Medicare Advantage Plans in the District of Columbia
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: Jun 25, 2021
Medicare Advantage, which is sometimes referred to as Medicare Part C, offers D.C. seniors an alternative to Original Medicare. Plans are provided by Medicare-approved private insurers and have benefits similar to Medicare Parts A and B. All plans include coverage for medical and hospitalization services and emergency medical treatment but may also include bundled options for vision, dental, and hearing benefits and prescription drugs. Some plans even provide extra services, such as medical transportation, fitness programs, and over-the-counter drugs. Premiums, covered services, and out-of-pocket costs for treatment can vary widely by region, carrier, and type of plan.
- 1 In 2019, there were seven Medicare Advantage plans available in the District of Columbia.
- 2 16% of the total Medicare population in the District of Columbia is enrolled in Medicare Advantage plans as of 2018.
- 3 SNP enrollment in the District of Columbia made up 55% of the regions’ total Medicare Advantage program during 2020.
- 4 In 2020, approximately one in five Medicare Advantage participants are enrolled in employer- or union-sponsored plans designed for their retirees.
Original Medicare and Medicare Advantage plans must adhere to the same overarching set of rules, so enrollees can expect identical rights and protections. By bundling services, MA plans offer an extensive choice of comprehensive coverage options, often limiting out-of-pocket expenses so seniors can better manage their healthcare expenses. Plans do have notable differences in coverage. Members of some plans may be required to choose a primary care physician, obtain referrals for specialist visits, or receive in-network care depending on the policy they select.
Medicare Advantage Plans in the District of Columbia
Types of Medicare Advantage Plans
The District of Columbia’s Medicare Advantage program lets seniors choose from several types of plans, including HMOs, PPOs, and PFFS plans. SNPs may also be available to seniors who have certain disabling or chronic medical conditions, such as diabetes or cancer, and individuals receiving long-term residential care. Coverage rules vary widely among plan types, and prescription drug coverage is available through selected policies.
Health Maintenance Organizations (HMO)
Members of HMO plans usually receive all care services through a network of plan-approved physicians, specialists, and hospitals. Upon enrollment, each participant must choose a primary care physician (PCP), who provides general and preventative care services, initiates treatment, and supplies referrals to specialists. Members generally aren’t covered for out-of-network care, except in emergencies. Because these plans typically offer low premiums and small or no deductibles and co-pays, HMOs are considered to be the most affordable option out of all the Medicare Advantage plan types. Members may bundle in prescription drug coverage and usually incur a higher premium by doing so.
Preferred Provider Organizations (PPO)
Medicare Advantage participants can opt for more flexibility by choosing a PPO plan, although higher premiums and deductibles may offset the benefit. PPO members may keep costs down by receiving care from in-network providers or opt to see out-of-network physicians and specialists at a higher cost. They may, however, seek emergency treatment at any hospital or medical facility. Members generally don’t have to declare a PCP, and referrals aren’t required for specialist visits. Depending on the plan, prescription drug coverage may be bundled in.
Private Fee-For-Service Plans (PFFS)
PFFS plans maintain networks of preferred providers to help seniors keep costs low. Still, members may opt to receive care from any Medicare-approved practitioner or facility that agrees to the plan’s terms. These highly flexible PFFS plans typically come with higher premiums, and Medicare always determines the cost of care. Unlike network providers, out-of-network practitioners and facilities have the option of refusing services to plan participants at their discretion. PFFS plans don’t require members to select a PCP, and members don’t need referrals for visits to specialists. Some policies may offer the option of bundling in prescription drug coverage. Members who want this benefit may also purchase a Medicare Part D plan to supplement their coverage.
Special Needs Plans (SNP)
SNPs are designed to accommodate the needs of special interest groups, such as seniors living with chronic or disabling conditions, including dementia, diabetes, and chronic heart failure. Dual Medicare/Medicaid-eligible seniors, residents of skilled nursing or long-term care facilities, and individuals with drug or alcohol dependencies may also qualify for SNPs. These targeted benefit plans offer tailored networks of providers and special drug formularies to meet the unique needs of their members. Except for emergencies, all services must be rendered by in-network providers and facilities. Designated care coordinators oversee all treatment, and participants must typically obtain referrals for specialist visits. SNP availability may vary by year and geographical area, but prescription drug coverage is always included.
Enrollment & Eligibility for Medicare Advantage Plans in District of Columbia
Depending on a beneficiary’s circumstances, Medicare enrollment may be automatic, or the enrollee can initiate it. Applicants of the District of Columbia’s Medicare Advantage program must meet the following eligibility criteria:
- Qualify for Medicare Parts A and B
- Be aged 65 or older (or be diagnosed with a qualifying disability if younger)
- Be citizens or legal residents of the United States
- Not enrolled in Medigap insurance
For a qualified applicant to enroll in a policy, Medicare Advantage plans must be available in their state and county of residence. Seniors with End Stage Renal Disease don’t qualify for most Medicare Advantage plans, although they may enroll in applicable SNPs.
If a senior has been receiving Social Security or Railroad Retirement Board benefits for a minimum of four months prior to turning 65, they are automatically enrolled in Medicare Parts A and B. In lieu of Original Medicare, they may elect to receive benefits through an Advantage plan. They may also opt to switch from Original Medicare to an MA plan during their annual enrollment period.
During four specific enrollment periods, seniors may modify or drop their Medicare Advantage plan or enroll for the first time. Participants may switch policies or insurers or revert to Medicare Parts A and B. Seniors who’ve recently lost their healthcare coverage or who’ve experienced specific life events such as release from jail, a change of address, or a move into a residential care facility may also qualify for a special enrollment period.
- The seven-month period surrounding and including a senior’s 65th birthday month is known as the initial coverage election period. During this period, seniors who are aging into the program may enroll in a Medicare Advantage plan.
- The annual election period starts on October 15th and ends on December 7th. At this time, current Medicare Part A and B recipients may switch to an MA plan, and current Advantage enrollees may switch policies or carriers or opt for a plan that bundles in prescription drug coverage.
- During Medicare’s open enrollment period, current Medicare Advantage participants may change policies, switch to another carrier, or revert to Medicare Parts A and B. The period begins on January 1st and runs through March 31st each year.
- Between April 1st and June 30th, seniors can take advantage of Medicare’s general enrollment period. During this time frame, Medicare A participants who’ve added Part B during the recent open enrollment period may switch to a Medicare Advantage plan.
Prescription Drug Coverage
Prescription drug coverage is available through an array of Medicare Advantage Prescription Drug plans (MA-PDs), which are often bundled with the different types of MA plans. Members participating in HMO and PPO plans should make sure to choose a plan that bundles in prescription drug coverage if they want this benefit because they can’t add on a separate Medicare Part D prescription drug plan. Members who attempt to add a Part D plan to their coverage forfeit Medicare Advantage. Members of PFFS plans have flexibility regarding prescription drug coverage and can receive benefits bundled into their plan or add on a separate Medicare Part D plan. SNPs are the only type of MA plan that requires the inclusion of prescription drug coverage by law. The types of medications covered, their costs, and the price of premiums vary by insurance carrier and individual policy.
Medicare Advantage Resources in District of Columbia
D.C. seniors have a wide array of Medicare Advantage healthcare plans to choose from, creating challenges in selecting the right coverage. Navigating the ins and outs of benefits can be overwhelming, especially for members looking to switch plans or those enrolling in Medicare for the first time. Resources throughout the District of Columbia can help current and future enrollees understand the program’s stringent eligibility requirements and compare available plans and carriers so they can find coverage that suits their unique healthcare needs while staying within their budget.
The Department of Aging and Community Living (DACL)
The DACL’s Health Insurance Counseling program offers several no-cost services to D.C. residents aged 60 and older, their caregivers, and their families. Trained counselors provide information, education, and one-on-one assistance to help Medicare beneficiaries understand the coverage options available to them. The agency may also help seniors appeal insurance denials, obtain prescription medications, and resolve unpaid medical bills.
Contact Information: Website | 202-727-8370
Neighborhood Legal Services Program (NLSP)
NLSP provides no-cost civil legal services to low-income seniors living in the D.C. area. The agency helps seniors obtain healthcare benefits, such as Medicare and Medicaid, and may also help them fight the wrongful denial or termination of benefits. If NLSP is unable to assist with an issue, it provides referrals to applicable organizations. An online intake form is available 24 hours a day to help seniors determine if they’re eligible for services.
Contact Information: Website | 202-832-6577
D.C. Office of Health Care Ombudsman and Bill of Rights
The District of Columbia’s Office of Health Care Ombudsman and Bill of Rights was designed to help guide D.C. residents through the complexities of the nation’s healthcare system. Agency representatives provide confidential guidance and advocacy, helping seniors understand their Medicare coverage options and file appeals. The agency also sponsors a monthly Health Care On Tap program, which creates a casual group atmosphere where seniors can get answers to benefit-related questions.
Contact Information: Website | 202-724-7491
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https://www.medicare.gov/sign-up-change-plans/get-started-with-medicare | Last accessed June 2021
https://www.medicare.gov/blog/medicare-enrollment-period-2020 | Last accessed June 2021
https://www.medicare.gov/sign-up-change-plans/joining-a-health-or-drug-plan | Last accessed June 2021
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Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.