Medicare in the District of Columbia

Most beneficiaries of Medicare in DC are enrolled in Original Medicare, but about 22% have private Medicare coverage instead

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At a glance: Medicare health insurance in the District of Columbia

Medicare enrollment in District of Columbia

As of July 2020, there were 94,045 residents with Medicare in the District of Columbia. That’s about 13 percent of the District’s population, versus nationwide Medicare enrollment that amounts to almost 19 percent of the United States population.

Most Americans become eligible for Medicare coverage enrollment when they turn 65. But Medicare eligibility is also triggered when a person has been receiving disability benefits for 24 months (people with ALS or end-stage renal disease do not have to wait 24 months for Medicare enrollment). Nationwide, 15 percent of all Medicare beneficiaries are eligible due to disability. It’s a little higher in DC, where 17 percent of Medicare beneficiaries are under the age of 65.

Medicare Advantage in District of Columbia

Although Medicare is funded and run by the federal government, enrollees can choose whether they want to receive their benefits directly from the federal government via Original Medicare or enroll in a Medicare Advantage plan offered by a private insurer, if such plans are available in their area. There are pros and cons to Medicare Advantage and Original Medicare, and no single solution that works for everyone.

There are 12 Medicare Advantage plans available for purchase in DC in 2020. Sixeen percent of the District’s Medicare beneficiaries were enrolled in Advantage plans as of 2018. More than 22 percent of DC’s Medicare population had private coverage as of mid-2020. DC previously had Medicare Cost plan coverage available (as of 2018), but that was no longer the case as of 2019 (by that point, the only available private Medicare plans in DC were Medicare Advantage HMO and PPO plans).

Medicare Advantage enrollment is available during Medicare’s annual election period (October 15 to December 7 each year). This window allows Medicare beneficiaries the opportunity to switch between Medicare Advantage plans and Original Medicare and/or add or drop a Medicare Part D prescription plan. Medicare Advantage enrollees also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.

Medigap in District of Columbia

Original Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage. More than half of Original Medicare beneficiaries nationwide receive their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans) are designed to pay some or all of the out-of-pocket costs (deductibles and coinsurance) that Medicare beneficiaries would otherwise have to pay themselves.

As of 2018, there were 11,068 DC residents with Medigap coverage. DC does not regulate Medigap plans, so federal rules apply in the District (in the rest of the country, state regulations apply to Medigap plans if they go above and beyond what’s required by the federal government). The DC Department of Securities and Banking does not maintain a list of Medigap insurers — although they noted that they are considering doing so in the future. But Medicare’s plan finder tool indicates that there are 15 insurers offering Medigap plans in DC.

Medigap plans are sold by private insurers, but the plans are standardized under federal rules, with ten different plan designs (differentiated by letters, A through N). The benefits offered by a particular plan (Plan F, Plan G, etc.) are the same regardless of which insurer is selling the plan. So plan comparisons are much easier for Medigap policies than for other types of health insurance; consumers can base their decision on premiums and less tangible factors like customer service, since the benefits themselves are uniform. All Medigap insurers must offer at least Plan A. And if they offer any other plans, they must offer at least Plan C or Plan F.

Unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no annual open enrollment window for Medigap plans. Instead, federal rules provide a one-time six-month window when Medigap coverage is guaranteed-issue. This window starts when a person is at least 65 and enrolled in Medicare Part B (you must be enrolled in both Part A and Part B to buy a Medigap plan).

People who aren’t yet 65 can enroll in Medicare if they’re disabled and have been receiving disability benefits for at least two years, and more than 15,000 beneficiaries with Medicare in DC are under 65. Federal rules do not guarantee access to Medigap plans for people who are under 65, but the majority of the states have stepped in to ensure at least some access to private Medigap plans for disabled enrollees under the age of 65. DC does not regulate Medigap plans though, so federal rules apply. Insurers can voluntarily choose to offer Medigap plans to people under 65. According to Medicare’s plan finder tool, two insurers in DC offer Medigap plans to beneficiaries under the age of 65: CareFirst offers Medigap Plan A, and United American offers Plan B and high-deductible Plan F (note that under federal rules, Plan F and high-deductible Plan F are only available for beneficiaries who were already eligible for Medicare prior to 2020).

Federal legislation, including 2018’s H.R.6431, has been considered to expand access to Medigap plans to all Medicare beneficiaries, regardless of age, but the rules have thus far not changed.

In DC, a disabled Medicare beneficiary under age 65 can enroll in a Medicare Advantage plan, unless they have end-stage renal disease (federal rules allow Medicare Advantage plans to decline enrollments for new applicants with ESRD, although this will change starting in 2021; under the terms of the 21st Century Cures Act, beneficiaries with end-stage renal disease will no longer be barred from enrolling Medicare Advantage plans). But when they turn 65, they have access to the normal Medigap open enrollment period, and can select from among any of the available Medigap plans, at the standard age-65 rates.

Although the Affordable Care Act eliminated pre-existing condition exclusions in most of the private health insurance market, those regulations don’t apply to Medigap plans. Medigap insurers can impose a pre-existing condition waiting period of up to six months, if you didn’t have at least six months of continuous coverage prior to your enrollment. And if you apply for a Medigap plan after your initial enrollment window closes (assuming you aren’t eligible for one of the limited guaranteed-issue rights), the insurer can look back at your medical history in determining whether to accept your application, and at what premium.

District of Columbia Medicare Part D

Original Medicare enrollment does not cover outpatient prescription drugs. More than half of Original Medicare beneficiaries have supplemental coverage via an employer-sponsored plan or Medicaid, and these plans often include prescription coverage. But Medicare enrollees without creditable drug coverage need to obtain Medicare Part D prescription coverage. Part D coverage can be purchased as a stand-alone plan, or as part of a Medicare Advantage plan with integrated Medicare Part D benefits.

Insurers in the District of Columbia are offering 27 stand-alone Medicare Part D plans for sale in 2020, with premiums that range from about $13 to $80/month.

As of mid-2020, there were 58,521 Medicare beneficiaries in DC with Part D prescription coverage. The majority (more than 38,000 people) had stand-alone Medicare Part D plans, while the rest had Medicare Advantage plans with built-in Part D coverage.

Medicare Part D enrollment is available during Medicare’s annual enrollment period each fall, from October 15 to December 7. Plan changes made during this time will take effect January 1. Part D enrollees are encouraged to carefully compare the available plan options each year, as a different plan might present a better value for the coming year. This can be due to changes in the beneficiary’s prescription needs, or to changes in the available plans (including the person’s existing plan), such as the covered drug lists, participating pharmacies, and out-of-pocket costs.

Medicare in DC: Resources for Medicare beneficiaries and their caregivers

Need help filing for Medicare benefits in DC, or have questions about Medicare eligibility in DC? You can contact HICP, DC’s Health Insurance Counseling Project, for general help with Medicare in DC.

The DC Office of Disability Rights has an overview of Medicaid and Medicare benefits for disabled District residents.

The DC Office of Health Care Ombudsman and Bill of Rights has a compilation of resources that would be helpful for Medicare beneficiaries in DC.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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