Medicare Advantage Plans in Washington
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: March 10, 2021
Medicare Advantage, also known as Medicare Part C, offers Washington seniors at least the same benefits as Original Medicare Parts A and B but may provide extra perks as well. In addition to hospital and general costs, Medicare Advantage plans in Washington typically cover the costs of prescription drugs, vision, dental, and hearing services. Instead of being managed directly by the federal government, Medicare Part C is administered by private insurance companies approved by Medicare.
- 1 In 2019, there were 106 Medicare Advantage plans available in Washington.
- 2 31% of the total Medicare population in Washington was enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $8,163 per beneficiary in Washington, which is 19% lower than the national average.
- 4 Available Medicare Advantage plans range from 1 to 53 across Washington’s 39 counties.
Medicare Advantage plans in Washington vary in coverage and cost. This allows seniors to easily compare plans to find the level of coverage that suits their individual needs. The availability of plans will depend on the individual health insurance provider and also the geographic location of the member enrolling. Any selected plan must also follow the coverage rules set out by Medicare and offer the same benefits, rights and protection as the Original Medicare plan. Plan options include Health Maintenance Organizations, Preferred Provider Organizations, Special Needs Plans, and Private Fee-For-Service plans.
Medicare Advantage Plans in Washington
Types of Medicare Advantage Plans
Washington’s Medicare Advantage program offers several types of plans, and availability may vary throughout the state. For example, seniors typically have the option of choosing between Health Maintenance Organization (HMO) plans and Planned Provider Organization (PPO) plans. Another plan category that may be available is Special Needs Plans (SNP). These plans are designed for beneficiaries with specific conditions and illnesses. Each plan has its own eligibility rules and criteria when it comes to enrollment, especially in the case of SNPs. The good news is that the private insurance companies administering these plans will be able to answer any questions and recommend the most suitable plan.
Health Maintenance Organization (HMO)
When enrolled in an HMO plan, the participant must receive medical care from a specific network of medical providers, unless emergency medical treatment is required. If they seek general medical treatment beyond this network of providers, all costs must be covered by the participant. The participant is also required to select a primary care physician who will be responsible for all treatment decisions and making specialist referrals if necessary. While an HMO plan is one of the most restrictive plans when it comes to network rules, most plans in this category are more affordable than other Medicare Advantage plans in Washington and come with low or no deductibles.
Planned Provider Organizations (PPO)
While a PPO plan may generally cost more than an HMO plan and always includes deductibles, this type of plan offers participants more flexibility regarding network rules. PPOs still use a preferred network of providers, but the selection will typically offer more choice than other plans. These plans usually pay the participant at least a fraction of the cost of any healthcare services that are received outside this network. However, because in-network providers offer reduced rates to PPO members, they will receive the lowest co-pay and coinsurance rates. PPO participants are not required to choose a primary care provider or obtain a referral to see a specialist.
Private Fee-For-Service Plans (PFFS)
PFFS plans offer the highest level of flexibility when it comes to choosing a healthcare provider. This type of plan may have a full or partial network of providers or no network at all. Members can opt for out-of-network doctors, hospitals, and other providers who accept the terms of the plan. However, the costs incurred will usually be lower if the member stays within their network. Healthcare providers receive payments on a fee-for-service basis when they are part of a PFFS plan and decide how much members pay for services and how much the plan pays. As a result, PFFS plans can command higher premiums.
Special Needs Plans (SNP)
SNPs come with stricter enrollment requirements than other plans and are only available to certain members. As a result of their specific enrolment criteria and the cover they provide, SNP premiums may be higher than other plans. However, they offer a range of benefits tailored to a member’s specific needs. For example, seniors who have certain disabling or chronic illnesses or diseases may be eligible for an SNP designed to cover their specific circumstances. SNPs also have a network of targeted providers, and participants must receive all care from within this network. Another point to note about SNPs is that they are quite limited in geographic coverage. For this reason, it may be harder for qualified participants to find a plan in their area.
Enrollment & Eligibility for Medicare Advantage Plans in Washington
Seniors who are eligible to enroll in Medicare Parts A and B will also qualify to enroll in Washington’s Medicare Advantage program if they meet the following criteria:
- Are at least 65 years old, or if younger, have a qualifying disability
- Live in an area where Medicare Advantage plans are sold
- Not be enrolled in Medigap insurance
- Be a U.S. citizen or permanent resident
- Live in an area where Medicare plans are sold
- Not have end-stage renal disease, but SNPs may still be an option
The enrollment periods for Medicare Advantage can vary depending on a number of criteria. Some may be open to first-time applications, while others may only be available to existing members who wish to change to a different plan. Enrollment periods are as follows:
- The initial coverage election periods for Medicare Advantage are for first-time members and run over a seven-month period. This period includes the three months before an applicant’s 65th birthday month and the three months that follow.
- Annual election periods run from October 15 to December 17. This enrollment period is limited to Medicare members switching to Medicare Advantage for the first time, or to existing Medicare Advantage members looking to change their plan.
- Open enrollment periods are limited to existing Medicare Advantage members who are changing plans or moving back to Original Medicare and run from January 1 to March 31.
- General enrollment periods run from April 1 to June 30. They are only available to Medicare Part A members who enrolled in Part B for the first time during the open enrollment period and who want to switch to Medicare Advantage.
Prescription Drug Coverage
Medicare prescription drug coverage, also known as Medicare Part D, is an optional benefit available to anybody with a Medicare plan. Prescription drug coverage may come bundled in a Medicare Advantage Prescription Drug plan, otherwise known as an MA-PD. Members with an HMO or PPO that does not include drug coverage will not be allowed to obtain stand-alone Medicare Part D coverage. Some PFFS plans may come with prescription drug coverage or permit beneficiaries to enroll in a stand-alone Medicare Part D plan. SNPs are legally required to include coverage for prescription drugs.
Medicare Advantage Resources in Washington
It is so important that seniors have access to healthcare resources that are suited to their needs and deliver a high standard of care. Medicare Advantage offers the perfect solution for seniors looking for extensive and comprehensive health insurance coverage. Washington’s Medicare Advantage program provides a wide range of plans and options throughout the state. However, such a broad range of plans and options can often confuse first-time applicants and those looking to switch plans to find the right coverage. To ensure seniors have access to the answers they need to make these decisions, Washington offers a number of resources at local and state levels that provide free Medicare counseling services to qualifying seniors.
SHIBA stands for Statewide Health Insurance Benefits Advisors. Part of the insurance commissioner’s consumer protection services, SHIBA offers free, confidential, and unbiased assistance to individuals considering a Medicare plan in Washington. The service provides a number of ways to receive Medicare counseling, including one to one phone counseling or remote counseling over Zoom. SHIBA also runs several programs throughout the month, including a Medicare fraud presentation, open enrollment events, health fairs, walk-in clinics, and personalized support sessions.
Contact Information: Website | 800-562-6900
Washington State Health Care Authority
Washington State Health Care Authority (HCA) is dedicated to providing the highest standard in whole-person care. On the HCA website, individuals interested in enrolling in Medicare can find the answers to common questions, including what coverage different plans have to offer, how to obtain coverage for prescription drugs, Medicare insurance supplements (Medigap), and more.
Contact Information: Website | 1-855-682-0787
Aging and Disability Services
Aging and Disability Services is located in Seattle and is one of Washington’s 13 Area Agencies on Aging. These agencies offer counseling for those looking to enroll in a Medicare plan and arrange Medicare presentations throughout the year. Aging and Disability Services may also be able to help individuals to enroll in Medicare plans at a lower cost by coordinating longer-term interventions and transitional care for high-risk patients with multiple medical and social requirements.
Contact Information: Website | 206-684-0660
- Sources [-]
https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans Last accessed April 2021
https://www.medicare.gov/blog/medicare-enrollment-period-2020 Last accessed April 2021
https://www.medicare.gov/drug-coverage-part-d Last accessed April 2021
https://www.insurance.wa.gov/statewide-health-insurance-benefits-advisors-shiba Last accessed April 2021
http://www.carewashington.org/list10_wa_Aging_Services_senior_centers.htm Last accessed April 2021
https://www.agingkingcounty.org/ Last accessed April 2021
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.