Medicare Advantage plans are a comprehensive alternative to Original Medicare. These plans, which may also be referred to as Medicare Part C or MA plans, are offered by private health insurance companies approved by Medicare. Like Original Medicare Parts A and B, Medicare Advantage plans cover hospital and medical costs. They may also feature additional covered services, such as prescription drug, hearing, vision and dental coverage. Unlike Original Medicare, Medicare Advantage plans vary in out-of-pocket limits, coverage options and availability.
Medicare Advantage plans, which were first offered in 1997, have become increasingly popular in the past decade and comprise a significant part of the Medicare program. Nationwide, roughly 34% of all seniors are enrolled in a Medicare Advantage plan. In Washington, the stats are comparable, with about 32% of seniors opting for a Medicare Advantage plan over Original Medicare. Medicare Advantage is most popular in Spokane, Lewis, Thurston, Mason and Whatcom Counties, where between 31%-40% of seniors are enrolled in a Medicare Advantage plan. Less than 1% of seniors in Garfield, Ferry, Lincoln, Klickitat and Pend Oreille Counties have Medicare Advantage plans.
Washington seniors who are interested in exploring Medicare Advantage plans have several insurance providers and plans to choose from. In some cases, plans and benefits vary by county. In Washington, there are five main types of Medicare Advantage plans, including PPO, HMO, SNP, PFFS and MSA plans. In this guide, we’ve outlined these five plan types, prescription drug coverage of Washington seniors enrolled in Medicare Advantage and when enrollment is open. We’ve also included Medicare resources for Washingtonians who want assistance in finding the best plan type for their needs and budget.
Medicare Advantage features several different plan types for seniors in Washington to choose from. These include Preferred Provider Organizations, Health Maintenance Organizations, Special Needs Plans, Private-Fee-for-Service plans and Medical Savings Account plans.
Preferred Provider Organizations
PPO plans have network hospitals and health care providers with whom the health insurance company has negotiated special rates for services. Members pay less when they use doctors, specialists and hospitals that are within their PPO plan’s network. While coverage is typically available for out-of-network providers, out-of-pocket costs are generally considerably higher. In most cases, PPO plans cover prescription drugs and the member isn’t required to choose a primary care doctor and doesn’t need a referral to see a specialist.
Health Maintenance Organizations
HMO plans also feature in-network health care providers and hospitals that members must receive care from to have their medical bills covered. Some plans allow for out-of-network emergency care and out-of-area urgent care and dialysis, as well as some types of services. Under normal circumstances, if a member goes out-of-network for medical care, they are responsible for the full cost. In most cases, members with HMO plans are required to choose a primary care doctor and receive a referral to see a specialist. Most HMO plans provide prescription drug coverage.
Special Needs Plans
SNPs are exclusively for members who have certain characteristics or diseases, such as those who live in nursing homes, those who are dually eligible for Medicare and Medicaid and those who have a specific chronic condition, such as dementia or diabetes. These plans have benefits, drug formularies and provider choices that are tailored to fit the needs of the groups they serve. They have in-network hospitals and health care providers that members must receive care from to have services covered, except in the event of an emergency or urgent care or if they have end-stage renal disease and need dialysis outside of their plan’s service area. All SNPs are required to provide prescription drug coverage, and in most cases, members need a referral to see a specialist.
PFFS plans are unique from other Medicare Advantage plans in that the health insurance company, not Medicare, determines how much it pays the health care provider and how much the member pays for a covered service. Members can use their plan at any health care provider that accepts that plan’s payment terms. Nonnetwork providers can accept the plan’s payment terms on a patient-by-patient, case-by-case basis, and they may refuse to accept the plan’s coverage for a particular service. All PFFS plans must cover any service that’s considered medically necessary under Original Medicare, and some plans cover prescription drugs. Members don’t need to choose a primary care physician and they don’t need a referral to see a specialist.
Medical Savings Account Plans
An MSA plan is a type of Medicare Advantage plan that combines a high-deductible health insurance plan with a medical savings account. These plans, which are also called consumer-directed Medicare Advantage plans, are similar to Health Savings Account plans that are available outside of Medicare. They feature high-deductible Medicare Advantage plans that only cover medical costs once the member meets their high annual deductible, along with a special type of savings account with funds that are used to pay for health care costs before the deductible is met. MSA plans don’t include prescription drug coverage, but some plans cover dental, vision and long-term care services not covered by Original Medicare.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
In Washington, many Medicare Advantage plans provide coverage beyond what Original Medicare requires, including coverage for prescription drugs. Seniors enrolling in an HMO plan, PPO plan or SNP who want prescription drug coverage should ensure that the plan they choose has this coverage. Medicare Advantage plans that cover prescription drugs are required to follow the same rules as Medicare Part D and are often referred to as MA-PD plans. The state allows Medicare beneficiaries to add Part D prescription coverage to some Medicare Advantage plans, including PFFS and MSA plans. In this case, the member generally pays two separate premiums, including one for their health care plan and one for prescription drug coverage.
Medicare is an essential service that enables seniors to receive the medical care they need, even as their needs change. However, there isn’t a one-size-fits-all plan, and many seniors find it difficult to determine which plans are available in their area and provide the right coverage at an affordable price. We’ve compiled a list of state and local resources in Washington to help seniors find the best coverage for their needs.
Washington’s SHIBA program provides free unbiased and confidential help to seniors who are researching their Medicare Advantage options. Its volunteer advisors are located throughout the state and help seniors assess their coverage needs, determine what plans they’re eligible for and evaluate and compare health insurance plans. SHIBA volunteers can also help seniors enroll in Medicare, speak with the Medicare office on the senior’s behalf and provide referrals to other programs and local agencies. SHIBA serves Washington residents of all ages and backgrounds and doesn’t restrict eligibility for services. SHIBA also collects and reports possible fraud complaints and organizes an array of events, including Medicare classes and Open Enrollment events, walk-in clinics, one-on-one counseling sessions, health fairs and presentations about insurance fraud.
WASHAA is a nonprofit organization that promotes health advocacy and assists individuals in understanding and accessing health care. It helps seniors understand what Medicare plans they’re eligible for and explains their out-of-pocket costs, such as coinsurance and co-pays. Its volunteer advocates assist seniors in researching in-network health care providers, and they clarify the out-of-network options and associated costs. The organization also advises on the denials and appeals process for health care services that are denied coverage. Its health advocates help people from all walks of life, and services are available to anyone who needs them. In addition to helping seniors understand their Medicare options, the organization offers a variety of services, including helping patients and families understand complicated medical information and diagnoses, resolve billing errors and negotiate to reduce medical bills and facilitate older adult services, such as transportation and meal delivery and end-of-life planning.
The Washington Office of the Insurance Commissioner serves as an advocate for Medicare beneficiaries and educates the public about access to insurance and medical care. Through this resource, seniors can learn how health insurance works, get information regarding their coverage options and out-of-pocket costs and receive free, unbiased Medicare counseling in their area. The Office of the Insurance Commissioner also assists seniors in appealing Medicare coverage or payment decisions and filing complaints against their insurance company. This office serves all Washington residents, regardless of income or age. Other services it provides include educating the public on identifying and reporting Medicare fraud and abuse, outlining health insurance options for those with disabilities and enrolling in Original Medicare or a Medicare Advantage plan.
The AdvoConnection Directory is an extensive directory of independent health advocates who provide an array of supports to seniors. Some services that advocates may provide include accompanying participants to medical appointments, finding legal assistance after a medical error, helping to research Medicare Advantage plan options and handling claim denials and appeals for medical billing. Seniors can search for advocates who are experienced in specific fields, such as medical navigation assistance, health insurance, legal assistance related to health care and paperwork. All advocates and case managers listed in the directory are registered members of the Alliance of Professional Health Advocates. This service is available to everyone and doesn’t have eligibility requirements. On the website, seniors can also read about topics on patient empowerment.
The Washington Association of Area Agencies on Aging (W4A) is a membership organization that comprises over a dozen Area Agencies on Aging in the state. W4A provides a variety of resources to seniors and individuals with disabilities, including advocacy and informational resources. Services vary by location and include caregiver support, information on Medicare Advantage plans and guidance on assistance programs that are available for low-income seniors who are unable to afford their premiums, deductibles and copays. To be eligible for assistance through W4A, seniors must be at least 65 years old and live in the service area of a local agency. In addition to helping seniors understand their Medicare Advantage options, W4A facilitates services, such as meal deliveries, volunteer chore services and case management.
Aging and Disability Resource Centers, which are operated by the Washington State Department of Social and Health Services, provide easy access to home and community supports and services for seniors and those with disabilities. Its local centers increase awareness of the options that are available to seniors, including insurance programs like Medicare Advantage. It provides objective information, advice and counseling, enabling seniors to make informed decisions and more easily access public and private supports and services programs. These services are available to all Washington residents and have no age or income restrictions. In addition to options counseling, ADRC provides a wide array of services, including informational resources for long-term services and supports, adult abuse and prevention and in-home care.