Medicare in West Virginia

Medicare is a government-run health insurance program for seniors 65 or older and adults with end-stage kidney disease or specific disabilities such as ALS. It covers the cost of many in-patient and outpatient medical services to ensure the availability of affordable health care for vulnerable individuals.

Medicare is divided into several parts. Part A covers in-patient services such as hospitalization and nursing home care and is typically premium-free for most people, as long as the enrollee or their spouse paid sufficient Medicare taxes during their lifetime. Part B requires beneficiaries to pay a monthly premium of $164.90 for access to in-patient services such as doctor’s visits, lab tests and medical devices. Original Medicare, which pairs Part A and B together, is how many people in West Virginia access Medicare benefits. However, a significant number of enrollees access Medicare through Medicare Advantage Plans, also known as Part C.

Offered through private insurance companies, Medicare Advantage provides an alternative way to utilize Part A and B benefits in addition to Part D prescription drug benefits. Of West Virginia’s population of 1,775,156, there were 446,562 residents eligible for Medicare as of 2023, amounting to just over 25% of the population, up 0.86% from 2022. Medicare Advantage enrollees comprise 212,190, or 48%, of all eligible residents, equal to the national average but up by 11.69% since 2022. West Virginia spends $2.67 billion annually on Medicare Part A and B as of 2021, and this number is likely to continue growing as more people become eligible for benefits each year in the state.

Seniors can read this guide to learn more about Medicare, including the personalization options and costs associated with their coverage. The free resources listed at the end also offer additional information to help individuals understand the complex U.S. health insurance landscape.

Options for Medicare Coverage in West Virginia

For many older adults, Original Medicare’s basic coverage is exactly what they need. For some, it is not sufficient. Thankfully, West Virginia offers a number of programs that will help those who qualify for Medicare find coverage that works well for their needs. The primary program, which the federal government runs, is one option, but additional alternatives from private health insurance providers can also work well.

Original Medicare (Parts A & B)

Under Original Medicare, seniors must pay annual deductibles for Parts A and B. In 2023, the deductible for Part A is $1,600 for the first 60 days of hospitalization in a benefit period, with extra daily costs for subsequent days if in-patient care exceeds that initial time frame. Part B requires payment of a deductible of $226 and a monthly premium of $164.90. After deductibles and premiums, Medicare covers 80% of all eligible services, but beneficiaries pay the remaining 20% out-of-pocket.

Who Should Consider Original Medicare

Original Medicare may be a good option for those who:

• Travel frequently within the United States
• Don’t need extra benefits such as home-delivered meals and coverage for over-the-counter medication
• Want to choose their own prescription drug coverage

Medicare Advantage (Part C)

Medicare Advantage Plans fall into four main categories: Preferred Provider Organization (PPO), Health Maintenance Organization (HMO), Private Fee For Service (PFFS) and Special Needs Plans (SNPs). While all plans offer equivalent benefits to Original Medicare (except hospice care), some Medicare Advantage Plans have additional coverage options, and the eligibility rules, networks and costs may vary slightly.

The Medicare.gov Plan Compare page has more information about plans in West Virginia.

Who Should Consider Medicare Advantage 

Seniors may benefit from Medicare Advantage plans if they:

• Need to control their out-of-pocket costs
• Like the idea of a managed care planning
• Need additional coverage options, such as prescription drug coverage or vision
• Who are generally healthy and can benefit from low premiums 

The Top Medicare Advantage Plans in West Virginia

Many providers in West Virginia offer Medicare Advantage plans. The table below highlights the top options based on how many people are enrolled. It shows the costs for these plans as of August 2023, the type of plan offered and the Medicare star rating. The Medicare Advantage Plans in West Virginia page has more information about these options.

Medicare Prescription Drug Coverage (Part D)

Original Medicare doesn’t pay for most prescription drugs through Part A or B coverage. Instead, seniors purchase separate prescription drug policies, also called Part D coverage. Medicare contracts with private health insurance companies to provide this coverage. There are multiple plans to choose from with varying monthly premiums, which beneficiaries pay in addition to their Original Medicare premiums. While seniors don’t have to purchase prescription drug coverage when they’re first eligible for Medicare, not obtaining this coverage at this time may result in late enrollment penalties they pay for as long as they have Medicare if they enroll later.

Each prescription drug plan has its own formulary, or list of covered drugs. Formularies are typically split up into tiers. The tier a medication is in determines how much the insurance company pays and how much the beneficiary pays for it. Lower-level tiers are usually made up of generic and low-cost brand name drugs, while higher tiers are composed of more expensive brand name and specialty drugs. In most cases, the lower the tier, the lower the policyholder’s cost-sharing responsibility.

Who Should Consider Medicare Prescription Drug Coverage

Seniors who may benefit from prescription drug coverage include those who:

• Currently take prescription medication or expect to in the future
• Want to avoid late enrollment penalties
• Want to reduce out-of-pocket prescription drug expenses

Medicare Supplement Insurance (Medigap)

While Original Medicare provides coverage for many medical costs, seniors may still have significant out-of-pocket expenses. These may include copays, coinsurance and deductibles. Seniors may be able to reduce their cost-sharing obligations by purchasing a Medigap plan. These plans can only be used with Original Medicare. It’s illegal for private insurance companies to sell Medigap plans to those with Medicare Advantage plans.

For more information on Medigap plans, seniors can refer to the Best Medicare Supplement Companies of 2023 page.

Who Should Consider Medicare Supplement Insurance

Good candidates for Medigap may be those who:

• Have ongoing health issues and expenses
• Travel overseas often
• Want to access an expanded network of health care providers
• Expect to need health services not covered by Original Medicare

Medicare Resources in West Virginia

Applying for Medicare is complicated, and many seniors find themselves wondering how to go about the process properly. The state of West Virginia has a number of resources seniors and their caregivers can tap to help with the application process. From assistance with appeals to help with the actual applications, here are some resources that provide assistance to those seeking Medicare coverage.