Know your options for Medicare Advantage Plans in Washington D.C. and find out how to enroll.
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When you become eligible for Medicare, you have two primary options for coverage. You could get Original Medicare, which includes Medicare Part A for hospital insurance and Part B for medical insurance. Or you could opt for a Medicare Advantage Plan.
Medicare Advantage Plans (also called Medicare Part C) are an all-in-one alternative to Original Medicare that provide the same coverage as Parts A and B. Plans also frequently include other benefits Original Medicare won’t cover, like prescription drug coverage, hearing, dental, and vision.
This article contains everything you need to know about Medicare Advantage Plans in Washington D.C.
You have choices in Medicare coverage. While you can opt to stick with Original Medicare, a Medicare Advantage Plan – also known as Part C – may be a better alternative for you.
|Original Medicare||Medicare Advantage Plans|
|Original Medicare covers your Part A hospital insurance and Part B medical insurance.||Medicare Advantage Plans combine Part A, Part B, and additional benefits.|
|You can add Part D prescription drug coverage.||Prescription drug coverage is usually included.|
|You’re able to use any medical provider in the U.S. that accepts Medicare.||You’ll usually need to use doctors in your plan’s network.|
|You can buy supplemental coverage to manage out-of-pocket costs, including your coinsurance.||Your Medicare Advantage Plan may have lower out-of-pocket costs than Original Medicare.|
|Vision, hearing, dental, and other benefits aren’t covered.||Your plan may offer additional benefits, including vision, hearing, and dental.|
Medicare Advantage Plans cover benefits from Original Medicare Part A (hospital insurance), Part B (medical insurance), usually Part D (prescription drug coverage), and sometimes additional benefits that Original Medicare doesn’t cover. Each Medicare Advantage Plan insurer sets the rules about how you receive and pay for these benefits.
|Hospital and skilled nursing facility inpatient care||Home health care||Prescription drug coverage (if included in your plan)|
|Medically necessary outpatient services, such as:
||Preventive services, such as:
||Additional benefits (depending on your plan), such as:
With 16 Medicare Advantage Plans available in Washington D.C., you likely have several options in your area. To help you choose the best plan for you, consider what is most important to you before selecting a plan. There are several factors to keep in mind:
There are 17 Medicare Advantage Plans available in Washington D.C. for 2023. Washington D.C. has 11 Medicare Advantage Plans rated 3.5 or higher on Medicare.gov.
|Number of Medicare Advantage Plans available||Medicare Advantage Plan types available||Medicare Advantage Plans rated 3.5 or higher by NCQA|
In the District of Columbia, the most common Medicare Advantage plans available are HMOs or PPOs, although there are also a few SNPs and regional PFFS plans available. Seniors eligible for Medicare may choose from plans provided by multiple private insurers, although the choices available vary by county.
|HMOs||HMOs typically require that you receive all services from in network providers:
|PPOs||PPOs include a preferred network of providers, but you have the option of choosing doctors or hospitals from outside of the network for a higher cost.
|PFFS Plans||PFFS plans don’t require a primary care physician or referrals for specialists:
|SNPs||SNPs are only for people with specific conditions and characteristics, and include care coordination and targeted benefits tailored to meet your specific needs:
You’re eligible for Medicare when you turn 65 or if you’re younger and have a qualifying disability. A qualifying disability means at least one of the following applies:
When you become eligible for Medicare, you are also eligible for Medicare Advantage Plans. There are specific times of the year when you can enroll for the first time in a Medicare Advantage Plan: during your Initial Enrollment Period and the Open Enrollment Period.
Medicare Advantage Open Enrollment occurs between January 1 and March 31 of each year. This period is only for beneficiaries already in a Medicare Advantage Plan, and you can change plans or switch to Original Medicare. You cannot switch from Original Medicare to Medicare Advantage during Medicare Advantage Open Enrollment.
There are exceptions to these enrollment periods called Special Enrollment Periods. Certain events or circumstances may make you eligible to change your Medicare Advantage Plan outside of the open enrollment periods, such as if you move outside of your existing plan’s service area or to a location with new plan options you didn’t have before. If you think you may qualify for a Special Enrollment Period, call 1-800-MEDICARE and explain your situation.
|Enrollment period||When it happens||Medicare plans you can choose||What you can do|
|Initial Enrollment Period||Three months before you turn 65, the month you turn 65, and three months after||Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan||Sign up for Medicare Part A and Part B. Complete your Part B enrollment to avoid a late enrollment penalty.|
|General Enrollment Period||January 1 – March 31||Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan. If you enroll in Medicare during this period, your MAP enrollment is April through June.||Sign up for Medicare if you missed your IEP|
|Open Enrollment Period||October 15 – December 7||Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan||Join, switch, or drop a plan|
|Medicare Advantage Open Enrollment Period||January 1 – March 31||Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan||If you’re enrolled in a Medicare Advantage Plan, you can change your plan or switch to Original Medicare|
|Special Enrollment Period||When you have a qualifying event||Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan||Make changes to your plan|
Most Medicare Advantage HMO and PPO plans and all SNP plans provide prescription drug coverage like you would get from Medicare Part D. Some PFFS plans may provide prescription drug coverage, but not all do. Evaluate a plan’s prescription drug coverage when deciding which Washington, D.C. Medicare Advantage Plan to use.
Prescription drug coverage may vary by cost, coverage, and convenience among Medicare Advantage Plans. Your monthly premium may include a premium for the drug coverage in the plan. There is usually a copayment or coinsurance amount that you have to pay for each prescription after you reach your annual deductible.
Some plans use different cost tiers with different costs for different drugs. For instance, you may pay less for generic drugs than brand-name drugs or less for brand-name drugs within different tiers. If your plan uses tiers, the formulary will list all covered drugs and their tiers. Verify your preferred or local pharmacies are included in the plan’s network.
|Resource||Contact||How they help|
|DC Office on Aging||(202) 724-5626||The DC Office on Aging offers a range of programs, from nutrition and transportation to wellness and adult protective services.|
|DC Department of Health Finance||(202) 442-5988||Get help paying for health care with the D.C. Department of Health Finance.|
|District of Columbia Department of Insurance, Securities and Banking||(202) 727-8000||They help consumers by answering their questions, investigating their complaints, and helping them to understand their insurance.|
|Legal Aid of the District of Columbia||(202) 628-1161||Legal help for low-income District of Columbians seeking assistance with civil legal needs.|
|Qualified Medicare Beneficiary Program||(202) 442-5988||The Qualified Medicare Beneficiary Program helps DC Medicare-eligible residents pay for related expenses.|
|DC Health Insurance Counseling||(202) 724-5626||DC Health Insurance Counseling provides access to free health insurance information, counseling, education, and assistance through the DC State Health Insurance Assistance Program (SHIP).|
|DC Medicaid||(202) 442-5988||DC Medicaid is public health insurance for residents who qualify.|
|Resource||Contact||How they help|
|211 Answers, Please!||211||2-1-1 Answers, Please! can connect you to critical resources (such as shelter availability childcare, or rent payment assistance) simply by dialing a three-digit number.|
|District of Columbia Senior Medicare Patrol||(202) 434-2099||The District of Columbia’s SMP is a volunteer organization that is focused on watching out for Medicare fraud. If you suspect fraud, misuse, or waste, you can contact SMP and they will look into the situation. Their main goal is to protect consumers.|
|DC Department of Human Resources||(202) 442-9700||The D.C. Department of Human Resources provides information about Medicare and Medicare Advantage, along with connecting D.C. government employees and retirees with benefits.|
|District of Columbia Office on Aging||(202) 724-5622||The Office on Aging can connect you with one of its regional agencies, all of which provide a comprehensive selection of services for the region’s older adults. The agencies have programs designed to help seniors 60 and older maintain their health and independence, including resources to guide you through the Medicare enrollment process, and the counselors will help you understand the available benefits fully.|
|DC Office of the Health Care
Ombudsman and Bill of Rights
|(202) 724-7491||The office’s purpose is to guide, educate, and help people navigate the healthcare system.|
|Resource||Contact||How they help|
|CMS Medicare Managed Care Appeals & Grievances||(800) MEDICARE||Offers information and guidance on Medicare and its connected programs.|
|CMS Medicare Managed Care Eligibility and Enrollment||(800) 633-4227||This resource contains information for current and future contracting Medicare Advantage (MA) organizations, other health plans, and other parties interested in the operational and regulatory aspects of Medicare health plan enrollment and disenrollment.|
|CMS Medicare Prescription Drug Eligibility and Enrollment||(800) 424-4301||This page contains enrollment and disenrollment guidance for current and future contracting Part D plan sponsors and other parties interested in the operational and regulatory aspects of Part D plan enrollment and disenrollment.|
|Medicare.gov||(800) MEDICARE||The main government website for signing up for (or making changes to) Medicare coverage.|
Tammy Burns is an experienced health insurance advisor. She earned her nursing degree in 1990 from Jacksonville State University, obtained her insurance billing and coding certification in 1995, and holds a health and life insurance license in Alabama, Georgia, Iowa, Mississippi, and Tennessee. Burns is Affordable Care Act (ACA)-certified for health insurance and other ancillary, life, and annuity products. She maintains an active nursing license and practices private-duty nursing.
Burns’ background as a nurse, insurance biller and coder, and insurance consultant includes infectious disease, oncology, gynecology, phlebotomy, post operative, family medicine, geriatrics, home health, hospice, human resources, management, billing, coding, claims, fixed annuities, group and individual health and life products, and Medicare. She’s always been driven by a desire to help people, spending more than 25 years as a practicing nurse in hospitals, private doctors’ offices, home health, and hospice. As a nurse, Burns supported patients filing insurance claims with Medicare, Medicaid, and private insurance companies as well as responding to billing questions from confused patients.
Seeing firsthand how unsuspecting patients are frequently confused by an overly complex system they don’t understand led Burns to become an insurance agent and health care consultant, now helping people understand the medical system. Since becoming an insurance agent in 2013, she has worked with some of the largest and most reputable insurance carriers and agencies in the nation, and she has built a large and loyal clientele by way of her commitment to transparency and personalized service.