West Virginia Health Insurance: Find Affordable Plans

While the number of health insurance providers in West Virginia is relatively limited, the state offers many ways for individuals and families to obtain health care. After the state accepted the Affordable Care Act (ACA) Medicaid expansion in 2013, West Virginia has reduced its uninsured rate to one of the lowest in the nation.

This guide presents detailed information about your health care options in West Virginia and how you find the best plan for the lowest price.

• Marketplace plans: Two plans are available on the Health Insurance Marketplace in West Virginia and one off-exchange plan. You can purchase other health care plans in West Virginia, but the plans may not offer the guaranteed protections of ACA-compliant plans.
• Open enrollment: The standard marketplace health insurance enrollment period is from November 1 to January 15.
• Special enrollment: A Special Enrollment Period allows you to sign up for health coverage outside of Open Enrollment. You may qualify for special enrollment if you have a qualifying life event (QLE) that caused you to lose coverage. For example, moving into a different zip code, losing your job, getting married, or having a child. You have 60 days from the time of the event to select a new plan.
• Health Insurance Marketplace: West Virginia’s health insurance marketplace is a partnership exchange. West Virginians enroll in health care through Healthcare.gov, which the federal government operates. However, the state government regulates Marketplace plans.
• Premium tax credit: If you use the Health Insurance Marketplace, you may qualify for a premium tax credit. You can purchase coverage directly from one of West Virginia’s health insurance companies if you don’t qualify for an Advanced Premium Tax Credit or don’t want to take the credit.
• Coverage types: West Virginia has a low uninsured rate (6.6%) because of Medicaid expansion. Although most West Virginians still receive health insurance through an employer (44%), Medicaid is the next largest group (26.6%) than Medicare (19%), nongroup insurance (2.5%), and military (1.3%).

West Virginians who wish to enroll in the state health marketplace should use Healthcare.gov. Once you create an account, you’ll be able to compare plans and see which offers you the best choices for copays, deductibles, and coinsurance. You’ll provide personal information, including your Social Security number and your household income. You’ll need this information for each member of your family you are enrolling.

Once you create your account, you’ll be able to see if you qualify for any premium subsidies or cost-sharing reductions. These will help you reduce your premiums and out-of-pocket expenses.

Small businesses in West Virginia will also see the lowest rates available via SHOP (Small Business Health Option Programs). Businesses that employ between one and 50 people can use SHOP to buy ACA-compliant health care for employees.

There are two plans available for individual health insurance in West Virginia. Both plans are available statewide.

• CareSource West Virginia
• Highmark West Virginia

When comparing plans for yourself or your family, there are questions that you need to answer.

• Am I healthy?
• Does a member of my family have a serious health concern?
• How much am I willing to pay for premiums or out-of-pocket expenses?
• Can I afford to pay this maximum out of pocket in the event of a catastrophe or worst-case scenario?
• Is the specialist I like to go on in-network for this plan?

These questions will help guide you while comparing your health insurance options.

Insurance for individuals in West Virginia

When considering which individual plan to choose, it’s wise to consider your current health situation, usage level, and precise needs for health care coverage when selecting a plan. For example, if you plan to have a baby, look for plans with good maternity coverage and lower deductibles.

If you are generally healthy and don’t often use insurance, look for a balance of premiums and deductibles that you can afford. You may be better off with a plan that charges a higher premium, has a lower deductible and makes it easier to see out-of-network specialists if you have a chronic health problem.

There are different kinds of plans that may fit your needs.

• A Health Maintenance Organization plan (HMO) offers lower overall costs but fewer options for getting health care. For example, you can only use in-network medical providers and will have a pre-assigned primary care provider. You’ll need a referral from your PCP to see a specialist.
• With a Preferred Provider Organization (PPO), you’ll pay a higher monthly premium, but you’ll have more flexibility. For example, you can use out-of-network providers, although it may cost a bit more. In addition, you won’t need to obtain a referral to see a specialist or name a primary care physician.
• A Point of Service Plan (POS) prices strike a balance between cost and choice. If you want to see a specialist, you’ll still need a referral, but you can see out-of-network providers if necessary.

Insurance for families in West Virginia

Your considerations might be a little bit more complex when buying health care for your family. While you may be healthy, if your spouse has a severe health care condition, like prostate or breast cancer, it will impact the kind of health care choices you’ll make. Separate policies may be more cost-effective.

If your family is in relatively good health, an HMO plan with a lower monthly premium and higher deductibles may be a good option. Families with more complex health issues may need to pay a higher premium. If your family requires regular visits to the doctor or needs expensive prescriptions, you’ll want to consider a plan with a lower deductible.

When you buy a plan through the West Virginia Healthcare.gov marketplace, you’ll have an option of four levels of plans. Each level is associated with a different metal: Bronze, Silver, Gold, and Platinum. All ADA-compliant plans offer the same quality health care, regardless of the level.

Whichever plan you pick, you can use premium tax credits that lower your monthly premiums if your income is between 100% to 400% of the Federal Poverty Level. You may also be eligible for cost-sharing reductions (CSRs), which reduce your deductible. However, CSRs apply only to silver plans.

• Bronze plans are the least expensive plans in terms of monthly premiums. Conversely, you will have high deductibles. You’ll also pay a 40% coinsurance fee when you need health care. A bronze plan could work for you if your current health care needs are minimal. The most affordable Bronze plan in West Virginia has a monthly premium of $621.
• Silver plans have higher premiums, but you’ll pay a lower deductible when you need health care. The coinsurance fee is 30% with a silver plan. If you qualify for cost-sharing reductions (CSRs), you could pay less for a Silver plan than a Bronze plan. The lowest-priced Silver plan in West Virginia is $752 a month.
• Gold and Platinum plans are ideal for those with chronic health issues who need a plan with a low deductible. Coinsurance payments are also lower (only 20% for Gold and 10% for Platinum). The downside of the Gold and Silver plans is the much higher monthly premiums. The lowest-priced Gold plan in West Virginia has a monthly premium of $839 a month.

• West Virginia has two programs that provide health coverage for low-income residents: Medicaid and CHIP. Medicaid is a joint effort between West Virginia and the federal government. CHIP covers children in low-income households with coverage based on age and household income.

Medicaid in West Virginia

To be eligible for Medicaid in West Virginia, you need to be one of the following:

• A resident of West Virginia
• AS. citizen
• A permanent resident
• An undocumented immigrant who needs health insurance assistance and whose financial situation is low-income or very low-income

Under the expanded Medicare guidelines, any adult age 19 to 64 is eligible for Medicaid if they have a household income equivalent to 133% of the Federal Poverty Level.

Asset limits are $2,000 for an individual, $3,000 for a couple. The limit is based on income and property but does not include home, furnishings, appliances, and one vehicle.

West Virginia Children’s Health Insurance Program (CHIP)

CHIP provides quality and comprehensive health insurance to eligible children. It is a free or low-cost plan that covers children from birth to age 19. CHIP covers preventive care, immunizations, prescriptions, and well-child visits.

Your family can qualify for CHIP in West Virginia if you earn up to 300% of the federal poverty level. A family with one child cannot earn more than $32,200 a year, with two children $43,550 a year and three children $54,900 a year. Households with more than eight family members can add $11,350 per person to the income limit.

In September 2019, the West Virginia Legislature passed a law enabling pregnant women to receive maternity care under CHIP.

When you approach your 65th birthday, or if you have a qualifying disability, you’ll start to receive notices from the federal government that it’s time to sign up for Medicare. Medicare is the federal health insurance program designed for people aged 65 and older or who are disabled.

• Original Medicare is the most basic form of Medicare. It includes Part A hospital insurance and Part B medical insurance. Original Medicare does not cover prescription drug costs. If you have regular prescriptions, you’ll need to purchase a Medicare Part D plan. 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, or Medicare Part C, is another option. Medicare Advantage offers four different types of plans: HMOs, PPOs, Private Fee-For-Service Plans, and Special Needs Plans. These plans offer vision, dental, and hearing, and many plans offer fitness programs and prescription drug coverage. As of 2022, there were 46 Medicare Advantage Plans available in West Virginia.

A Medicare Supplement Insurance plan fills in the gaps in coverage for Original Medicare. It covers deductibles, co-pays, and coinsurance and can provide you with coverage if you travel outside of the U.S. These plans do not work with Medicare Advantage Plans.

Eligibility

• You must be a U.S. citizen or a permanent resident
• You must be aged at least 65 or have a qualifying disability
• You qualify if you have certain conditions or diseases like End-Stage Renal Disease (ESRD) or Lou Gehrig’s Disease/Amyotrophic Lateral Sclerosis (ALS) or have received Social Security Disability Insurance for 24 months

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

Seniors or their caregivers with questions about Medicare in West Virginia can get help from the West Virginia Office of The Insurance Commissioner, Consumer Services. Another option is the State Health Insurance Assistance Program (SHIP). SHIP counselors are trained volunteers who can help you navigate Medicare options and find the best solution for your situation with free, unbiased, and confidential counseling.

West Virginia has short-term health insurance plans that last for an initial term of up to 364 days. You can renew short-term health insurance for up to 36 months.

These plans are for emergency care if you’re unemployed and don’t qualify for Medicaid or missed open enrollment for a marketplace plan but want coverage for a defined short duration. Short-term plans do not cover pre-existing conditions. Renewal is not guaranteed if you develop a health condition while on the plan.

Some of the conditions not covered by short-term insurance include:

• AIDS
• Asthma
• Cancer
• COPD
• Pregnancy

• Benefits.gov | West Virginia Medicaid | Last accessed January 2022
• CMS.gov | Medicare Open Enrollment | Last accessed January 2022
• Healthcare.gov | ACA-compliant plans (qualified health plan) | Last accessed January 2022
• Healthcare.gov | Cost-Sharing Reduction | Last accessed January 2022
• HealthCare.gov | Deductible | Last accessed January 2022
• HealthCare.gov | Health Maintenance Organization (HMO) | Last accessed January 2022
• HealthCare.gov | Point of Service (POS) Plans | Last accessed January 2022
• HealthCare.gov | Preferred Provider Organization (PPO) | Last accessed January 2022
• Healthcare.gov | Premium Tax Credit | Last accessed January 2022
• HealthCare.gov | The ‘metal’ categories: Bronze, Silver, Gold & Platinum | Last accessed January 2022
• KFF | Health Insurance Coverage of the Total Population | Last accessed January 2022
• Medicare.gov | Part A & Part B sign up periods | Last accessed January 2022
• Special Enrollment Period (SEP) – HealthCare.gov Glossary | Last accessed January 2022
• Verywellhealth | How the ACA’s Subsidy Cliff Has Been Temporarily Eliminated | Last accessed January 2022
• West Virginia Division of Health Promotion and Chronic Disease | Statistics about the Population | Last accessed January 2022