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Medicare Advantage in Washington

Last Updated on

October 6, 2016

If you’re a resident of Washington State and enrolled in Original Medicare, Part A and Part B, you may have some Medicare plan options (offered through private health insurance companies) available to you through Medicare Advantage (Medicare Part C), depending on the zip code in which you live. Medicare Advantage is required by law to offer at least the same benefits as Original Medicare (Part A and Part B). Like residents of other states, Washington residents receive an alternative way to get their Original Medicare benefits while enrolled in a Medicare Advantage plan (except for hospice care, which is still covered by Part A).

How Medicare Advantage works in Washington

Washington Medicare beneficiaries may enroll in a Medicare Advantage plan as an alternative to their Original Medicare coverage. Offered by Medicare-approved private insurance companies in Washington, Medicare Advantage plans cover the same hospitalization and medical benefits offered by Original Medicare. Washington Medicare Advantage plans may offer additional benefits such as vision, hearing, and dental coverage.

In Washington, as in other states, you can enroll in Original Medicare starting three months before you turn 65 up to your birthday month and three months after that. This is the seven-month Initial Enrollment Period (IEP). If you don’t sign up for Original Medicare during your IEP, you can still enroll during the General Enrollment Period, which runs from January 1 to March 31 each year, but you may have to pay a late-enrollment penalty in the form of higher premiums. You can also choose to enroll in a Medicare Advantage plan during the Medicare Initial Coverage Election Period.

If you’re already enrolled in a Medicare Advantage plan and wish to change plans, the best time to do so is during the Annual Election Period (AEP), also called Open Enrollment Period, which runs from October 15 to December 7 each year. When you change Medicare plan options during the AEP in Washington, your new coverage generally begins on January 1 of the following year.

Medicare has special provisions to help you deal with unexpected happenings. If you go through certain special circumstances during the year, you may be able to change Medicare plan options during Special Enrollment Periods (SEPs). These events include moving to a new address, losing your current coverage, qualifying for other coverage, or changes in your current plan that affect your health benefits.

If you’re enrolled in a Medicare Advantage plan and want to switch back to Original Medicare, you can do so during the Medicare Advantage Disenrollment Period, which runs from January 1 to February 14 each year.

Types of Medicare Advantage plans in Washington

Medicare Advantage plans in Washington include, among others, Health Maintenance Organizations (HMOs), Preferred Provider Organization (PPO) plans*, Special Needs Plans (SNPs), Private Fee-for-Service (PFFS) plans, and Medical Savings Account (MSA) plans.

Under a HMO plan, you are required to visit doctors, health-care providers, and hospitals on the health plan’s list, and you may also need a referral from your primary doctor in order to receive coverage for certain health services. HMO Point-of-Service (HMO-POS) plans, on the other hand, usually let you go out of network for certain health services, usually at a higher cost.

A PPO plan in Washington may let you choose doctors, health-care providers, and hospitals outside of the plan’s network, but will pay more by exercising this option.

Medicare SNPs generally limit enrollment to people with special health needs or those living in an institution (such as nursing homes) or people who also qualify for Medicaid. Medicare SNPs offer customized coverage for those specific beneficiaries.

Under a Medicare PFFS in Washington, the plan itself decides how much it will pay for your doctor, health-care provider, and hospital visits, and also determines your share of each expense.

MSA plans provide additional health coverage options for Medicare beneficiaries. These plans generally combine a high deductible with a savings account that beneficiaries can use to pay for their health care expenses.

Many Medicare Advantage plans in Washington also include prescription drug coverage. These plans, known as Medicare Advantage Prescription Drug plans, combine health and prescription drug coverage (Medicare Part D) into one plan. Note that even if you choose to enroll in a Medicare Advantage Prescription Drug plan, you will continue to be enrolled in Original Medicare and must continue paying your Medicare Part B premiums in order not to lose your health coverage.

Comparing Medicare Advantage plans in Washington

Remember that it’s important for you to compare all your available plan options when selecting a Medicare Advantage plan.

The availability and cost of Medicare Advantage plans varies depending on your state and county of residence. Premiums for a Medicare Advantage plan with the same coverage and benefits can vary between different counties within the state of Washington. Some Medicare Advantage plans in Washington may offer premiums as low as $0; but do keep in mind that you must continue paying your Medicare Part B premiums, no matter which Medicare Advantage plan you choose.

Medicare Advantage plans may also offer additional benefits beyond what is included in Original Medicare coverage. You should also decide whether or not you want prescription drug coverage with your Medicare Advantage policy through a Medicare Advantage Prescription Drug plan. With all these options, you can see why it can be important to compare Medicare plan options with the benefits and costs best suited to your specific health needs.

Learn more about how Medicare plans work in Washington including:

* Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.