must accept them even if they have pre-existing medical conditions and the health insurance company cannot even charge them more for having health issues. Individuals who enroll after the Medigap OEP are subjected to medical underwriting. The health insurance company offering the plan can review the medical history of the person applying for the plan and decide whether to accept their application or not and may even charge a higher premium rate if they have any health issues.

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