Medicare has been improving the quality of life and enhancing health outcomes for elderly people since July 30, 1965. The health insurance program was passed into law under President Lyndon B. Johnson’s administration. In 1972, the program was expanded to provide Medicare Coverage for people with End Stage Renal Disease (ESRD). If you’re looking for Medicare Advantage Plans in Washington, here’s a few things you should know.
Medicare initiated Part A Medicare to cover inpatient care in a hospital or skilled nursing facility, Hospice services, and some home health services. The 1965 plan also created Medicare Part B providing outpatient care like office visits, most physician services, costs of durable medical equipment (DME), outpatient tests, and preventative care.
Part A and B Medicare does not include a list of preferred providers or create a network of accepted facilities for patient care. Each patient can choose which doctor to see and which medical facility (such as a hospital or skilled nursing facility) to access, so long as the doctor or facility accepts Medicare.
A wide range of medical services is covered by Medicare Parts A and B. Some non-covered services include:
There are some out of pocket costs for recipients of Medicare A and B. The patient is responsible for coinsurance and deductibles, applicable copayments, and prescription drug costs, except medications like chemotherapy and certain injectable drugs that are administered by a health care professional. The amounts of the copayment or coinsurance are determined by the federal government, and they are usually the same for all recipients.
Part B Medicare beneficiaries may be eligible for a Medicare Supplement Plan (Medigap) to help cover out-of-pocket expenses not covered by Part B Medicare. Premiums for Medigap plans in Washington vary with the insurance company accessed and the type of plan. This is true of Medicare Advantage Plans in Washington as well.
Part A Medicare carries no deductible for people with a qualifying work history. The Part B deductible is set yearly by the government, and there is no increase in the amount based on age or medical condition. The standard Part B premium in 2019 is $135.50, but it may be more for people in a higher income bracket.
People with original Part A and B Medicare who wish to have drug coverage will have to buy a stand-alone Prescription Drug Plan through Medicare Part D.
Since its inception, Medicare has been administered by the Federal Government through the Centers of Medicare and Medicaid Services (CMS) whose main office is in Baltimore, Maryland. Medicare Advantage Plans (Part C Medicare) are administered by private insurance companies that are authorized by Medicare to provide coverage to Medicare recipients in specific service areas. You’ll want to review your health care providers to ensure that your plan options are accepted at your preferred provider.
Medicare Advantage Plans in Washington are required by law to offer all the advantages available through Medicare A and B. The federal government provides Hospice benefits to Medicare Advantage recipients. It also covers certain expenses involved in clinical research studies. Advantage plans can opt to not cover any service that is not deemed medically necessary by Medicare. In all Medicare Advantage Plans, emergency and urgently needed care are covered.
The individual plans offer many medical benefits that are not covered by original Medicare. Additional medicare benefits may include:
Medicare Advantage Plans include a specified limit (cap) on out-of-pocket spending. Once the stated amount has been reached, the insured pays nothing for covered healthcare costs within a set time period. Under original Medicare, out-of-pocket expenses have no limits. Medicare Advantage Plans in Washington usually have a Star Rating. You’ll probably want to find plans using a licensed Medicare agent.
In 2003, the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) brought significant changes to Medicare. In addition to creating Part c Medicare (Medicare Advantage Plans), this legislation expanded Medicare by providing an optional benefit for prescription drugs (Part D Medicare) which became effective in 2006.
Approximately one-third of all recipients of Medicare were enrolled in various Medicare Advantage Plans in 2017 with increases in 2018. Number projections in 2018 estimated that 36.7% of Medicare recipients will be enrolled in a Medicare Advantage Plan.
Efforts have been made to make Medicare Plans more affordable. Since 2015, there has been a decline in the rate of the average monthly premium amount from $32.91 in 2015 to $28.00 in 2019. The Centers for Medicare and Medicaid have encouraged each insurance company to provide more innovative plans to meet individual needs and ensure high-quality care for beneficiaries.
The number of Medicare plans available varies with geographical location. Currently, access to Part C Medicare and Part D Prescription Drug coverage is available to 100 percent of Medicare recipients.
Medicare Advantage Plans are expected to increase nationwide from 3,100 (2018) to 3,700 (2019). In 2018, almost 86 percent of Medicare recipients had 10 or more Medicare Advantage Plan available to choose from, and this number is expected to rise to 91 percent in 2019. About 211 Medicare Advantage Plans are available to state residents in Washington.
Health Maintenance Organizations (HMO)
Many people choose a Health Maintenance Organization (HMO) because these health plans generally have lower premiums and out of pocket costs than other types of Medicare Advantage Plans in Washington. In exchange for the lower costs, plan members have to go to in-network doctors for all their health care except for emergency care. If an out-of-network provider is seen, the patient costs may be higher.
Health Maintenance Organization members typically have a primary care physician, and a referral is required to see a specialist. HMO (and PPO) members must continue to pay the monthly Part B premium in addition to the Medicare Advantage Plan’s premium. In both Health Maintenance Organizations and Preferred Provider Organizations, participating providers accept the Medicare-approved fee as full payment for covered services. Cost-sharing amounts still have to be paid by the patient at the time of service.
The majority of Medicare Advantage HMOs and PPOs offer part D plans (prescription drug coverage). If your plan does not include this coverage, you cannot continue with your plan and enroll in a stand-alone Prescription Drug Plan. During the Annual Enrollment Period (October 15 to December 7), you can change to a different plan that offers the needed coverage. There are usually around 20 different Medicare Prescription Drug Plans to choose from in Washington.
Preferred Provider Organizations are similar to Home Maintenance Organizations in many ways. A network of preferred providers will probably be available to choose from. Seeing a doctor out of network is allowed, but the costs may be higher. Choosing a primary care physician is not required. You do not need to get a referral to consult a specialist.
Private Fee-For-Service plans allow recipients to receive care from any provider who accepts the plan’s terms. Accepting or declining the terms of the plan is not required, even if the physician is a Medicare-participating provider. PFFS plans offer greater flexibility of doctor choice, but the patient needs to confirm each service ahead of time to be sure of coverage.
A Special Needs Medicare Plan is a kind of HMO that enrolls patients with certain health conditions such as congestive heart failure or diabetes, or HIV/AIDS. A Special Needs Plan may also be restricted to residents of a Skilled Nursing Home Facility.
During your initial enrollment period, the annual open enrollment period, or by phone anytime, you can seek advice from an insurance agent familiar with what each insurance company has to offer.
Consider your specific health needs and look for a policy that will fit your unique situation.
If you want to keep your current care provider, make sure that doctor or facility is covered before committing to a health plan.
Be sure to ask your insurance agent what plans are available in your area. You can also go to medicare.gov and enter your zip code in any state for a comparison of benefits.
Medicare rates each plan yearly on a 5-star basis so you can check out the plan you are interested in before making any commitment to a specific plan.
With a combination of Medicare A and B, Medicare Advantage Plans, and Prescription Drug Plans, 3,997,520 Medicare recipients enjoy the life-enhancing benefits of Medicare.
Medicare Advantage Plans in Washington are available with a premium as low as $0.
100 percent of beneficiaries with a Medicare Advantage Plan can access a plan with a lower premium than they paid in 2018. In some state you may qualify for medical assistance for a plan.
Low-Income Subsidy (LIS) offers Extra Help to 31 percent of people who have stand-alone prescription plans, with premiums as low as $10.40/month.
If you’d like more information about Medicare Advantage Plans in Washington, feel free to call us toll free and speak with a licensed agent.
Explore medicare.gov for answers to all your questions.