In this guide, you’ll learn the basics about Medicare in DC to help you make the right Medicare choices and get the most value from Medicare.
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There are 94,000 DC Medicare beneficiaries, making up 14% of the state’s total population. Most DC residents age into Medicare when they turn 65, but about 14% are on Medicare due to disability. 36% of Medicare enrollees are dually eligible, meaning they also receive Medicaid benefits to help them pay for some or all of their healthcare costs. This is high in comparison to the 50 states.
Medicare beneficiaries have options and can either stay on Original Medicare or switch to a Medicare Advantage plan. In DC, 75% choose to remain on Original Medicare and 25% enroll in a Medicare Advantage plan. We’ll explain more about the pros and cons of Medicare Advantage plans in later sections.
All US citizens have the same Medicare eligibility requirements. If you’re 65 or older, you’re eligible. You also may be eligible if you have certain disabilities, including ALS and End-Stage Kidney Disease.
Most people age into Medicare. If you’re drawing from Social Security, you’ll be automatically enrolled in Original Medicare. Otherwise, you’ll need to sign up for Original Medicare during their Initial Enrollment Period (IEP). Original Medicare consists of:
Medicare Part A: your hospital insurance
Medicare Part B: your outpatient insurance
Your IEP is a 7-month period of time surrounding your 65th birthday month. It starts three months before the month you turn 65 and ends three months after it. In some cases, people choose to delay their Part B enrollment because they’re still working and receiving employer coverage. If you are still working and plan to delay Part B coverage, we recommend you do two things:
Make sure you’ll be eligible for the Part B Special Enrollment Period once you stop working, so you don’t have to pay the Part B late enrollment penalty.
Compare your employer insurance with Medicare to see if you’d be better off moving to Medicare. We often find that Medicare is better!
Once you’re enrolled in Original Medicare, you have options. You can stay on Original Medicare or switch to Medicare Advantage. In short, Medicare Advantage plans are provided by private insurance companies as an alternative to Original Medicare. They bundle together Part A, Part B, and generally Part D (prescription) coverage. They also tend to come with additional benefits, like dental, vision, and hearing coverage. If you stay on Original Medicare, you can choose to add a Medicare Supplement (also known as Medigap) plan and/or a Part D (prescription drug) plan to complete your coverage.
Each of these paths has its own set of pros and cons, and there’s not one best decision for everyone. When making a decision between Medicare Advantage and Original Medicare, you should take a look at the coverage and its costs, then choose what best fits your unique health and financial needs.
Choosing the best combination of Medicare insurance options for your needs is just the first step to ensure you get the most from your Medicare. Once you’ve chosen your coverage, you should make sure to use all of your benefits, including:
Your preventive care services, like annual wellness visits and vaccinations
Any perks unique to your Medicare Advantage plan
And finally, each year, be sure to review your coverage during the Medicare Annual Enrollment Period, which lasts from October 15 - December 7. Medicare Advantage and Part D plans change each year, and your healthcare needs can change too! During this time, you can switch plans without consequence, so it’s a good idea to shop around to make sure you’re still on the plan that gets you the most value for your money.
There are 13 Medicare Advantage plans in DC. These plans offer an alternative to Original Medicare, and legally must provide at least the same amount of coverage as Medicare Part A and Part B. Most Medicare Advantage plans also include prescription coverage. They may also include other health benefits, including the following:
Dental, vision, and hearing care
Home safety devices and modifications
Many Medicare Advantage plans have $0 premiums. Keep in mind that Medicare Advantage enrollees still need to pay their Original Medicare premiums. Still, additional coverage for no added premium sounds nice. So, what’s the catch? There are some big disadvantages that come with Medicare Advantage plans:
Pre-authorization requirements for covered services
High out-of-pocket costs (compared to Original Medicare + Medicare Supplement)
Reach out to our licensed DC Medicare Advisors to discuss specific Medicare Advantage plans (as well as your other options) that meet your healthcare needs.
Original Medicare doesn’t cover about 20% of costs for covered services. For this reason, many Medicare recipients add a Medicare Supplement (also called Medigap) plan to their coverage. DC residents have ten Medigap plans available to them, labeled by letters A-N.
Policies of the same letter type (e.g., all Medicare Supplement Plan A policies) are identical in coverage, even if the pricing differs. Each type of Medigap plan covers different out-of-pocket expenses, but all of them reduce your costs significantly. Medigap Plan G is the most comprehensive Medigap plan. On a Plan G, once you’ve met your annual Part B deductible, you won’t pay anything else for the year for Medicare-covered services!
The best time to enroll in a Medigap plan is during your Medigap Open Enrollment Period. This guaranteed issue period lasts for six months after your Part B effective date. During this time, insurance carriers cannot ask you questions about your health history or deny you coverage. Outside of this and a handful of other guaranteed issue periods, insurance questions may ask you questions about your health and deny you coverage.
Medigap plans sit on top of your Original Medicare coverage, while Medicare Advantage plans replace Original Medicare. Compared to Medicare Advantage plans, Medigap has some big benefits that improve your access to care:
You can see any doctor who accepts Medicare (~90% of doctors nationwide)
You won’t need to get prior authorization for covered services
Your out-of-pocket costs are much lower
Original Medicare doesn’t provide prescription drug coverage. Most Medicare Advantage enrollees will receive Part D (prescription) coverage through their Medicare Advantage plans. Those who don’t or who choose to stay on Original Medicare can enroll in a Part D plan. There are 22 stand-alone Part D plans available in DC, with an average monthly premium of $42.70.
If you don’t take any prescriptions when you first enroll in Medicare, we still recommend you enroll in a low-cost drug plan to avoid paying Part D enrollment penalties later on!
If you have questions about Medicare options or want to compare plan benefits and pricing, schedule a free consultation with one of our licensed DC Medicare Advisors or give us a call at (888) 604-0055.
Healthcare costs can be overwhelming for many Americans. These three government programs that can help low-income DC Medicare beneficiaries pay for health-related expenses.
DC Medicaid has two primary programs for Medicare beneficiaries: Medicaid for Aged, Blind, and Disabled residents (commonly called ABD Medicaid) and a Medicare Savings Program.
ABD Medicaid in DC
You’re eligible for DC Medicaid under the aged, blind, and disabled category if you meet all of the following criteria:
You’re 65 or older, blind, or disabled
You’re a DC resident
You’re a US citizen
You have resources under $4,000 (for individuals)
Your income is less than or equal to 100% of the federal poverty limit (FPL)
DC Medicare Savings Program
DC only has one Medicare Savings Program—the Qualified Medicare Beneficiaries (QMB) Program. While most states require QMB beneficiaries to have incomes less than or equal to 100% of the federal poverty limit (FPL), DC has expanded eligibility to include anyone with income less than 300% FPL.
The QMB Program pays for:
Medicare Part A and Part B premiums
QMB beneficiaries also receive Extra Help, which we explain in the next section.
Extra Help is a federal program that helps pay for costs associated with prescription drug coverage, including premiums, deductibles, and coinsurance. It’s also commonly called the Part D Low-Income Subsidy (LIS).
You automatically qualify for Extra Help if you:
Receive full Medicaid coverage from DC
DC pays your Part B premium
Are eligible for Supplemental Security Income (SSI)
If you don’t automatically qualify for Extra Help, you can learn more about the program here or talk to one of our licensed DC Medicare Advisors to get free support with your application.
Eligible US citizens receive monthly payments from the SSI program. You’re considered eligible if you meet the following criteria:
You are 65 and older, blind, or have a disability
You have limited income and limited resources