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Medicare in West Virginia

West Virginia is among the minority of states where there is no rule guaranteeing access to Medigap for people under 65

Key takeaways

How many West Virginians have Medicare coverage?

As of September 2020, there were 442,837 residents in West Virginia with Medicare coverage. That’s nearly 25 percent of the state’s population, compared with less than 19 percent of the United States population enrolled in Medicare.

As of 2017, 21 percent of beneficiaries attained Medicare eligibility in West Virginia due to a disability (as opposed to being age 65+), versus 15 percent nationwide. According to data compiled by the University of New Hampshire, West Virginia had the highest percentage of disabled residents in the country in 2016 (although Alabama, Arkansas, Kentucky, and Mississippi all had a slightly higher percentage of their Medicare beneficiaries eligible due to disability).

West Virginia also has among the nation’s highest percentages of elderly residents (age 65+). Combined with the high rate of disability, it makes sense that a larger-than-average number of residents are enrolled in Medicare in West Virginia.

Medicare Advantage in West Virginia

Twenty-six percent of people with Medicare in West Virginia were enrolled in private Medicare Advantage plans in 2018. Nationwide, the average was 34 percent, so Medicare Advantage enrollment was a little less popular in West Virginia at that point than it was nationwide. The other three-quarters of West Virginia’s Medicare beneficiaries had opted for coverage under Original Medicare. But by 2020, about 38 percent of West Virginia’s Medicare beneficiaries were enrolled in private Medicare Advantage plans; nearly catching up with the 40 percent nationwide average.

Medicare Advantage plans provide all of the benefits of Medicare Part A and Part B, and most Advantage plans also incorporate Medicare Part D (coverage for prescription drugs) as well as extras like dental and vision. But the deductible and coinsurance amounts vary with Medicare Advantage, and the provider networks tend to have much more localized service areas than the nationwide provider access that Original Medicare enrollees can use.

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Medicare Advantage plans are often less costly in terms of monthly premiums (compared with Original Medicare plus a Medigap plan and Part D plan), but the out-of-pocket costs might end up being higher with the Medicare Advantage plan (assuming the person would otherwise have a Medigap plan) and the network restrictions can be challenging depending on the circumstances. There are pros and cons either way, and no single solution that works for everyone.

There is a robust Medicare Advantage market in West Virginia. The number of available plans for 2021 ranges from 23 to 32, depending on the county, with a fairly uniform number of options available throughout the state.

Medicare beneficiaries can switch from Medicare Advantage to Original Medicare or vice versa during the annual election period in the fall (October 15 through December 7), with coverage effective January 1. There is also a Medicare Advantage open enrollment period in the first quarter of the year (January 1 to March 31) during which people who are already enrolled in Medicare Advantage plans can switch to a different Medicare Advantage plan or drop their Medicare Advantage plan and enroll in Original Medicare instead.

Medigap in West Virginia

Because Original Medicare includes out-of-pocket costs that can be substantial and that aren’t limited under the terms of Medicare’s coverage, many enrollees rely on Medigap plans to supplement Original Medicare, covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that they would otherwise have to pay themselves if and when they need medical care.

According to data compiled by AHIP, there were 91,448 West Virginia Medicare beneficiaries with Medigap coverage as of 2018.

West Virginia implemented new regulations in 2019, requiring Medigap insurers that use attained-age rating (ie, prices that increase as enrollees get older) to adjust rates annually, as opposed to keeping them flat for several years and then adjusting them all at once when the insured crossed into a new age band. But the state amended the rules to allow insurers that were already using multi-year age bands to transition to the new method over a period of no more than five years. The state also clarified that insurers can continue to have a maximum rate that applies once an insured reaches a certain age (ie, rates do not have to continue to increase annually for an insured’s entire lifetime).

Medigap plans offer benefits that are standardized under federal rules, with ten different plan designs (denoted by letters, A through N). And federal rules allow for a six-month guaranteed-issue window for Medigap plans, which begins when the person is at least 65 and enrolled in Medicare Part B.

But federal rules do not guarantee access to a Medigap plan if you’re under 65 and eligible for Medicare as a result of a disability. The majority of the states have adopted rules to ensure at least some access to Medigap plans for under-65 enrollees, but West Virginia is not among them.

According to the West Virginia Office of the Insurance Commissioner, there is no state rule requiring Medigap insurer to offer coverage to people under 65, and most of the insurers choose not to (people under 65 who are eligible for Medicare are, by definition, disabled, so their medical expenses can be expected to be higher than the average enrollee who qualifies for Medicare based on age alone). But according to Medicare’s plan finder tool, there are three insurers in West Virginia that provide Medigap plans to people under the age of 65:

  • United American (Plan B and high-deductible Plan F)
  • Transamerica (multiple plans available)
  • Highmark Blue Cross Blue Shield (as of 2019, the West Virginia Office of the Insurance Commissioner noted that Highmark offered all of their Medigap plans to enrollees under age 65, but only if the person is transitioning from another Highmark plan to Medicare.)

The premiums for Medigap plans for people under 65 are higher than the standard premiums for people who are eligible for Medicare due to their age. Disabled enrollees who have a higher-priced Medigap plan when they’re under 65 are allowed another enrollment window when they turn 65, so they can then switch to lower-cost Medigap coverage at that point.

Information about West Virginia’s Medigap regulations is available here.

West Virginia Medicare Part D

Original Medicare does not cover outpatient prescription drugs. People enrolled in Medicare plans can obtain prescription coverage through a Medicare Advantage plan (most Advantage plans have built-in prescription coverage), an employer-sponsored plan (offered by a current or former employer), or a stand-alone Medicare Part D prescription drug plan.

Insurers in West Virginia offer 33 stand-alone Medicare Part D plans for 2021, with premiums ranging from about $7 to $164 per month.

As of September 2020, there were 177,765 beneficiaries of Medicare in West Virginia with stand-alone Medicare Part D plans, and another 139,573 had Medicare Part D enrollment integrated with Medicare Advantage plans. As Medicare Advantage enrollment has increased in West Virginia, the number of residents with coverage for prescription drugs under stand-alone Part D coverage has been shrinking while the number with Part D coverage as part of an Advantage plans has been growing.

Medicare spending in West Virginia

In 2018, average per beneficiary spending for Medicare in West Virginia was $9,852 per beneficiary, based on data standardized to account for regional differences in payment rates. The data did not include costs for Medicare Advantage enrollees, but three-quarters of West Virginia Medicare beneficiaries had Original Medicare.

Nationwide, average per beneficiary Original Medicare spending that year was $10,096 per enrollee, so Medicare spending in West Virginia was about 2 percent lower than average. In three states (Florida, Louisiana, Mississippi, Oklahoma, and Texas), Original Medicare’s per-beneficiary spending was more than $11,000, while in Hawaii it was just $6,971.

How does Medicaid provide financial assistance to Medicare beneficiaries in West 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 West Virginia includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.

Medicare in West Virginia: Resources for beneficiaries and their caregivers

You can contact the West Virginia State Health Insurance Assistance Program (SHIP), with questions related to Medicare eligibility in West Virginia, or for assistance with the enrollment process.

For Medicare beneficiaries with limited means (income and assets), this overview of how West Virginia Medicaid can assist Medicare beneficiaries is a helpful resource.

The West Virginia Office of the Insurance Commissioner oversees, licenses, and regulates health insurance companies and the brokers and agents who sell policies to West Virginia residents. The WVOIC can answer questions, provide information, and address complaints related to any of the entities they regulate.

The Medicare Rights Center is a nationwide resource, with a website and call center that can provide assistance, education, and information about 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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