Virginia Health Insurance: Find Affordable Plans

Virginians can get healthcare through an employer, insurance brokers and agents, or through Medicare if you’re disabled or 65 or older. This guide will show you the options available to Virginians, the cost of many of these options, and how you or your family can enroll in a health plan.

• Marketplace plans: In Virginia, if the health care you receive from your employer does not provide enough coverage for yourself or for your family, if you work for a small company that does not provide insurance, if you’re unemployed, or if you are under 30 and are no longer covered by your parent’s insurance, you can purchase an Affordable Care Act (ACA) plan through the Healthcare.gov website.
• Open enrollment: open enrollment takes place between November 1 and January 31. The only way you can enroll outside of this period is if you qualify for a Special Enrollment Period.
• Special enrollment: You may qualify for a special enrollment period if you have experienced a qualified life event (QLE) that caused you to lose coverage, or if you need to make changes to your current plan (due to a life change such as getting married, having a child, or getting divorced, etc.), or if you have had a change in eligibility for Medicare or Medicaid. You have 60 days from the time of the event to sign up for a new plan or make changes to your current plan.
• Health Insurance Marketplace: In 2021, Virginia uses the Healthcare.gov website to offer plans to its residents. Starting in 2023, Virginia will have its own online exchange website which residents will use to purchase ACA-compliant plans.
• Coverage types: In 2021, most Virginians received their healthcare through an employer (54.1%). The two next highest groups were Medicare (14.8%) and Medicaid (13.5%). Nongroup insurance (which includes full health care plans not sold on the ACA Marketplace and short-term insurance plans) accounted for 5.9%. The military provides healthcare for 4.4% of Virginians. Due to the Medicaid expansion in 2020, Virginia lowered its uninsured rate to 8%.

Currently, Virginians interested in purchasing an ACA-compliant health care plan can purchase one through Healthcare.gov. However, starting in 2023, Virginia will operate its own exchange.

On Healthcare.gov, you’ll need to register to see available plans. You will be asked to provide your Social Security number, your household income, your address, and your phone number. You’ll also be asked to provide some of this information for any member of your family you wish to include in your plan as well.

Once you’ve registered, you’ll be able to see up to three plans simultaneously to compare costs. In 2022, eight companies offer plans on the Virginia section of Healthcare.gov. Some of these plans are available statewide, while others are only available in certain areas. The following providers offer ACA-compliant plans in Virginia.

• Anthem HealthKeepers
• CareFirst BlueCross BlueShield
• Cigna Health and Life Insurance Co.
• Kaiser Permanente
• Optima Health Plan
• Oscar Insurance Co.
• Piedmont Community HealthCare HMO Inc.
• UnitedHealthcare

If you don’t wish to use healthcare.gov, you can still purchase health care plans through private companies, brokers, or insurance agents.

There are some important considerations when shopping for individual coverage, whether for yourself or for multiple people. These considerations include:

• Medical needs
• Preferred plan type
• Premium affordability
• Individual vs. family deductibles

Insurance for individuals in Virginia

If you’re healthy with few or no prescriptions, you probably want a plan with a low monthly payment and a high deductible. On the other hand, if you have a chronic health condition, you’ll probably want to select a plan that offers a lower deductible but comes with a higher monthly premium.

The following are the types of plans you’ll have to choose from:

• A Health Maintenance Organization plan (HMO) is a good choice for a healthy individual who makes few visits to the doctor and doesn’t need many prescriptions. However, this plan has more restrictions in terms of how you access your health care. Whichever plan you select, you’ll need to use that plan’s in-network medical providers, obtain referrals to see any specialists, and name a primary care physician.
• There is more flexibility with a Preferred Provider Organization (PPO) plan. You can see out-of-network providers, although this may cost a bit more. A PPO plan won’t require you to name a primary care physician nor obtain a referral to see a specialist, so is a good choice for people with a chronic health condition who see specialists on a regular basis.
• A Point of Service Plan (POS) is an option with similarities to both an HMO plan and a PPO plan. You can see an out-of-network provider, but if you want to see a specialist you’ll still need to obtain a referral.

Insurance for families in Virginia

Choosing the right health care plan for a family can be a little more complicated. You need to think about how each person might use the plan. While you and your spouse may be healthy, if you have children with chronic health problems, you could end up paying a lot of out-of-pocket costs. In this case, you might be better off selecting a plan with a higher monthly premium but a lower deductible. Review the plan details carefully to make sure the services you need are covered. If someone in your family receives specialty care, you should also check to make sure the specialist participates in the plan’s network.

Another consideration for family plans is that many plans have an individual deductible and a family deductible. An individual deductible applies to each person covered by the plan, while the family deductible applies to the entire family. If one of your family members is hospitalized or undergoes an expensive surgery, it’s possible to meet the family deductible before every person on the plan has met their individual deductible.

The Virginia section of the Healthcare.gov website uses the familiar metal tier structure to organize health care plans: Bronze, Silver, Gold, and Platinum. There is no difference in the kind of coverage you receive, only the cost. With a Bronze plan, you’ll pay more in coinsurance and you have a higher deductible. With a Gold plan, you’ll pay a lower coinsurance cost but have larger monthly premiums.

• Bronze plans are a good choice if you’re healthy and make few visits to the doctor. Bronze plans have low monthly premiums but high deductibles. You’ll also pay 40% coinsurance every time you visit a medical provider. The lowest-priced Bronze plan in Virginia costs $343 a month.
• Silver plans have a higher monthly premium, but lower deductibles and lower coinsurance payments (30%). These are the plans that offer the most tax credits and benefits. Once all benefits are calculated, a Silver plan could cost less than a Bronze plan. The most affordable Silver plan in Virginia costs $445 a month.
• Gold and Platinum plans are your best choice if you have chronic health issues. They have the lowest cost for deductibles and the lowest coinsurance fee (20% for a Gold plan and 10% for a premium plan), so your out-of-pocket costs will be kept low. On the other hand, these plans have hefty monthly premiums. The lowest-priced Gold plan is $435 a month.

Virginians who have no or low income according to the Federal Poverty Level may be eligible for Medicaid. In 2019, the state expanded Medicaid to include all low-income individuals between the ages of 19 and 64.

Medicaid in Virginia

Medicaid is available to low-income residents who meet at least one of the following criteria:

• At least 65 years old
• Pregnant
• Responsible for a minor child
• Have a disability
• Have a household member with a disability

Medicaid is available to residents aged 19 to 64 who live in households that earn less than 130% of the federal poverty level. In 2022, this is $17,131 for an individual, while for a family of three, it’s $29,207. You can find out more about what coverage is available and if you are eligible for Medicaid assistance at Cover Virginia.

Family Access to Medical Insurance Safety (FAMIS) in Virginia

Even if you don’t qualify for Medicaid, your children may be eligible for FAMIS or FAMIS Plus. A family’s monthly income determines eligibility, and a family of four can earn up to 205% of the Federal Poverty Level and qualify. Coverage includes doctor visits, hospital care, prescription medicines, mental health services, dental care, eyeglasses, regular checkups, and immunizations.

Medicare is the federal government program to provide health care for seniors aged 65 and older and those with qualifying disabilities.

• Original Medicare is the basic form of Medicare. It’s composed of two parts: Part A (inpatient care) and Part B (preventive care and outpatient medical services). There are no limits on out-of-pocket expenses under Original Medicare and no prescription drug coverage. You’ll need to purchase a Medicare Part D plan if you require regular prescriptions. The Medicare Part A Premium and Deductible for inpatient hospital stays is $1,556 in 2022, up from $1,484 in 2021. Medicare Part B enrollees pay a standard monthly premium of $170.10 for 2022, up from $148.50 in 2021.
• Medicare Advantage plans are sold by private insurance companies, but approved by Medicare. Also known as Medicare Part C, these plans are legally required to provide all the coverage that you would receive under Original Medicare; however, the plans also offer vision, dental, and hearing coverage with many plans offering prescription drug coverage and fitness memberships. Medicare Advantage Plans come in four categories: HMOs, PPOs, Private Fee-For-Service Plans, and Special Needs Plans. As of 2022, there are 132 Medicare Advantage Plans available in the state, however, you can only select a plan that’s available in your county.

If you want some help paying for out-of-pocket costs with Original Medicare, you should purchase a Medicare Supplement Insurance Plan, also known as Medigap. A Medicare Supplement Insurance Plan will pay for out-of-pocket costs such as coinsurance, deductibles, and copays. These plans do not pay for vision, dental, or hearing, nor coverage for long-term care. If you travel out of the country, however, a Medicare Supplement Insurance Plan can provide health insurance for your trip. A Medicare Supplement Insurance Plan will not work with any Medicare Advantage Plan.

Eligibility

To qualify for Medicare, you must be:

• A U.S. citizen or a permanent resident who has resided in the U.S. for the past five years.
• Aged at least 65 or be disabled.
• Certain conditions or diseases can qualify you for Medicare such as End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS — also known as Lou Gehrig’s disease).

Enrollment

If you start receiving your Social Security or Railroad Retirement Board benefits at least four months before you turn 65, you’ll be automatically enrolled in Medicare. Otherwise, you must fill out an application online or contact your local Social Security office. You can enroll in Medicare during the following periods:

• Initial enrollment: Your initial enrollment period starts three months before your 65th birthday and ends three months after your 65th birthday. If you’ve never had Medicare, you can enroll during this period. If you started receiving Medicare when you were younger, you can also make changes to your plan.
• General enrollment: Choose this enrollment period if you missed your initial enrollment period. The Medicare general enrollment period is January 1 to March 31. You can choose Original Medicare, Medicare Advantage, Medigap, or Part D.
• Medicare Advantage open enrollment: You can make changes to your Medicare Part C, also known as Medicare Advantage, from January 1 to March 31.
• Open enrollment: You can join, switch plans, or drop your coverage from October 15 to December 7 each year.

• Special enrollment periods: You may qualify for a special enrollment period if you lose your coverage or have changes to your eligibility outside the regular enrollment periods.

Medicare Resources

The Virginia Insurance Counseling and Assistance Program (VICAP) provides free, unbiased, and confidential counseling for Medicare beneficiaries and their caregivers. The program’s trained volunteers can provide information and assistance concerning Medicare coverage and how to enroll. Each volunteer provides unbiased advice and no counselor will ever try to sell you insurance.

In Virginia, there are short-term healthcare insurance plans available, but plans are limited to a minimum of three months with a maximum duration of six months. You cannot purchase a short-term plan if it would result in you having short-term coverage for more than six months in any 12-month period. You will also not be able to buy any short-term insurance during the ACA’s Open Enrollment period from November 1 to December 15.

Short-term insurance does not cover pre-existing conditions, pregnancy, or mental health care. In most cases, short-term insurance is only available to people who are in good health and aged between 18 and 64.

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• HealthCare.gov | Point of Service (POS) Plans | Last accessed January 2022
• HealthCare.gov | Preferred Provider Organization (PPO) | Last accessed January 2022
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