Comparing Medicare plans in Virginia
Original Medicare is the federal health insurance program administered by the Centers for Medicare & Medicaid Services (CMS). It forms the foundation of senior healthcare in Virginia, built on two primary components: Part A, which acts as your hospital insurance, and Part B, which acts as your medical insurance for outpatient care.
When you first become eligible for Medicare, Original Medicare is the default coverage path. It provides access to any doctor or hospital in the United States that accepts Medicare, requiring no network restrictions or specialist referrals. However, Original Medicare is not comprehensive. It generally covers 80% of approved outpatient costs, leaving you responsible for the remaining 20% with no annual out-of-pocket maximum, and it entirely excludes routine dental, vision, hearing, and prescription drug coverage. Understanding exactly how Original Medicare is structured, how its costs work, and what gaps it leaves behind is the prerequisite to making any informed Medicare decision.
Medicare Part A is designed to protect you against the catastrophic costs of inpatient hospital care. If you are formally admitted to a medical facility, Part A is the side of Medicare that pays for your room, meals, nursing care, and the facility services provided during your stay.
Part A covers inpatient stays in acute care hospitals, critical access hospitals, and inpatient rehabilitation facilities. However, you are only covered under Part A if you are formally admitted as an inpatient following a doctor’s order. If you are placed under “observation status”—even if you spend the night in a hospital bed—your care is billed under Part B as outpatient services, which completely changes your cost-sharing obligations.
If you require skilled nursing care or rehabilitation after a hospital stay, Part A covers services in a certified Skilled Nursing Facility. To qualify, you must have a prior qualifying inpatient hospital stay of at least three consecutive days, and you must enter the SNF within 30 days of your discharge for a related condition.
Under the SNF benefit, Part A covers the first 20 days of your stay in full. For days 21 through 100, you are responsible for a daily coinsurance amount. After 100 days, Original Medicare stops paying entirely, and you are responsible for all costs. Part A does not cover long-term custodial care (such as standard nursing home residency for activities of daily living).
Part A covers hospice care for beneficiaries whose doctor certifies they have a terminal illness with a life expectancy of six months or less. Hospice coverage is remarkably comprehensive, paying for pain relief, symptom management, grief counseling, and short-term inpatient respite care. Your only costs are typically minor copayments for prescription medications aimed at symptom control.
For home health care, Part A will cover part-time or intermittent skilled nursing care, physical therapy, and occupational therapy provided in your home, provided you are homebound and the care is ordered by a doctor.
Costs under Part A are not calculated on an annual, calendar-year basis like most commercial health insurance. Instead, Part A operates on Benefit Periods.
A benefit period begins the day you are admitted as an inpatient to a hospital or SNF. It ends only when you have been out of the hospital or SNF, receiving no inpatient care, for 60 consecutive days.
When a benefit period starts, you must pay the full Part A inpatient deductible before Medicare pays anything. If you are discharged and readmitted three months later (after 60 days have passed), a new benefit period begins, and you must pay that full deductible all over again. There is no limit to the number of benefit periods you can have in a year, meaning you could theoretically pay the Part A deductible multiple times in a single calendar year if you have recurring, spaced-out hospitalizations.
While Part A handles the facility side of healthcare, Medicare Part B covers the services required to diagnose and treat medical conditions on an outpatient basis. Because modern medicine heavily relies on outpatient care, Part B is the component of Original Medicare you will use most frequently.
Part B covers services from doctors and other healthcare providers, regardless of whether those services are delivered in a clinic, a hospital outpatient department, or a private practice. This includes consultations, surgeries, lab tests, diagnostic imaging (like X-rays, MRIs, and CT scans), and emergency room visits.
Original Medicare heavily emphasizes preventive care. Part B covers a wide array of preventive services at no cost to you, provided the provider accepts Medicare assignment. This includes a one-time “Welcome to Medicare” preventive visit during your first 12 months on Part B, and an Annual Wellness Visit every year thereafter. It also fully covers specific screenings, such as mammograms, colonoscopies, bone mass measurements, and cardiovascular screenings, as well as flu shots and pneumococcal vaccines.
If your doctor prescribes medical equipment for use in your home, Part B covers it. Common DME includes blood sugar monitors, test strips, CPAP machines, oxygen equipment, walkers, and wheelchairs. To ensure coverage, both the prescribing doctor and the DME supplier must be formally enrolled in Medicare.
Part B covers outpatient mental health care, including visits with a psychiatrist, clinical psychologist, or clinical social worker. It covers annual depression screenings and counseling services, subject to standard Part B cost-sharing rules.
Unlike Part A’s benefit periods, Part B operates on a standard calendar year. Each year, you must satisfy a fixed annual Part B deductible. Once that deductible is met, Original Medicare generally covers 80% of the Medicare-approved amount for covered services.
You are responsible for the remaining 20% coinsurance. Crucially, this 20% has no upper limit. Whether your 20% amounts to $50 for a doctor’s visit or $50,000 for complex outpatient chemotherapy, you remain responsible for that percentage in perpetuity unless you have supplemental insurance.
Furthermore, if a provider does not fully accept Medicare assignment—meaning they do not agree to accept the Medicare-approved amount as payment in full—they can legally bill you for up to 15% above the approved amount. This is known as a Part B excess charge.
Original Medicare was designed in 1965, and its core benefit structure reflects the medical landscape of that era. Consequently, it explicitly excludes several massive categories of modern healthcare needs. Knowing what is excluded is critical, as you will need to plan for these expenses separately.
Original Medicare does not cover outpatient prescription drugs you pick up at a retail pharmacy. It will cover drugs administered to you by a medical professional in a clinical setting (like IV infusions or injectables under Part B), and drugs provided during an inpatient stay (under Part A). But standard daily medications for blood pressure, cholesterol, or diabetes require you to purchase a separate private Medicare Part D plan.
Part A and Part B will not pay for routine dental care, cleanings, fillings, tooth extractions, or dentures. They will not pay for routine eye exams, eyeglasses, or contact lenses. They will not cover hearing exams, hearing aids, or exams for fitting hearing aids.
Medicare only steps in for these areas if they are an integral part of a covered medical procedure—for example, if you need a tooth extracted in preparation for jaw surgery, or if you need an eye exam due to diabetic retinopathy or cataracts.
If you develop a condition that requires help with activities of daily living (bathing, dressing, eating, using the bathroom), Original Medicare will not pay for it. Whether provided in a nursing home or via a home health aide, long-term custodial care is entirely excluded from Medicare coverage.
With exceptionally rare exceptions (such as living immediately on the border and the nearest hospital is in Canada or Mexico, or crossing through Canada to get to Alaska), Original Medicare provides no coverage for healthcare services received outside the United States.
Medicare eligibility is governed by age, disability status, or specific medical diagnoses. You generally qualify for Original Medicare if you meet one of the following criteria:
Medicare enrollment is governed by strict, unforgiving timelines. Navigating these enrollment windows correctly is essential to avoid permanent financial penalties.
Your primary window to enroll in Original Medicare is your Initial Enrollment Period. This is a seven-month window built around your 65th birthday. It includes:
If you enroll during the first three months of your IEP, your coverage will seamlessly begin on the first day of your birth month. If you enroll later in the window, your coverage start date will be delayed.
If you completely miss your IEP and do not qualify for a Special Enrollment Period, you must wait for the General Enrollment Period. The GEP runs from January 1 through March 31 every year. If you enroll during this time, your coverage will begin on the first day of the following month. However, relying on the GEP usually means you will be subjected to late enrollment penalties.
If you continue to work past age 65 and are covered by a qualifying employer group health plan, you do not need to enroll in Part B immediately. You are granted a Special Enrollment Period later.
Your SEP lasts for eight months, beginning the month after your employment ends or your employer-sponsored health insurance ends, whichever happens first. Enrolling through an SEP allows you to join Medicare without facing any late penalties. Importantly, COBRA coverage and retiree health plans do not count as active employer coverage; keeping COBRA instead of enrolling in Part B will result in severe penalties.
If you fail to enroll when first eligible and do not have a valid SEP, you will be penalized.
Part A Penalty: If you are one of the few individuals who must pay a premium for Part A (because you have fewer than 40 work credits), the late penalty increases your monthly premium by 10%. You will pay this higher premium for twice the number of years you were eligible but did not enroll. (e.g., If you waited two years, you pay the penalty for four years).
Part B Penalty: The Part B penalty is permanent. For every full 12-month period you were eligible for Part B but did not enroll, your monthly premium increases by 10%. If you wait three full years to sign up, your Part B premium will be 30% higher than the standard rate, and you will pay that 30% surcharge for the rest of your life.
Original Medicare is not free. Even if you qualify for premium-free Part A, Part B requires a monthly payment.
The Part B premium is determined annually by CMS. While most beneficiaries pay the standard base premium, high-income earners are subject to a surcharge known as the Income-Related Monthly Adjustment Amount (IRMAA).
IRMAA is a statutory calculation based on your Modified Adjusted Gross Income (MAGI) from your IRS tax return two years prior. (For example, 2026 premiums are based on your 2024 tax return). If your income crossed specific thresholds, your Part B premium scales upward across several brackets. This surcharge also applies to Medicare Part D prescription drug plans.
If you experience a life-changing event—such as retirement, divorce, or the death of a spouse—that drastically reduces your income compared to two years ago, you can file an appeal with the Social Security Administration (Form SSA-44) to have your IRMAA recalculation expedited based on your current, lower income.
Because Original Medicare exposes you to uncapped 20% coinsurance under Part B and excludes prescription drugs, relying on it alone is highly risky. In Virginia, beneficiaries generally choose one of two distinct paths to protect themselves: adding supplemental coverage, or replacing Original Medicare with a private plan.
You can choose to keep Original Medicare as your primary insurance and purchase a Medigap (Medicare Supplement) policy from a private insurance company.
Medigap policies are standardized by the federal government and identified by letters (e.g., Plan G, Plan N). These plans are designed to pay secondary to Medicare. When you receive a medical bill, Original Medicare pays its approved share, and the bill is then automatically forwarded to your Medigap carrier, which steps in to pay the remaining deductibles, coinsurance, and copayments according to your specific plan’s rules.
With this setup, you retain the primary advantage of Original Medicare: total freedom of access. You can see any doctor or visit any hospital in the United States that accepts Medicare. Because Medigap policies do not cover prescriptions, you must also purchase a standalone Part D plan for your medications.
The alternative is Medicare Advantage, also known as Part C. When you enroll in a Medicare Advantage plan, you still legally have Medicare, and you must continue paying your Part B premium. However, the private insurance company completely takes over the administration of your Part A and Part B benefits.
In Virginia, the Medicare landscape is vast, with 141 total Medicare plans available across the state depending on your specific county. These plans are offered by major carriers including Aetna Medicare, Anthem Blue Cross and Blue Shield, Anthem HealthKeepers, Devoted Health, HealthSpring, Humana, Johns Hopkins Advantage MD, Kaiser Permanente, and UnitedHealthcare.
Medicare Advantage plans introduce an annual out-of-pocket maximum, protecting you from catastrophic medical debt. They typically bundle prescription drug coverage into the plan and often include extra benefits Original Medicare ignores, such as dental, vision, and hearing allowances.
However, they achieve these efficiencies through managed care. Most Advantage plans in Virginia are HMOs or PPOs, requiring you to use a specific local network of doctors and hospitals, and often requiring prior authorization before major procedures or specialist visits.
| Feature | Original Medicare + Medigap | Medicare Advantage (Part C) |
|---|---|---|
| Network Restrictions | None. Any provider nationwide that accepts Medicare. | Usually restricted to local HMO or PPO networks. |
| Referrals Required | No. You can see specialists directly. | Often required, especially on HMO plans. |
| Out-of-Pocket Cap | Yes, Medigap pays most/all back-end costs. | Yes, plans have a hard annual maximum limit. |
| Monthly Costs | Higher. (Part B + Medigap Premium + Part D Premium). | Lower. (Part B + Plan Premium, which is often $0). |
| Prescription Drugs | Not included. Must buy separate Part D plan. | Usually bundled directly into the plan. |
| Extra Benefits | None. Medical care only. | Often includes dental, vision, hearing, and fitness perks. |
If you have additional insurance alongside Original Medicare, strict “Coordination of Benefits” rules determine which insurance pays first (the primary payer) and which pays second (the secondary payer).
Employer Group Health Plans: If you are 65, still working, and your employer has 20 or more employees, your employer group health plan pays primary, and Medicare pays secondary. Because your employer plan is primary, you can safely delay enrolling in Part B without penalty. If your employer has fewer than 20 employees, Medicare automatically becomes the primary payer at age 65. If you do not enroll in Part A and Part B immediately, your small employer plan will only pay secondary, leaving you effectively uninsured for 80% of your medical costs.
Veterans Affairs (VA) Benefits: VA benefits and Medicare do not directly coordinate. If you go to a VA facility, your VA benefits pay. If you go to a civilian facility, Medicare pays. Because VA benefits are not considered creditable coverage for Part B, veterans who delay Part B will still face lifetime late enrollment penalties. It is highly recommended that veterans enroll in both to ensure they can seek civilian care if a VA hospital is unavailable.
TRICARE For Life: If you are a retired military member using TRICARE For Life, you must enroll in Medicare Part A and Part B. Once you do, Original Medicare pays primary for civilian healthcare, and TRICARE For Life pays secondary, acting effectively as a Medigap policy to cover your deductibles and coinsurance.
Because Original Medicare covers specific services under strict definitions of “medical necessity,” you may occasionally encounter a situation where a claim is denied. If Original Medicare refuses to pay for a service or item you believe should be covered, you have the legal right to appeal the decision through a formalized five-level process.
This structure ensures that beneficiaries are not left at the absolute mercy of an initial claim denial and have legal recourse to secure coverage for legitimate medical needs.
Making your Medicare decision means evaluating your current health, your financial stability, and how much flexibility you demand from your healthcare access.
You should heavily lean toward keeping Original Medicare and adding a Medigap policy if:
You should heavily lean toward replacing Original Medicare with a Medicare Advantage plan if:
Original Medicare is a profound, life-altering entitlement, but it is not a complete insurance solution out of the box. By understanding its mechanics, recognizing its limitations, and properly meeting its enrollment deadlines, you can build a stable, financially secure healthcare strategy for your retirement.
Speak with a licensed producer to compare your Medicare coverage options, check provider networks, and find the right strategy for your situation.
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