Medicare in Washington DC

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Overview of Medicare in Washington D.C.

Medicare is the federal health-care program signed into law in 1965 to cover hospital and medical expenses for individuals age 65 and older. Since its inception, the Medicare program has expanded to include people under 65 years of age who have certain medical conditions. Also, Medicare added plan options to offer alternative or broader coverage, which are often referred to as Medicare Part C (or Medicare Advantage) and Medicare Part D (or Medicare prescription drug coverage). Whether you are one of the nearly 88,000 Medicare beneficiaries residing in Washington D.C. in 2015 (according to a 2015 report from the Centers for Medicare & Medicaid Services, or CMS), or newly eligible to enroll in Medicare, you may be puzzled about how Medicare works and what coverage options are available in the District of Columbia. We hope this article will help you understand the basics of Medicare.

First, we’ll talk about Original Medicare, the health insurance program administered by the federal government. Original Medicare (Part A and Part B) follows the same rules no matter where beneficiaries live in the United States. To qualify for Original Medicare, you must be a U.S. citizen or a legal resident who has lived in the U.S. for at least five years and be age 65 or older. Some individuals under 65 may qualify for Original Medicare based upon a disability, if they have a health condition called end-stage renal disease (permanent kidney failure requiring a kidney transplant or continuous dialysis treatments) or amyotrophic lateral sclerosis also known as Lou Gehrig’s disease.

Original Medicare consists of Part A and Part B.

  • Medicare Part A helps pay for inpatient hospital stays, skilled nursing facility care as a follow-up to a hospital stay, some blood transfusions, hospice care and certain skilled home health-care services. If you or your spouse paid Medicare taxes while employed for at least 10 years, you probably get Part A without paying a premium. This is referred to as “Premium-Free Part A,” which applies to most people.
  • Medicare Part B helps pay for doctor visits including some disease prevention screenings and wellness check-ups, outpatient services, laboratory work, durable medical equipment, physical therapy, and limited home health-care services. For Medicare Part B, most people pay a monthly premium.

You should be aware that there are coverage limitations if you have Original Medicare. Generally, you must pay your deductible before Medicare pays its portion for covered hospital and medical services. After you have met your deductible, you’ll be responsible for 20% of the total cost for most outpatient medical services. Also you may experience gaps in your coverage depending on the length of care you receive in certain health-care settings, such as skilled nursing facilities. There is no yearly maximum, or cap, on the amount you can spend out-of-pocket. In addition, Original Medicare does not generally include prescription drug coverage for medications you take at home. It typically doesn’t cover most dental or vision care, custodial long-term care (nursing home care), or health services or supplies received outside the United States.

You might want to learn about Medigap (Medicare Supplement) plans if you decide to stay with Original Medicare. Medigap plans are offered by private insurance companies and can help pay your out-pocket costs for services covered under Original Medicare.

As a Washington D.C. beneficiary you may also have the option of enrolling in a stand-alone Medicare Prescription Drug Plan (PDP) to help pay for prescription drug costs. These are separate Medicare plans, available through Medicare-approved private insurance companies, which work alongside your Original Medicare coverage. When you enroll in a Medicare Prescription Drug Plan, you pay a monthly premium to the insurer for prescription drug coverage, along with any deductibles, copayments, and coinsurance amounts that apply to the plan you select.

Some beneficiaries may qualify for Extra Help-a government-sponsored subsidy available to beneficiaries with income and resources below a certain level-to reduce their Medicare prescription drug coverage costs. (See the “Resources” section below for links to agencies who have counselors available to help you see if you are eligible to take advantage of this subsidy.)

As an alternative to Original Medicare coverage, you may be eligible to enroll in a Medicare Advantage plan in Washington, D.C. These plans provide a different way of getting the same Medicare Part A and Part B benefits that you’d have through the government program. The exception is hospice care coverage, which still comes directly from Medicare Part A even if you’re enrolled in a Medicare Advantage plan. Medicare Advantage plans are offered by private insurance companies approved by Medicare.

Here are some quick facts about Medicare Advantage plans:

  • Medicare Advantage plans are required to limit beneficiaries’ out-of-pocket spending for services covered under Medicare Parts A and B. All Medicare Advantage plans must include a yearly out-of-pocket spending limit. If your out-of-pocket costs reach this limit (including the deductible), your Medicare Advantage plan pays 100% of covered health-care costs for the remainder of the year. In contrast, Original Medicare doesn’t have a maximum spending cap, so there’s no limit to your out-of-pocket costs.
  • Many Medicare Advantage plans provide additional benefits besides those covered under Medicare Part A and Part B. Some of these additional benefits may include routine dental and vision care, nutrition counseling, and wellness programs.
  • Many Medicare Advantage plans include Medicare prescription drug coverage. Often called Medicare Advantage Prescription Drug (MA-PD) plans, these plans give you the convenience of getting your Medicare medical and prescription drug benefits through one plan, instead of having to enroll in a separate Medicare Prescription Drug Plan to cover your medications.

If you’re interested in enrolling in a Medicare Advantage plan, you must:

  • Have Medicare Part A and Medicare Part B
  • Live in the Medicare Advantage plan’s service area
  • Not have end-stage renal disease (unless you meet certain exceptions).

Keep in mind that generally, Medicare Advantage members must continue to pay their Medicare Part B premium and may also pay an additional premium directly to their Medicare Advantage plan.

If you would like to compare Medicare plan options where you live, the eHealth plan finder tool makes it easy to do so. Just type your zip code into the tool on this page to get started.

Medicare resources in Washington D.C.

The District of Columbia Office on Aging (DCOA) develops and administers a wide range of services for seniors. The DCOA is also the local Area Agency on Aging (AAA). It acts as a leader for health programs in the D.C. area and advocates fiscal responsibility and astute program management on behalf of its intended audience. There are more than 30 senior programs coordinated by the DCOA, which is meant to be a one-stop resource for Washington D.C. Medicare beneficiaries and all seniors 60 and over. Some of the services and programs sponsored by the DCOA include:

  • Wellness centers
  • Adult educational programs
  • Senior home repair service
  • Legal services for seniors
  • Long-term care ombudsman services
  • Adult protective services

Health Insurance Counseling Project: Sponsored by the George Washington University School of Law, this program (abbreviated HICP) provides a host of important and free advocacy services for Medicare beneficiaries. The HICP provides confidential telephone counseling on Medicare plans. The HICP even offers free legal representation to advocate on behalf of a beneficiary. In addition, the HICP sponsors community health outreach with programs and seminars at local churches, schools, and senior centers in Washington, D.C.

The Office of Health Care Ombudsman and Bill of Rights is a department of the city government offering health-care related advocacy services to all residents of the District of Columbia. This office offers a host of other services, including educational programs and community events and outreach. Medicare beneficiaries can get confidential assistance with Medicare issues. The Ombudsman office will also help seniors understand their Medicare bills, coverage and benefits, and coverage denials. They can even assist with appeals or grievances related to Medicare.

Medicare statistical trends in Washington D.C.

Here are some statistics about Medicare coverage in Washington D.C. in 2016 that may be of interest to you. According to a CMS report*:

  • All Medicare beneficiaries in Washington, D.C. have access to at least one Medicare Advantage plan.
  • 14 Medicare Advantage plans and 24 Medicare Prescription Drug Plans are available.
  • $18.40 is the lowest monthly premium for a Medicare Prescription Drug Plan.
  • 94% of Washington D.C.’s beneficiaries with Medicare Part D prescription drug coverage have access to a plan with a lower premium than they paid in 2015.
  • 64% of people with Medicare prescription drug coverage may qualify for Extra Help (also called the low-income subsidy, or LIS) to reduce the costs associated with their Medicare Part D prescription coverage.

*Statistical data from the Centers for Medicare & Medicaid Services, “On its 50th anniversary, more than 55 million Americans covered by Medicare” as of July 28, 2015; and “2016 MA Part D Landscape State-by-State Fact Sheet” as of September 21, 2015.

This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.


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