Since it first was introduced, Medicare Advantage (MA) has grown more popular every year, with the number of enrollees doubling over the past decade. Over 30 million people were enrolled in an Advantage plan in 2023, accounting for over one-half of all eligible Medicare beneficiaries. This page describes Medicare Advantage plans in Washington, D.C., explaining how the program works, who is eligible, and how to compare your options.
What is Medicare Advantage in Washington, D.C.?
Private insurance companies sell Medicare Advantage plans in Washington, D.C., which are similar to the employer-sponsored group health insurance most Americans are familiar with.
Also known as Medicare Part C, every Advantage plan must provide the same benefits you get with Original Medicare. This includes:
- Medicare Part A, which covers inpatient services received in a hospital or skilled nursing facility (SNF)
- Medicare Part B, which covers outpatient services such as doctor visits, lab work, urgent care, and durable medical equipment (DME)
Original Medicare does not include prescription drug coverage. For that, you need Medicare Part D.
One reason Medicare Advantage has become so popular is that most plans provide more coverage than you get with Original Medicare. For example, around 90 percent of Advantage plans offer prescription drug coverage.
Washington, D.C. Medicare Advantage plans with prescription drug coverage
Medicare Advantage Prescription Drug plans (MA-PD) bundle your Medicare Parts A, B, and D benefits into a single policy. Other common add-on benefits include:
- Routine vision care, including eye exams and prescription lenses
- Routine dental care, such as cleanings and x-rays
- Hearing aids
- Fitness programs like SilverSneakers
Even if your Advantage plan has a monthly premium, you're still responsible for the Medicare Part B premium.
Who is eligible for Medicare Advantage in Washington, D.C.?
If you have Medicare Parts A and B, you are eligible for Medicare Advantage in Washington, D.C.
American citizens and permanent legal residents who have been here for at least 5 years qualify for Medicare when they turn 65. Please note that enrollment in Parts A and B is only automatic if you started collecting Social Security benefits at least 4 months before your 65th birthday. Everyone else must apply for Medicare. You can do that on the Social Security website here.
You also qualify for Medicare if you collect Railroad Retirement Board (RRB) or Social Security disability benefits for 24 months. Enrollment is always automatic if you qualify for Medicare due to a disability.
Finally, if you're 18 or older and have amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease) or end-stage renal disease (ESRD), you're eligible for Medicare.
When can you sign up for a Medicare Advantage plan in Washington, D.C.?
Joining a Medicare Advantage plan in Washington, D.C. is restricted to specific enrollment periods.
Your Initial Enrollment Period (IEP) begins 3 months before your Medicare eligibility month and lasts for a full 7 months. For example, if your 65th birthday or 25th month of collecting RRB or Social Security disability occurs in September, then your IEP starts on June 1 and ends on December 31. However, if your birthday is on the first, move those dates forward one month (May 1 through November 30 if your birthday is September 1).
If you miss your Initial Enrollment Period and do not qualify for a Special Enrollment Period (SEP), you may sign up for Medicare Part A and/or Part B during the General Enrollment Period. This lasts from January 1 through March 31. Once General Enrollment ends, you have from April 1 through June 30 to sign up for a Medicare Advantage plan.
The Medicare Annual Enrollment Period (AEP) lasts from October 15 through December 7 and is available to anyone who is currently enrolled in Medicare. You may make any change you want during AEP, including joining an Advantage plan.
If you currently have a Part C plan, you may switch to another one or return to Original Medicare during the Medicare Advantage Open Enrollment Period. If you lose your prescription drug coverage after making that change, you may also sign up for a standalone Part D plan during Open Enrollment.
Please note that you cannot have both an MA-PD plan and a standalone Medicare Part D plan.
Finally, Medicare offers Special Enrollment Periods for beneficiaries who experience certain life changes, such as moving or losing their current coverage. There are dozens of ways to qualify for an SEP. Medicare.gov provides the full list of special circumstances here.
Types of Medicare Advantages plans in Washington, D.C.
There are four main types of Medicare Advantage plans in Washington, D.C. The most common by far are health maintenance organizations (HMOs), which account for over half of all MA plans. HMOs use a provider network that may include pretty much any entity that provides healthcare services:
- Urgent care centers
- Nursing homes
- Nurse practitioners
- Medical clinics
- Durable medical equipment
Most HMOs will only cover care received from an in-network provider. However, if you choose an HMO that has a point-of-service (POS) option, you may be able to get out-of-network care. Just know that your out-of-pocket cost will be higher. HMO plans also require members to choose a primary care physician who manages their care and provides referrals to specialists.
Preferred provider organizations (PPOs) have networks that are similar to HMOs. However, you may visit an out-of-network provider for a higher cost. In addition, PPO plan members do not have to choose a primary doctor or get a referral to see a specialist.
Private fee-for service (PFFS) plans determine how much they'll pay providers. You then cover any remaining amount. Most PFFS plans have a provider network but allow members to go out-of-network for a higher copay.
Special needs plans (SNPs) are limited to Medicare beneficiaries who meet certain criteria. Populations covered by an SNP include people who:
- Have a certain chronic condition, such as diabetes, ESRD, or HIV/AIDS
- Live in an institution, such as a nursing home, or require in-home care
- Are eligible for both Medicare and Medicaid
If you meet the plan's criteria, you may join an SNP at any time. Most require members to choose a primary doctor who coordinates care and provides referrals.
How to choose a Medicare Advantage plan in Washington, D.C.
To get the best plan for your particular needs, consider the following metrics:
- Cost: This may include a yearly deductible, monthly premiums, and copays or coinsurance due at the time of service.
- Coverage: Benefits vary widely from plan to plan, so look carefully at what the plans offer to be sure you're comparing apples to apples. If it's an MA-PD plan, don't forget to review the drug formulary. This is the list of covered prescription medications. If it doesn't include yours, keep looking until you find a plan that does.
- Network: If you have complex, ongoing medical issues, you probably want to choose an Advantage plan that covers your providers.
- Ratings: Each fall, Medicare releases its ratings of Medicare Advantage and Part D plans to help beneficiaries better compare their options during Annual Enrollment.
Our Find a Plan tool makes comparing Medicare Advantage plans in Washington, D.C. easy. Just enter your location information to review the Medicare plan options in your area.
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