At a glance: Medicare health insurance in Virginia
- Nearly 1.5 million Virginia residents are enrolled in Medicare; 15 percent are under age 65 and eligible due to a disability.
- Fewer than one in five Virginia Medicare beneficiaries are enrolled in Medicare Advantage plans.
- All counties in Virginia have Medicare Advantage plans available, with plan availability ranging from just seven plans in Accomack County to 34 plans in Loudoun County.
- In Virginia, 39 insurers offer Medigap plans and nearly 400,000 Medicare beneficiaries in the state have Medigap coverage.
- Virginia lawmakers have previously considered requiring Medigap insurers to offer plans to people under age 65, but for the time being, only First Care does so (voluntarily), and they only offer plans in Northern Virginia. But legislation to require guaranteed-issue Medigap for under-65 enrollees has passed unanimously in Virginia’s Senate in 2020.
- There are 27 stand-alone Part D prescription plans available in Virginia in 2019, with premiums ranging from about $15 to $97 per month. More than 950,000 Virginia Medicare beneficiaries have Part D coverage, either under stand-alone plans or as part of their Medicare Advantage coverage.
- Per-enrollee Original Medicare spending in Virginia is about 8 percent lower than the national average.
Medicare enrollment in Virginia
1,518,884 Virginia residents were covered by Medicare as of late 2019. That’s a little more than 17 percent of the state’s population, versus a little more than 18 percent of the total US population enrolled in Medicare.
Most Americans become eligible for Medicare when they turn 65. But nationwide, there are nearly 10 million people under the age of 65 who are covered by Medicare, accounting for about 16 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. In Virginia, 14 percent of Medicare beneficiaries were under age 65 as of 2017.
In Alabama, 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.
Medicare Advantage in Virginia
Medicare beneficiaries can choose to get their coverage through private Medicare Advantage plans, or directly from the federal government via Original Medicare. 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 in 2019, but plan availability ranges from just nine plans in Accomack County to 48 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 late 2019, total private Medicare enrollment in Virginia (not counting people with private supplemental coverage like Part D and Medigap) stood at 339,984 people, or a little more than 22 percent 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 1,178,900 Medicare beneficiaries in Virginia had Original Medicare as of late 2019.
The popularity of Medicare Advantage varies from one state to another. In Minnesota, 56 percent 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).
Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to switch between Medicare Advantage 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 costs, 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.
393,691 Virginia Medicare beneficiaries had Medigap coverage as of 2016, 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 39 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, 15 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. But it’s 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 they are not currently able to join most Medicare Advantage plans (that will change in 2021), and their 20 percent share of the cost of dialysis under Medicare Part B can become unaffordable very quickly.
Similar bills ( SB1351 in 2017 and SB161 in 2018) were introduced in Virginia in prior years but didn’t advance out of committee. But for the time being, Virginia is still among the states where Medigap insurers are not required to offer plans to people under 65; most do not, and the one that does has a coverage area that’s limited to Northern Virginia, and premiums that are more than three times higher than average prices for enrollees who are 65 years old (more details below).
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.
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 (that will change in 2021, when enrollees with kidney failure will be able to select Medicare Advantage plans). Medicare Advantage plans are otherwise available to anyone who is eligible for Medicare, and the premiums are not higher for those under 65. But Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $6,700 per year for in-network care, plus the out-of-pocket cost of prescription drugs.
As of 2020, 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. [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 (well over $6,500 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.
Medicare Part D in Virginia
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 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 29 stand-alone Part D plans for sale in Virginia in 2019, with premiums that range from about $13 to $75/month.
There were 691,699 Virginia Medicare beneficiaries with stand-alone Part D plans as of late 2019, and another 294,825 with Medicare Advantage plans that included integrated Part D coverage.
Medicare spending in Virginia
Original Medicare’s average per-beneficiary spending in Virginia was about 8 percent lower than the national average in 2017, at $9,000 (nationwide, the average was $9,761). 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.
You can read more about Medicare in Virginia in our state Medicare guide. You can also contact VICAP (Virginia Insurance Counseling and Assistance Program), with questions related to Medicare coverage in Virginia.
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 healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.