Comparing Medicare plans in Washington
Medicare is the federal health insurance program that serves as the foundation of healthcare for Americans aged 65 and older, as well as certain younger individuals with specific disabilities. However, turning 65 does not mean you are handed a single, simple insurance card that pays for everything. Instead, Medicare is divided into “Parts,” each covering a different aspect of your healthcare, and it requires you to make active decisions about how you want to receive and pay for your medical services.
If you are approaching your 65th birthday in Washington, you face a critical fork in the road: you must choose between pairing Original Medicare with a Medigap policy, or enrolling in a private Medicare Advantage plan. Making the wrong choice can lead to lifetime financial penalties, restricted access to doctors, or unexpected out-of-pocket costs that derail your retirement budget.
This guide serves as your complete roadmap to the entire Medicare system. We will break down what each part of the alphabet soup actually does, explain how Washington’s specific state rules protect you, and provide the exact framework you need to evaluate which path makes the most sense for your health, your lifestyle, and your budget.
Before navigating the specific plans and options available in Washington, you must understand what Medicare is—and what it is not.
Medicare is a national social insurance program administered by the Centers for Medicare & Medicaid Services (CMS), an agency within the federal government. It is funded through payroll taxes you pay during your working years, general federal revenues, and the premiums paid by the people enrolled in the program.
A common point of confusion is the difference between Medicare and Medicaid. Medicare is primarily an age-based program; your income level does not determine whether you are eligible to enroll, though higher earners do pay higher premiums. Medicaid (known in this state as Washington Apple Health) is a joint federal and state program designed for low-income individuals and families. It is entirely possible to qualify for both programs simultaneously—a status known as “dual eligible.”
To make sense of the program, you must separate it into its core components. The government originally designed Medicare with just two parts (A and B). Over time, Congress added Part C and Part D to address gaps in coverage and modernize the system. Your entire Medicare journey consists of deciding how to assemble these parts to fit your needs.
Review these conditions to determine if you are eligible to enroll in Medicare in Washington state.
| Condition | When Coverage Begins |
|---|---|
| Turning 65 | The first day of your birth month (or the month prior if born on the 1st). |
| Receiving SSDI | The 25th month of your disability benefit entitlement. |
| Diagnosed with ALS | The first month you receive disability benefits. |
Original Medicare is the traditional fee-for-service program directly managed by the federal government. When you have Original Medicare, you can see any doctor, specialist, or hospital in the United States that accepts Medicare. There are no geographic network restrictions and no need to ask a primary care doctor for referrals to see a specialist.
Part A is primarily responsible for inpatient care. Think of Part A as your “room and board” coverage if you are admitted to a medical facility.
What it covers:
What it costs: For the vast majority of Washington residents, Medicare Part A is premium-free. If you or your spouse worked and paid Medicare taxes for at least 40 quarters (approximately 10 years) during your lifetime, you do not pay a monthly premium for Part A.
However, “premium-free” does not mean “cost-free.” Part A uses a unique cost-sharing structure based on “benefit periods” rather than a standard annual calendar year deductible. A benefit period begins the day you are admitted to an inpatient facility and ends when you have been out of the hospital for 60 consecutive days.
When you are admitted to the hospital, you must pay a substantial Part A deductible (which adjusts annually and is generally over $1,600) before Medicare covers your stay. This deductible covers your first 60 days in the hospital. If your stay extends beyond 60 days, you are responsible for steep daily copayments. Crucially, if you leave the hospital and are readmitted months later—after 60 days have passed—a new benefit period begins, and you must pay that deductible all over again.
Part B is the medical component of Original Medicare. This covers the everyday healthcare services you use when you are not formally admitted to a hospital as an inpatient.
What it covers:
What it costs: Unlike Part A, everyone pays a monthly premium for Part B. The federal government sets a standard base premium that changes each year. For most beneficiaries, this premium is deducted directly from their monthly Social Security check.
If your modified adjusted gross income (MAGI) from two years prior exceeds a certain threshold, you will be subject to the Income-Related Monthly Adjustment Amount (IRMAA). IRMAA is a surcharge added to your standard Part B premium. For example, your 2026 Medicare premiums will be based on the tax return you filed for the 2024 calendar year.
Beyond the monthly premium, Part B has an annual calendar-year deductible. Once you meet this relatively small deductible, Medicare Part B covers 80% of all Medicare-approved charges.
The Danger of the 20% Gap You are responsible for the remaining 20% coinsurance for all Part B services. Because Original Medicare has absolutely no maximum out-of-pocket limit, that 20% can be financially devastating if you face a severe illness. A 20% share of a $150 office visit is negligible; a 20% share of a $100,000 outpatient chemotherapy regimen is $20,000 out of your own pocket.
Because of this limitless financial exposure, relying solely on Original Medicare Parts A and B without any supplemental coverage is highly risky. To protect yourself, you must choose one of two distinct paths: adding a Medigap policy, or replacing Original Medicare with a Medicare Advantage plan.
Medicare Supplement Insurance, commonly known as Medigap, is private insurance designed to work alongside Original Medicare. Its sole purpose is to fill the financial “gaps” left behind by Parts A and B—specifically the deductibles, copayments, and that dangerous 20% coinsurance.
When you go to the doctor with Original Medicare and a Medigap policy, Original Medicare acts as your primary insurance and pays its share first. Then, the remainder of the bill is automatically forwarded to your Medigap carrier, which pays its portion according to the plan you selected.
Medigap plans are standardized by the federal government and labeled by letters (Plan A, Plan G, Plan N, etc.). Standardization means that a Plan G sold by Carrier A offers the exact same medical benefits as a Plan G sold by Carrier B. The only difference between them is the monthly premium and the company’s customer service reputation.
Choosing Medigap preserves the freedom of Original Medicare. You do not have network restrictions; if a provider accepts Original Medicare anywhere in the United States, they must accept your Medigap plan. You also do not need prior authorizations from an insurance company to get a procedure done, nor do you need a referral to see a specialist.
The Washington State Advantage: Washington is one of the few states in the country with highly favorable, consumer-friendly laws regarding Medigap. In most states, if you want to switch your Medigap plan after your initial open enrollment period, you must pass medical underwriting—meaning the insurance company can deny you or charge you more based on your health history.
In Washington state, if you currently hold a Medigap plan (Plans B through N), state law grants you a continuous guaranteed issue right. You can switch to any other Medigap plan of equal or lesser value offered by any carrier, at any time of the year, without being subjected to medical underwriting. Furthermore, Washington requires all individual Medigap policies to be “community-rated.” This means a carrier must charge everyone in the same geographic area the same premium regardless of their age or health status, though rates will still increase over time due to inflation and rising healthcare costs.
If you do not want to manage Original Medicare, a Medigap policy, and a separate prescription drug plan, you can choose Path 2: Medicare Advantage, also known as Part C.
Medicare Advantage plans are offered by private insurance companies approved by Medicare. When you enroll in a Medicare Advantage plan, you still have Medicare, and you must continue to pay your Part B premium. However, your private insurance company steps in and takes over the administration of your benefits. The government pays the private insurer a flat monthly fee to manage your care.
Instead of the 80/20 cost-sharing of Original Medicare, Medicare Advantage plans use their own schedule of copayments and deductibles. For example, you might pay a flat $10 copay for a primary care visit, $40 for a specialist, and $300 per day for the first five days of a hospital stay.
Crucially, every Medicare Advantage plan must include a maximum out-of-pocket (MOOP) limit. This is your financial safety net. If you require expensive treatments like chemotherapy or major surgery, and your copayments hit your MOOP limit, the plan pays 100% of your covered medical costs for the rest of the year.
Unlike Original Medicare, Medicare Advantage plans operate within managed care networks.
The primary draw of Medicare Advantage in Washington is the inclusion of benefits that Original Medicare expressly ignores. Most Medicare Advantage plans include built-in Part D prescription drug coverage at no additional premium. Many plans also offer routine dental care, vision exams and glasses allowances, hearing aids, over-the-counter pharmacy allowances, and fitness club memberships.
Original Medicare does not cover the routine prescription drugs you pick up at the pharmacy. To get this coverage, you need Medicare Part D. You can obtain Part D in one of two ways:
Every Part D plan has a formulary, which is the official list of drugs the plan agrees to cover. Formularies are divided into pricing “tiers.”
Part D is notoriously complex because your costs change as the year progresses. Coverage operates in phases based on the true total retail cost of the drugs you purchase over the calendar year:
If you fail to enroll in a Part D plan when you are first eligible and do not have creditable drug coverage from another source (like an employer), Medicare imposes a lifetime late enrollment penalty. The penalty is 1% of the national base premium for every full month you delayed, permanently added to your future monthly drug premiums.
The decision between Original Medicare plus Medigap versus a Medicare Advantage plan is the most critical healthcare choice you will make in retirement. There is no universally “right” answer; it depends entirely on your financial comfort zone and your desire for freedom of access.
| Feature | Original Medicare + Medigap + Part D | Medicare Advantage (Part C) |
|---|---|---|
| Doctor Choice | Any doctor or hospital in the US that accepts Medicare. No network restrictions. | Restricted to HMO or PPO networks. May need referrals. |
| Monthly Cost | Higher. You pay Part B, a Medigap premium, and a standalone Part D premium. | Lower. Many plans have a $0 premium (though you must still pay the Part B premium). |
| Out-of-Pocket Costs at the Doctor | Very low to zero. A Plan G covers almost all medical bills after the Part B deductible. | You pay copays for doctor visits, hospital days, and tests until you hit the plan's maximum out-of-pocket limit. |
| Extra Perks (Dental/Vision) | Not covered. Must buy separate standalone policies. | Often included (dental, vision, hearing, gym memberships). |
| Prior Authorizations | Not required. If Medicare covers it, Medigap pays its share automatically. | Often required. The insurance company must approve expensive tests, surgeries, or facility stays. |
Choose Original Medicare and Medigap if:
Choose Medicare Advantage if:
Timing is everything in Medicare. The government uses strict enrollment windows, and missing them can trigger permanent financial penalties or leave you without coverage.
Your IEP is a seven-month window built around your 65th birthday. It includes the three months before your birthday month, the month of your birthday, and the three months following it.
If you enroll during the first three months of your window, your coverage will begin on the first day of your birth month. If you wait until your birth month or the three months after to enroll, your coverage start date will be delayed.
This is a specific six-month window that begins the first month you are both 65 or older and enrolled in Medicare Part B. During these six months, you have a federal guaranteed issue right to buy any Medigap policy sold in Washington, regardless of any pre-existing conditions. The insurance company cannot ask you medical questions, cannot deny you a policy, and cannot charge you more because of your health.
If you miss this six-month window and try to buy a Medigap policy later, federal law allows the carrier to subject you to medical underwriting. However, as noted earlier, Washington’s consumer protection laws provide a continuous guaranteed issue right if you already hold a Medigap plan. The risk lies in never buying one initially and trying to get one years later when you are sick.
Running from October 15th through December 7th every year, AEP is when you can adjust your coverage for the following year. During AEP, you can:
Changes made during AEP take effect on January 1st of the new year. Note that AEP is not a guaranteed issue window to buy a Medigap policy if you do not already have one.
A massive portion of Washington residents continue working past age 65. If you have health insurance through your own active employment or your spouse’s active employment, and the employer has 20 or more employees, your group health plan pays primary to Medicare.
In this scenario, most people enroll in premium-free Part A but delay enrolling in Part B to save on the monthly premium. This is entirely legal and penalty-free, provided your employer plan is considered “creditable coverage.”
When you eventually retire or lose that employer coverage, you are granted an 8-month Special Enrollment Period (SEP) to sign up for Part B without any late penalties. Importantly, COBRA coverage and retiree health plans do not count as active employer coverage. If you leave your job and take COBRA, your 8-month window to enroll in Part B begins immediately upon leaving the job, not when COBRA ends.
If Medicare premiums, deductibles, and prescription costs stretch your budget, Washington offers robust programs to help.
Medicare Savings Programs (MSPs) Managed by the state, MSPs help pay for your Part B premiums. Depending on your income and asset levels, programs like the Qualified Medicare Beneficiary (QMB) program may also cover your Part A and Part B deductibles, coinsurance, and copayments.
Extra Help (Low-Income Subsidy) This federal program assists with Medicare Part D prescription drug costs. If you qualify for Extra Help, you will pay reduced or zero premiums for your Part D plan, lower deductibles, and strictly capped copayments for your medications at the pharmacy counter. Furthermore, qualifying for Extra Help eliminates the Part D late enrollment penalty and allows you a Special Enrollment Period to change your drug plan outside of the normal annual window.
SHIBA (Statewide Health Insurance Benefits Advisors) Washington’s Office of the Insurance Commissioner runs the SHIBA program, offering free, unbiased, and confidential counseling to residents navigating Medicare. They do not sell insurance but can help you understand your rights, screen you for financial assistance programs, and help resolve billing disputes.
Medicare is not a one-size-fits-all program. Your optimal strategy depends heavily on the prescriptions you take, the doctors you refuse to give up, and the county in Washington where you reside, as plan availability and pricing vary wildly from Spokane to Seattle to the Olympic Peninsula.
A licensed producer can help you compare available Advantage and Medigap options specific to your county, health needs, and budget.
Get a Free ConsultationWe do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1–800–MEDICARE to get information on all of your options.