Medicare in Washington

The federal government operates a nationwide health insurance system for seniors called Medicare. The Medicare program provides health coverage to seniors aged 65 and over, and to other adults with various qualifying medical conditions.

In 2020, about 1.4 million of Washington’s 7.7 million people were Medicare beneficiaries. These people participated in Medicare in various ways, including Medicare Advantage, sometimes called Part C. Medicare Advantage is a fairly popular choice among Washington seniors, with Part C growth outpacing Original Medicare year over year.

The number of Washingtonians who qualify for Medicare has been increasing for years, with further growth projected through 2040. Medicare currently spends about $830 billion a year on its coverage, or $12,888 for each beneficiary.

Most of the people enrolled in the program participate in Original Medicare. This is the traditional way to get coverage, and it comes in several parts. Part A is provided premium-free for most seniors and covers much of the cost of hospital stays. Part B is Medicare’s outpatient benefit. Unlike Part A, Part B benefits come with a premium, which in 2022 is $170.10 a month.

Some seniors choose to receive their benefits through Medicare Advantage, or Part C. Part C plans are required to offer all of the same benefits as Parts A and B, but they are free to offer extras, such as vision and dental coverage. Part D is the prescription drug benefit and is added to most Part C plans.

This guide discusses Medicare options in Washington, and it includes information about how seniors can personalize their coverage. It includes a list of resources seniors can turn to for help making decisions about their care.

Options for Medicare Coverage in Washington

Original Medicare may be the most popular choice for seniors to manage their benefits, but it isn’t the most appropriate path for every older adult. Washington’s seniors have several options available to help them build a care plan that works best for them. Available plans may include Original Medicare, Medicare Advantage, Medigap and other privately issued supplemental policies.

Original Medicare (Parts A & B)

Original Medicare is administered by the Centers for Medicare & Medicaid Services (CMS)and is open to seniors aged 65 and over, along with those under 65 years old, but with certain disabilities or end-stage kidney disease. It includes two parts. Part A covers inpatient hospital care, nursing home and skilled nursing care, hospice and home health care. Part B, or medical coverage, pays for medically necessary goods and services such as durable medical equipment, mental health services and emergency medical transportation. 

Unlike most private Medicare plans, Original Medicare’s provider network isn’t limited to the beneficiary’s geographic region, making it easier to obtain services while traveling within the country. In most cases, Medicare doesn’t pay for health services the individual receives outside the United States. 

Under this program, seniors pay for services as they receive them. They must pay an annual deductible, which is $1,556 for Part A and $233 for Part B in 2022. After they’ve paid this amount, Medicare covers all eligible services at 80%. Beneficiaries pay the remaining 20% out of pocket.

Who Should Consider Original Medicare

Original Medicare may be a good option for those who:

• Travel frequently within the United States
• Don’t need extra benefits such as home-delivered meals and coverage for over-the-counter medication
• Want to choose their own prescription drug coverage

Medicare Advantage (Part C)

Original Medicare is not the only path to getting the Medicare coverage seniors need. An ever-increasing number of seniors choose to sign up for a Medicare Advantage plan that’s more closely tailored to meet their unique coverage needs. Medicare Advantage, sometimes called Part C, is a comprehensive health plan that provides the same benefits as Parts A and B for a single premium. Part C plans also include additional benefits, such as dental and vision, that Original Medicare lacks. Hospice care is not covered by Advantage Plans, as remains covered under Medicare Part A.

Part C benefits come in four main Medicare Advantage plan types. These include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee For Service (PFFS) plans and Special Needs Plans (SNPs). The specific rules regarding senior eligibility, plan premiums, annual deductibles, copayments, coinsurance coverage, in-network providers and how to get referrals to specialists vary from one plan to another.

Who Should Consider Medicare Advantage 

Medicare Advantage may be a good option for those who: 

• Want more control over out-of-pocket medical expenses
• Need additional benefits such as prescription drug coverage and dental care 
• Are generally healthy and may benefit from low premiums 

The Top 10 Medicare Advantage Plans in Washington

Medicare Advantage providers are licensed to operate on a state-by-state basis. Washington seniors have several plans available to choose from. The table below lists some highly rated Medicare Advantage plans available in Washington, based on the number of residents enrolled in them. More information on Medicare Part C plans in Washington is available on the Medicare Advantage Plans in Washington page. 

Medicare Prescription Drug Coverage (Part D)

Original Medicare doesn’t pay for most prescription drugs through Part A or B coverage. Instead, seniors purchase separate prescription drug policies, also called Part D coverage. Medicare contracts with private health insurance companies to provide this coverage. There are multiple plans to choose from with varying monthly premiums, which beneficiaries pay in addition to their Original Medicare premiums. While seniors don’t have to purchase prescription drug coverage when they’re first eligible for Medicare, not obtaining this coverage at this time may result in late enrollment penalties they pay for as long as they have Medicare if they enroll later.

Each prescription drug plan has its own formulary, or list of covered drugs. Formularies are typically split up into tiers. The tier a medication is in determines how much the insurance company pays and how much the beneficiary pays for it. Lower-level tiers are usually made up of generic and low-cost brand name drugs, while higher tiers are composed of more expensive brand name and specialty drugs. In most cases, the lower the tier, the lower the policyholder’s cost-sharing responsibility.

Who Should Consider Medicare Prescription Drug Coverage

Seniors who may benefit from prescription drug coverage include those who:

• Currently take prescription medication or expect to in the future
• Want to avoid late enrollment penalties
• Want to reduce out-of-pocket prescription drug expenses

Medicare Supplement Insurance (Medigap)

While Original Medicare provides coverage for many medical costs, seniors may still have significant out-of-pocket expenses. These may include copays, coinsurance and deductibles. Seniors may be able to reduce their cost-sharing obligations by purchasing a Medigap plan. These plans can only be used with Original Medicare. It’s illegal for private insurance companies to sell Medigap plans to those with Medicare Advantage plans.

For more information on Medigap plans, seniors can refer to the Best Medicare Supplement Companies of 2022 page.

Who Should Consider Medicare Supplement Insurance

Good candidates for Medigap may be those who:

• Have ongoing health issues and expenses
• Travel overseas often
• Want to access an expanded network of health care providers
• Expect to need health services not covered by Original Medicare

Medicare Resources in Washington

It can be a challenge for seniors to navigate the complex web of Medicare Part C and Medigap options that are open to them, especially when they’re new to the programs. Fortunately, multiple state and nonprofit agencies are available to help Washington seniors find and apply for the benefits they may be eligible for, as well as to provide help with applications and appeals. Some agencies also offer referrals for professional help and financial assistance, especially with premium and prescription drug coverage.