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Medicare in Virginia

After two unsuccessful previous attempts, Virginia enacted legislation in 2020 to require Medigap insurers to offer at least one plan to disabled beneficiaries under age 65

Photo credit: Eli Christman | Flickr

Key takeaways

Medicare enrollment in Virginia

1,547,061 residents were covered by Medicare in Virginia as of September 2020, amounting to about 18 percent of the state’s population with Medicare benefits, versus 19 percent of the total US population.
Most Americans become eligible for Medicare enrollment when they turn 65. But nationwide, there are nearly 10 million people under the age of 65 who have Medicare coverage, accounting for about 15 percent of all Medicare beneficiaries. This is because Medicare eligibility is also triggered once a person has been receiving disability benefits for 24 months, or has kidney failure or ALS. As of 2017, 14 percent of Medicare eligibility in Virginia was for beneficiaries under age 65.

In Alabama, Arkansas, Kentucky, and Mississippi, 22 percent of Medicare beneficiaries are disabled and under age 65. At the other end of the spectrum, just 9 percent of Hawaii’s Medicare beneficiaries are eligible due to disability.

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Medicare Advantage in Virginia

Medicare beneficiaries can choose to get their healthcare coverage through private Medicare Advantage plans, or directly from the federal government via Original Medicare (which includes hospital coverage via Part A and outpatient/medical coverage via Part B).

Medicare Advantage plans include the same covered benefits of Medicare Part A and Part B, and most plans include Part D prescription drug coverage as well as additional benefits such as gym memberships, nurse hotlines, and dental and vision coverage. But provider networks are smaller with Medicare Advantage plans, and although monthly premiums tend to be lower than they’d be with Original Medicare plus Medicare Part D plus a Medigap plan, out-of-pocket costs will tend to be higher if the person has just a Medicare Advantage plan. There are pros and cons to either option, and the right solution depends on each enrollee’s circumstances and preferences.

Medicare Advantage plans are offered by private insurers, so plan availability varies from one area to another. All 95 counties and 38 independent cities in Virginia have Medicare Advantage plans available for 2021, but plan availability ranges from 15 plans in Culpepper County to 46 plans in Loudoun County.

As of 2017, just 17 percent of Virginia Medicare beneficiaries were enrolled in Medicare Advantage plans; nationwide, the average was 33 percent at that point. As of September 2020, total private Medicare enrollment in Virginia (not counting people with private supplemental coverage like Part D and Medigap) stood at 394,708 people, or a little more than a quarter of the state’s Medicare population. Most of those enrollees had Medicare Advantage plans, but there are also some people in Virginia who have Medicare Cost plans, which are a type of private Medicare coverage. The other 1,152,353 Medicare beneficiaries in Virginia had Original Medicare as of 2020.

The popularity of Medicare Advantage enrollment varies from one state to another. In Minnesota, nearly half of the state’s Medicare population is enrolled in Advantage plans, whereas only 1 percent of Alaska Medicare beneficiaries have Advantage plans (and those are via employer-sponsored coverage, as there are no Medicare Advantage plans available for individuals to purchase in Alaska).

The annual Medicare coverage enrollment window (annual election period) runs from October 15 to December 7 each year, and allows Medicare beneficiaries the chance to switch between Medicare Advantage enrollment and Original Medicare, and add, drop, or switch to a different Medicare Part D prescription plan. People who are already enrolled in Medicare Advantage also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.

Medigap in Virginia

Original Medicare does not limit out-of-pocket healthcare costs (coinsurance and deductibles), so most enrollees maintain some form of supplemental coverage. Nationwide, more than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans, or MedSupp) will pay some or all of the out-of-pocket costs they would otherwise have to pay if they had Original Medicare on its own.

429,851 beneficiaries of Medicare in Virginia had Medigap coverage as of 2018, according to an AHIP analysis. That’s about a third of the state’s Original Medicare beneficiaries (Medigap coverage cannot be used with Medicare Advantage plans).

Medigap plans are sold by private insurers, but they’re standardized under federal rules and regulated by state laws and insurance commissioners. There are 37 insurers that offer Medigap plans in Virginia as of 2020.

Virginia allows Medigap insurers to pick their own rating approach, so nearly all of the plans for sale in the state use attained-age rating, which means that an enrollee’s premiums will increase as they get older, regardless of how old they were when they first enrolled (the other two approaches to Medigap premiums are issue-age rating, in which premiums are based on the age the person was when they enrolled, and community rating, which means premiums don’t vary base on age; some states require one of these approaches, but Virginia does not).

Medigap in Virginia if you’re under 65

Federal rules require Medigap insurers to offer plans on a guaranteed-issue basis during an enrollee’s open enrollment period, which begins when the person is at least 65 years old and enrolled in Medicare Part B (and Part A; you have to be enrolled in both to obtain Medigap). But federal rules do not guarantee access to Medigap plans for people under age 65.

In Virginia, 14 percent of Medicare beneficiaries (more than 200,000 people) were under age 65 as of 2017. The majority of the states have enacted rules to ensure access to Medigap plans for disabled enrollees under age 65; Virginia joined them with legislation that was signed into law in 2020 and will take effect in 2021.

Under the legislation (SB250) that Virginia enacted, Medigap insurers in the state will have to offer at least one plan on a guaranteed-issue basis to Virginia residents who become eligible for Medicare prior to the age of 65 due to a disability (insurers are likely to select Plan A). And people who were already enrolled in Medicare prior to 2021 will have a one-time six-month open enrollment period, starting January 1, 2021, during which they can sign up for a Medigap plan under the new rules.

But eligibility under SB250 is based on disability as defined in U.S. Code § 426(b), which does not include people with kidney failure — their eligibility is defined in 42 U.S. Code § 426–1 instead. There are a few other states that require Medigap plans to be available to people under age 65 but specifically exclude people with end-stage renal disease. Notably, however, this is a population that is very much in need of Medigap coverage, as their 20 percent share of the cost of dialysis under Medicare Part B can become unaffordable very quickly. As of 2021, however, people with kidney failure can join Medicare Advantage plans, which do have caps on in-network out-of-pocket healthcare costs; prior to 2021, these beneficiaries could not join Medicare Advantage plans unless there was a special needs plan available in their area that matched their medical conditions.

Similar bills ( SB1351 in 2017 and SB161 in 2018) were introduced in Virginia in prior years but didn’t advance out of committee, but the legislation eventually succeeded in 2020.

In 2017, Virginia’s Joint Commission on Health Care conducted a study, led by Senior Health Policy Analyst, Stephen Weiss, to gather data and provide lawmakers with information related to the possibility of requiring Medigap insurers in the state to offer coverage to beneficiaries under age 65.

The JCHC study included surveying the state’s Medigap insurers; none of them indicated that they would exit the market if required to offer coverage to disabled beneficiaries under age 65, but more than half noted that if the state were to mandate coverage offerings for people under 65, the insurers would prefer that it be only Plan A, instead of all plan options (several states have taken this approach). And they also indicated that premiums would need to be between one and a half and five times higher for enrollees under the age of 65. Ultimately, however, JCHC voted to take no action on this issue at that point, and it wasn’t until 2020 that legislation was enacted to address it.

Through 2020, disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare, as long as they don’t have kidney failure (as noted above, that will change in 2021). But Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $7,550 per year for in-network care, plus the out-of-pocket cost of prescription drugs.

As of 2020 (ie, before SB250 takes effect), the Virginia State Corporation Commission’s data indicate that CareFirst Blue Cross Blue Shield is the only insurer in Virginia that offers Medigap coverage to people under age 65, and they only offer Plan A (for people who are at least 65, CareFirst offers Plans A, B, F, High-deductible F, G, High-deductible G, L, M, and N). CareFirst is also only available in Northern Virginia; people in the rest of the state do not have access to Medigap coverage prior to age 65. But as of October 2020, Medicare’s plan finder tool also indicates that Transamerica has Medigap plans available in Virginia for people under the age of 65. [The state has clarified that some other insurers may agree to sell Medigap coverage to a disabled person who is transitioning from one of that insurer’s commercial plans to Medicare, so they advise people enrolling in Medicare prior to age 65 to check with their current insurance company to see if they offer Medigap plans, and if so, whether they’ll be eligible to enroll.]

CareFirst’s Medigap Plan A for people under age 65 is significantly more expensive than the average Plan A premiums charged by other insurers for people who are 65 years old (over $7,000 per year as of 2020, whereas nearly every other company is charging 65-year-old enrollees less than $2,000 per year for Plan A).

Disabled Medicare beneficiaries have access to the Medigap open enrollment period when they turn 65. At that point, they have access to any of the available Medigap plans, at the standard age-65 rates.

Virginia Medicare Part D

Original Medicare does not provide coverage for outpatient prescription drugs. More than half of Original Medicare beneficiaries nationwide have supplemental coverage either through an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.

But Medicare Part D, created under the Medicare Modernization Act of 2003, provides drug coverage for Medicare beneficiaries who do not have another source of coverage for prescription costs. Medicare beneficiaries can buy Medicare Part D plans on a stand-alone basis, or obtain Part D coverage integrated with a Medicare Advantage plan (not all Advantage plans include Part D benefits, but most do). Both options are available for purchase (or plan changes) during the annual election period that runs from October 15 to December 7 each year, with the new coverage effective January 1 of the coming year.

There are 30 stand-alone Medicare Part D plans for sale in Virginia for 2021, with premiums that range from about $7 to $86/month.

As of September 2020, there were 674,671 Virginia beneficiaries with stand-alone Medicare Part D coverage, and another 349,078 with Medicare Advantage plans that included integrated Part D coverage.

Medicare Part D enrollment is available when a person is first eligible for Medicare, and during the annual open enrollment period each fall, from October 15 to December 7. Plan selections and changes made during this window take effect on January 1.

Medicare spending in Virginia

Average per-beneficiary spending on Medicare in Virginia was about 8 percent lower than the national average in 2018, at $9,328 (nationwide, the average was $10,096). The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage.

Average per-beneficiary Original Medicare spending was highest in Louisiana, at $11,932, and lowest in Hawaii, at just $6,971.

How does Medicaid provide financial assistance to Medicare beneficiaries in Virginia?

Many Medicare beneficiaries receive financial assistance through Medicaid with the cost of Medicare premiums and services Medicare doesn’t cover – such as long-term care.

Our guide to financial assistance for Medicare enrollees in Virginia includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.

Medicare in Virginia: Resources for beneficiaries and their caregivers

You can contact VICAP (Virginia Insurance Counseling and Assistance Program), with questions related to Medicare eligibility, enrollment, and coverage in Virginia.

The Virginia State Corporation Commission/Bureau of Insurance website offers a variety of information and resources about Medicare Advantage, Medicare Part D, and Medigap plans that are sold in Virginia. They can provide customer service, answer questions, and address complaints about entities they regulate, including health insurance companies and the brokers/agents who sell policies in the state.

This guide to Medicaid assistance for Medicare beneficiaries in Virginia is a useful resource that explains the various programs available to people with low income and asset levels, and how to apply for assistance.

Medicare Rights Center is a nationwide service, with a website and call center, where Medicare beneficiaries can get answers to their questions and assistance with understanding the eligibility and enrollment process for Medicare.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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