Medicare Advantage Plans in the District of Columbia (Washington D.C)

Fact Checked
Updated: June 18, 2021

Medicare Part C, also known as Medicare Advantage, is available to Medicare-eligible individuals who prefer to buy their health coverage from a private insurance company rather than enrolling in the Original Medicare program managed by the federal government. Like Original Medicare, Medicare Advantage covers a variety of inpatient and outpatient medical services; however, many Medicare Advantage Plans also offer additional coverage.

  • In 2019, there were seven Medicare Advantage Plans available in the District of Columbia.
  • 16% of the total Medicare population in the District of Columbia is enrolled in Medicare Advantage Plans as of 2018.
  • In the District of Columbia, 55% of Medicare Advantage beneficiaries are enrolled in special needs plans.
  • In 2020, there were 12 Medicare Advantage Plans available in the District of Columbia.

If you decide to enroll in Medicare Advantage instead of Original Medicare, you’ll have a chance to compare several plans and decide which one works best for your needs. Not all insurance companies are approved to offer Medicare Advantage Plans, so plan availability varies based on where you live and which insurance company you plan to use.

Medicare Advantage Plans in the District of Columbia

Types of Medicare Advantage Plans

The District of Columbia’s Medicare Advantage program includes several types of insurance plans. Before you choose one, it’s important to estimate your annual medical expenses so that you can determine how much coverage you need. HMO and PPO plans are the most common, but some insurance companies also offer private fee-for-service plans and special needs plans.

Health Maintenance Organizations (HMO)

Many companies offer HMO plans to their employees, so you may be most familiar with this type of insurance. If you choose an HMO, you typically have to visit doctors and hospitals within the HMO’s network. Most HMO plans also require subscribers to choose a primary care provider (PCP). Your PCP oversees your care and provides referrals to specialists when needed. If you see someone outside the HMO network, your plan may not cover any of the cost.

Preferred Provider Organizations (PPO)

If you want the freedom to see specialists without a referral, you may want to choose a PPO plan. Like HMOs, PPOs typically have networks of participating providers. A major difference between the two plan types is that a PPO may cover some of the cost of seeing an out-of-network provider, while an HMO usually doesn’t. You don’t have to choose a PCP, so a PPO is a good choice if you’re looking for something more flexible than an HMO.

Private Fee-for-Service Plans (PFFS)

Private fee-for-service plans are a little different from other types of Medicare Advantage Plans. While many Medicare Advantage Plans include prescription coverage, most PFFS plans don’t. Under this type of plan, providers receive a flat fee for each service they provide. One of the benefits of choosing a PFFS plan is that you can typically see any provider who agrees to treat you and accept the negotiated rate as payment.

Special Needs Plans (SNP)

If you have heart disease, cancer, end-stage liver disease, or another chronic health condition, you may be able to enroll in a special needs plan. These plans are set up to cover the most common medications, specialists, and procedures for people with certain medical problems. For example, if you have lupus, you may be able to join an SNP for autoimmune disorders, which is likely to provide excellent coverage for rheumatology care.

Enrollment and eligibility for Medicare Advantage Plans in the District of Columbia

Medicare Advantage Eligibility

You can’t sign up for Medicare Advantage unless you’re eligible for Original Medicare. You may qualify for Medicare coverage if you’re at least 65 years old and paid Medicare taxes for a minimum number of quarters. Original Medicare is also available to adults under 65 who have qualifying disabilities. If you want to enroll in Medicare Advantage, then you can’t be enrolled in Medicare Supplement Insurance (Medigap).

Enrolling in Medicare Advantage

You can typically enroll at one of the following times:

  • Initial enrollment: Your initial enrollment period starts three months before you turn 65. The earlier you enroll, the sooner your coverage will begin. You have until three months after you turn 65 to participate in initial enrollment.
  • Open enrollment: You can join the Medicare Advantage program or switch Medicare Advantage Plans during open enrollment, which starts on Oct. 15 and ends on December 7.
  • Medicare Advantage Open Enrollment: You can switch from Medicare Advantage to Original Medicare or switch from one Medicare Advantage Plan to another during Medicare Advantage open enrollment, which runs from Jan. 1 to March 31.

If you don’t sign up for Medicare Advantage during one of these periods, you may have to wait until the next available enrollment period. The exception is if you have a qualifying life event, such as moving outside of your current plan’s service area or losing your previous health coverage.

Prescription drug coverage

Most Medicare Advantage Plans include prescription drug coverage; however, many PFFS plans don’t. If you sign up for a plan that doesn’t include prescription coverage, you may be able to purchase Medicare Part D, a supplement that covers the cost of medications. You can’t sign up for Medicare Part D if you have a Medicare Advantage Plan that includes drug coverage; otherwise, you’ll be dropped from your plan and enrolled in Original Medicare. Part D coverage has a monthly premium that’s separate from the premium you pay for Original Medicare or Medicare Advantage.

Medicare Advantage Resources in the District of Columbia

Even if you research your options thoroughly, it’s not always obvious whether you should enroll in Medicare Advantage or stick with Original Medicare. If you’ve reviewed several plans and still don’t know which one is right for you, don’t hesitate to ask for help. The District of Columbia has several organizations working to help older residents secure affordable health coverage, including AARP’s Legal Counsel for the Elderly Program, the Department of Aging and Community Living, and the Department of Health Care Finance.

AARP Legal Counsel for the Elderly

AARP’s Legal Counsel for the Elderly Program operates a legal hotline for all D.C. residents who are at least 60 years old. The hotline is also available to residents 55 and older who have issues with their Social Security payments or Supplemental Security Disability Insurance benefits. More than 800 trained volunteers are on hand to answer questions and help you resolve problems with Medicare, Social Security, and other programs. Hotline volunteers can also refer you to other resources for help with Medicare enrollment.

Contact Information: Website | 202-434-2120

Department of Aging and Community Living

The Department of Aging and Community Living provides a variety of services to help older adults remain active and independent. DACL serves as the District of Columbia State Health Insurance Assistance Program (SHIP), which offers unbiased advice regarding Medicare eligibility and enrollment. The SHIP program also holds educational sessions to help older adults and their caregivers understand the benefits available to them under Medicare. If you have questions about Medicare Advantage, call DACL to speak with a SHIP counselor.

Contact Information: Website | 202-724-5626

District of Columbia Department of Health Care Finance

The Department of Health Care Finance operates several programs to help D.C. residents access affordable health care. If you’re eligible for Medicare but think you’ll have trouble paying your premiums and other out-of-pocket expenses, contact DHCF to see if you qualify for the Qualified Medicare Beneficiary program. Under this program, eligible individuals receive help paying their Part A and Part B premiums, coinsurance, deductibles, and Medicare Part D prescription costs. To qualify, you must be eligible for Original Medicare, live in the District of Columbia, and have an income that doesn’t exceed 300% of the federal poverty level.

Contact Information: Website | 202-442-5988

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