How It Works and Who It’s For

Anyone who lives in West Virginia, is a U.S. citizen or lawfully present, is not incarcerated, and is not enrolled in Medicare can buy Marketplace coverage. The Marketplace is especially useful for people without affordable employer coverage, Medicaid, or CHIP. Most enrollees qualify for financial assistance, such as premium tax credits and cost-sharing reductions, based on income and household size.

Open Enrollment Period in West Virginia

• Open Enrollment for 2025: November 1, 2024 – January 15, 2025

• Enroll by December 15 for coverage starting January 1, 2025

• Enroll between December 16 and January 15 for coverage starting February 1, 2025

Outside this window, you need a Special Enrollment Period (SEP) to enroll or change plans, usually triggered by a qualifying life event such as loss of coverage, marriage, or moving.

Special Enrollment Period (SEP) Rules

You may qualify for a SEP if you experience a qualifying life event, including:

• Loss of other health coverage

• Marriage or divorce

• Birth or adoption of a child

• Change in residence

Some SEPs are available without a specific event, such as for those with incomes below 150% of the poverty level or for Native Americans. There is also an extended SEP for people who lose Medicaid or CHIP coverage during certain periods.

Types of Health Insurance Plans Available

Marketplace plans in West Virginia are offered in four “metal” tiers:

• Catastrophic Plans: For those under 30 or with a hardship exemption; low premiums, high deductibles, and coverage for all essential benefits after the deductible is met.

Plan Types:

• HMO: Lower premiums, limited network, referrals required for specialists. CareSource is the main HMO provider.

• PPO: Higher premiums, broader network, out-of-network coverage, no referrals. Highmark Blue Cross Blue Shield is the main PPO provider.

• EPO: Must use network providers, no out-of-network coverage except emergencies, no referrals needed.

Eligibility for Subsidies and Cost Assistance

• Premium Tax Credits: Available for incomes between 100% and 400% of the federal poverty level, with expanded eligibility through 2025. Most West Virginia enrollees receive subsidies, which are among the largest in the nation.

• Cost-Sharing Reductions (CSR): For incomes up to 250% FPL on Silver plans, reducing deductibles and out-of-pocket costs.

• Medicaid/CHIP: West Virginia expanded Medicaid to adults up to 138% FPL. CHIP covers children in families with higher incomes. Medicaid and CHIP enrollment is open year-round.

How to Compare and Choose a Plan in West Virginia

When comparing plans, consider:

• Premiums: Monthly cost

• Deductibles/Out-of-Pocket Maximums: What you’ll pay before coverage kicks in

• Provider Networks: Ensure your doctors and hospitals are in-network

• Drug Formularies: Check if your medications are covered

Tips:

• Self-employed: Consider high-deductible plans with HSAs for tax benefits.

• Families: Look for pediatric dental/vision, family out-of-pocket limits.

• Retirees: Marketplace coverage bridges the gap until Medicare at 65.

Top Insurance Providers on the West Virginia Exchange

For 2025, two insurers offer Marketplace coverage statewide:

• CareSource: Best for affordable premiums and Silver HMO plans.

• Highmark Blue Cross Blue Shield: Best for low out-of-pocket costs and PPO options.

Off-exchange, The Health Plan of West Virginia offers additional policies but does not accept subsidies.

Navigating West Virginia’s Online Enrollment Portal

How to Apply:

1. Go to the federal enrollment website and create an account.

2. Enter household and income information to check eligibility for subsidies or programs.

3. Compare available plans by premiums, coverage, and network.

4. Select a plan and complete enrollment.

5. Pay your first premium to activate coverage.

Where to Get Help:

• Free, in-person help is available from ACA Navigators, agents, and community health centers statewide. Assistance is available in multiple languages and locations.

Alternatives to the Marketplace

• Short-term health plans: Available for up to three months (renewable for one month, max four months); not ACA-compliant and may exclude pre-existing conditions. Enrollment is open year-round.

• Off-exchange private plans: Purchased directly from insurers; no subsidies available, but may offer different networks or benefits.

• Faith-based health-sharing ministries: Not insurance, lack ACA protections, but recognized by state law as exempt from insurance regulation.

Common Mistakes to Avoid During Enrollment

• Waiting too long to enroll

• Not assessing your or your family’s needs

• Ignoring plan details

• Skipping preventive care

• Forgetting to update income or household information

• Underestimating costs

• Choosing the wrong metal tier for your needs

State-Specific Health Programs or Initiatives

• Medicaid Expansion: West Virginia expanded Medicaid to adults up to 138% FPL.

• Navigator Assistance: Free enrollment help is available statewide, including in-person, phone, and virtual support.

• Public Health Initiatives: Programs like ActiveWV 2030 promote healthy living, disease prevention, and access to care.

• Legislative Updates: Health care sharing ministries are recognized as separate from insurance by state law.

West Virginia’s Marketplace offers a range of plans, strong consumer protections, and robust assistance for residents seeking affordable health coverage.