Medicare Advantage Plans in Washington

Medicare Advantage plans are an alternative to Original Medicare, offered by Medicare-approved private insurance companies. These plans include Part A (hospital insurance) and Part B (medical insurance), and most also include Part D (prescription drug coverage). Many plans offer additional benefits like dental, vision, hearing, telehealth, and fitness programs.

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first enroll in Original Medicare (Parts A and B). Most individuals become eligible for Medicare enrollment at age 65, although those with disabilities or conditions like ALS or ESRD may qualify earlier.

Key enrollment periods include:

• Initial Enrollment Period (IEP)
• General Enrollment Period (GEP)
• Special Enrollment Periods (SEP)

Late enrollment may result in penalties or loss of access to premium-free coverage.

What Types of Medicare Advantage Plans Are Available in Washington?

Washington residents have access to multiple MA plan types:

• Health Maintenance Organizations (HMOs): Require in-network care and often a referral for specialists. You must typically choose a primary care physician (PCP).
• Preferred Provider Organizations (PPOs): Allow out-of-network care at higher costs. You usually don’t need a PCP or referrals.
• Private Fee-for-Service (PFFS) Plans: These plans let you see any provider who accepts the plan’s terms. No PCP required.
• Special Needs Plans (SNPs): Tailored for people with specific circumstances:
  • C-SNPs: For chronic conditions such as cancer or diabetes.
  • I-SNPs: For those in institutions or requiring skilled nursing care.
  • Dual Eligible Special Needs Plans (D-SNPs): For individuals who qualify for both Medicare and Medicaid. These plans often include drug coverage, dental, and coordinated care with little to no out-of-pocket cost.
• Medical Savings Accounts (MSAs): Pair a high-deductible plan with an insurer-funded savings account to help pay medical costs.

What Are Your Prescription Drug Options with Medicare Advantage?

Most Medicare Advantage plans in Washington include Part D drug coverage. However, MSAs and some PFFS plans may not.

If your plan doesn’t include drug coverage:

• You may enroll in a standalone Part D plan, if eligible.
• You could face a late enrollment penalty if you delay coverage without having creditable drug insurance.

How Do You Choose a Medicare Advantage Plan?

Before choosing a plan, understand Medicare Advantage costs:

• Premiums: Some plans offer $0 premiums, while others charge a monthly fee in addition to the standard Part B premium.
• Deductibles, Coinsurance & Copays: These vary. You’ll typically pay a fixed copay or percentage of costs for services.
• Out-of-Pocket Maximums: This cap limits your annual expenses for covered services. After reaching it, the plan covers 100% of your costs.
• Extra Benefits: Many plans offer dental, vision, telehealth, transportation services, and even fitness class memberships.

When and How Do You Enroll in a Medicare Advantage Plan?

You can enroll in Medicare during the following specific enrollment periods:

• Initial Enrollment: Starts 3 months before and ends 3 months after your 65th birthday month.
• Annual Open Enrollment (Oct 15–Dec 7): Join, switch, or drop your MA plan.
• General Enrollment (Jan 1–Mar 31): For those enrolling in Medicare Part B late.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Switch MA plans or return to Original Medicare.
• Special Enrollment Periods: Triggered by:
  • Moving outside your plan’s area
  • Losing employer or Medicaid coverage
  • Plan termination
  • Developing a qualifying medical condition for an SNP

What If You Want to Change Your Medicare Advantage Plan?

You can switch your MA plan during:

• Open Enrollment (Oct 15–Dec 7)
• Medicare Advantage Open Enrollment (Jan 1–Mar 31)

When you enroll in a new plan, your old plan is automatically canceled once the new one begins.

Understanding Medicare Advantage Star Ratings

The CMS star ratings system is how the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) plans using a 5-star quality scale. These ratings help consumers compare the performance of different plans based on a standardized set of measures.

CMS Star Ratings Overview

• 1 star: Poor performance
• 2 stars: Below average
• 3 stars: Average
• 4 stars: Above average
• 5 stars: Excellent

These ratings are updated annually and reflect data collected from Medicare Advantage (Part C) and Medicare Advantage Prescription Drug Plans (Part D).

What Are Medicare Resources in Washington?

Washington offers several state-run resources for Medicare support:

• Statewide Health Insurance Benefits Advisors (SHIBA): Offers free Medicare counseling and guidance.
• Washington Senior Medicare Patrol (SMP): Helps beneficiaries prevent, detect, and report Medicare fraud.
• Washington State Office of the Insurance Commissioner: Handles insurance-related complaints.
• Washington Apple Health (Medicaid): Offers assistance to low-income residents. Call 1-800-562-3022 or visit the website to check eligibility.

Learn more about the differences between Medicare and Medicaid.

Other Medicare Plan Options to Help with Out-of-Pocket Costs

Medicare Supplement Plans, also known as Medigap, help pay for costs that Original Medicare doesn’t cover, such as deductibles, coinsurance, and copays.

• You must be enrolled in Parts A and B to purchase a Medigap plan.
• The best time to enroll is during your six-month Medigap Open Enrollment Period after signing up for Part B. During this period, you’re guaranteed coverage.
• After this period, insurers may require medical underwriting.
• Medigap plans do not include prescription drug coverage, so you’ll need a separate Part D plan.

There are 10 standardized Medigap plans. Medicare Supplement Plan G had the highest enrollment in 2023 and is one of the fastest-growing options, alongside Plan N. Plan F is no longer available to new Medicare beneficiaries.

Learn more about Medicare Supplement plans in Washington.

Next Steps

If a Medicare Advantage plan in Washington sounds right for you, explore the available options in your ZIP code. Compare costs, provider networks, drug coverage, and added benefits. Be ready to enroll during your appropriate window.