Comparing Medicare plans in Washington
Medicare is not a single, comprehensive health insurance policy. It is a system composed of different “parts,” each designed to cover a specific sector of your healthcare needs. If Medicare Part A is your hospital insurance, Medicare Part B is your medical insurance.
For the vast majority of Washington residents entering their senior years, Part B is the workhorse of their healthcare coverage. It pays for the routine, day-to-day medical care that keeps you out of the hospital: your primary care physician, specialists, diagnostic tests, and outpatient procedures.
However, Part B is not free, nor does it cover everything. It requires a monthly premium, carries strict enrollment deadlines, and leaves you exposed to unlimited 20% coinsurance costs if you do not pair it with secondary coverage. Understanding exactly how Part B works is the mandatory first step to building a secure, financially sound Medicare strategy in Washington.
Medicare Part B covers two broad categories of medical services: medically necessary diagnostic/treatment services and preventive services. If a service or supply is needed to diagnose or treat a medical condition and meets accepted standards of medical practice, Part B is the component of Medicare that handles the bill.
To understand the scope of your coverage, it helps to break Part B down into its primary components.
Any time you see a doctor in a clinic, office, or hospital outpatient setting, Part B is engaged. This includes visits to your primary care provider for an illness and consultations with specialists like cardiologists, dermatologists, or neurologists. It also covers second opinions before surgery. If you go to the emergency room or an urgent care clinic and are ultimately discharged without being formally admitted as an inpatient, your entire visit is billed under Part B.
Medicare places a heavy emphasis on keeping beneficiaries healthy rather than just treating them when they are sick. Part B covers a wide array of preventive services, often at no out-of-pocket cost to you, provided the doctor accepts Medicare assignment.
When your doctor needs to look inside your body or run lab work to figure out what is wrong, Part B pays the bill. This includes bloodwork, X-rays, MRIs, CT scans, and EKGs done in an outpatient setting.
Part B covers equipment your doctor prescribes for use in your home. This is a vital benefit as mobility and health needs change. Common DME includes:
Mental health is treated with the same weight as physical health under Part B. It covers visits with psychiatrists, clinical psychologists, clinical social workers, and clinical nurse specialists. This includes individual and group psychotherapy, family counseling related to your treatment, and annual depression screenings.
Part B covers ground ambulance transportation to a hospital or skilled nursing facility when traveling in any other vehicle could endanger your health. In severe emergencies where ground transport is too slow, Part B may cover a medically necessary air ambulance. It does not cover non-emergency transport to routine doctor appointments.
Just as important as knowing what Part B covers is knowing what it statutorily excludes. Many beneficiaries are caught off guard when they realize Medicare offers no help with several common healthcare expenses.
Original Medicare Part B does not cover:
To bridge these gaps, many Washington seniors turn to standalone dental/vision plans or transition their benefits into a Medicare Advantage plan that bundles these extra services.
Original Medicare is a cost-sharing system. You pay a monthly premium to maintain the coverage, and you share the cost of the services you use via deductibles and coinsurance.
Everyone enrolled in Part B must pay a monthly premium. The Centers for Medicare & Medicaid Services (CMS) sets a standard base premium that changes every year. For most beneficiaries, this premium is automatically deducted from their monthly Social Security check. If you are not yet collecting Social Security, Medicare will mail you a quarterly bill.
IRMAA (Income-Related Monthly Adjustment Amount) While most people pay the standard premium, higher-income earners pay a surcharge known as IRMAA. Medicare looks at your Modified Adjusted Gross Income (MAGI) from your IRS tax return from two years prior. If your income exceeds a specific threshold set by the government, your Part B premium will be incrementally higher.
Before Part B begins paying its share of your medical bills, you must meet an annual deductible. This is a flat dollar amount that resets every January 1st. Once you have paid this amount out-of-pocket for covered Part B services, your Medicare coverage fully kicks in for the remainder of the calendar year.
Once your annual deductible is met, Part B generally pays 80% of the Medicare-approved amount for most doctor services, outpatient therapy, and durable medical equipment. You are responsible for the remaining 20%.
This is the most critical financial mechanism in Original Medicare to understand: There is no annual out-of-pocket maximum on Part B coinsurance.
If you require a minor outpatient procedure that costs $1,000, your 20% share is $200. But if you face a complex health year with $100,000 in outpatient chemotherapy, radiation, and specialist visits, your 20% share is $20,000. This unlimited financial exposure is the primary reason why relying solely on Original Medicare is financially dangerous, and why the vast majority of beneficiaries acquire secondary coverage.
| Coverage Type | Primary Function | Cost Structure | Out-of-Pocket Maximum |
|---|---|---|---|
| Part A (Hospital) | Inpatient hospital stays, skilled nursing | Usually premium-free; high per-benefit-period deductible | No annual limit |
| Part B (Medical) | Outpatient care, doctors, DME | Standard monthly premium; annual deductible; 20% coinsurance | No annual limit |
| Medigap (Supplement) | Pays Part A & B deductibles/coinsurance | Monthly premium paid to private carrier | Effectively limits OOP costs to $0 (depending on plan) |
| Part C (Advantage) | Replaces A & B with private network plan | May have $0 premium (must still pay Part B premium); copays per service | Strict annual OOP maximum required by law |
Understanding when to enroll in Part B is critical to avoiding permanent financial penalties and coverage gaps.
You are eligible for Medicare Part B in Washington if you are a U.S. citizen or permanent legal resident of at least five consecutive years and meet one of the following criteria:
You do not have a free-for-all window to enroll. Medicare dictates specific enrollment periods.
For most people, eligibility begins at age 65. Your Initial Enrollment Period is a 7-month window built around your 65th birthday. It includes:
If you enroll during the first three months, your Part B coverage starts on the first day of your birthday month. If you wait until the later months of your IEP, your coverage start date will be delayed, potentially leaving you uninsured.
If you miss your IEP and do not qualify for a Special Enrollment Period, your only chance to enroll in Part B is during the General Enrollment Period, which runs from January 1 through March 31 every year. Coverage will begin the month after you sign up. However, utilizing the GEP almost always means you will be subjected to a late enrollment penalty.
What if you are 65, still working, and covered by your employer’s health insurance? You do not necessarily have to drop your work plan and pay for Part B.
If you or your spouse are actively employed and you have health coverage through that employer, you may qualify to delay Part B without penalty. The crucial rule: The employer must have 20 or more employees. If the company has fewer than 20 employees, Medicare automatically becomes your primary insurance at age 65. If you lack Part B in that scenario, your small employer plan can legally refuse to pay 80% of your outpatient bills, arguing that Medicare should have paid first.
If you qualify to delay based on active large-employer coverage, you will be granted an 8-month Special Enrollment Period that begins the month after your employment ends or your employer coverage ends—whichever happens first.
Medicare uses a punitive system to ensure healthy people do not wait until they are sick to enroll in the system. If you fail to enroll in Part B when you are first eligible and you do not have creditable employer coverage, you will face a permanent financial penalty.
The Math: Your Part B premium will increase by 10% for every full 12-month period you were eligible for Part B but did not enroll.
If you retired at 65, skipped Part B because you felt healthy, and finally decided to enroll at age 70 during the General Enrollment Period, you waited five full years. You will pay a 50% penalty on top of the standard Part B premium.
This penalty does not expire after a few years. It remains attached to your Part B premium for the rest of your life.
When you receive care in Washington under Original Medicare, it is important to understand your doctor’s relationship with the Medicare system. There are three types of provider statuses:
If you are seeing a new specialist or undergoing a procedure, always ask, “Do you accept Medicare assignment?” to protect yourself from surprise billing.
If a doctor recommends a service they believe Medicare Part B might not cover, they are required to give you an Advance Beneficiary Notice of Noncoverage (ABN). This written notice explains what service is being provided, why Medicare might deny it, and the estimated cost you will owe if Medicare refuses to pay.
Part B does not exist in a vacuum. It is the central pillar around which you will build your entire healthcare strategy in Washington. Because Part B carries a 20% liability and no cap on out-of-pocket spending, residents typically secure their coverage through one of two pathways.
Many Washington residents choose to stay on Original Medicare (keeping the government as their primary insurance) and purchase a Medicare Supplement (Medigap) policy from a private carrier.
In this setup, Part B pays its 80%, and the Medigap plan steps in to pay the remaining 20% coinsurance. This structure gives you the ultimate freedom of network: you can see any doctor or specialist in the United States who accepts Medicare assignment without needing referrals. It requires paying three separate premiums (Part B, Medigap, and a standalone Part D prescription plan), but it provides highly predictable out-of-pocket costs at the doctor’s office.
In 2026, there are 124 Medicare Advantage plans available across Washington State from carriers like UnitedHealthcare, Kaiser Permanente, Humana, Regence BlueShield, Aetna Medicare, and Providence Medicare Advantage Plans.
A Medicare Advantage plan replaces Original Medicare with a private, all-in-one network plan (usually an HMO or PPO). If you enroll in a plan like the AARP Medicare Advantage from UHC (PPO), UnitedHealthcare becomes responsible for administering all your Part A and Part B benefits, and usually bundles in Part D drug coverage alongside dental and vision perks.
The unbreakable rule of Part C: To enroll in any Medicare Advantage plan, you must be actively enrolled in both Part A and Part B. Even if the Advantage plan advertises a “$0 monthly premium,” you are still legally required to pay your standard Part B premium to the government every month to keep the coverage active. Under Part C, you trade the unlimited 20% coinsurance of Original Medicare for a schedule of copays (e.g., $10 to see a primary doctor, $40 for a specialist) and a strict annual out-of-pocket maximum, but you generally must use the private carrier’s local network of doctors.
For beneficiaries struggling with the cost of the Part B premium and healthcare expenses, the state of Washington operates assistance programs through the Department of Social and Health Services (DSHS) and the Health Care Authority (HCA).
Medicare Savings Programs (MSPs): If you have limited income and resources, the state may help pay your Part B premiums, and in some cases, your deductibles and coinsurance.
Washington also operates the Statewide Health Insurance Benefits Advisors (SHIBA) program, which provides free, unbiased counseling to residents trying to navigate their Medicare options and check eligibility for these low-income subsidies.
If you are already receiving Social Security retirement benefits or Railroad Retirement Board benefits at least four months before you turn 65, you do not need to do anything. Your red, white, and blue Medicare card will arrive in the mail, automatically enrolling you in Part A and Part B.
If you are not drawing Social Security yet, you must actively apply. You do not enroll through a doctor’s office or a private insurance broker; enrollment is handled exclusively by the Social Security Administration (SSA).
You can apply for Part B in three ways:
If you are applying for Part B using a Special Enrollment Period because you recently left an employer plan, you will need to submit two specific forms: one filled out by you (CMS-40B) and one filled out by your former employer verifying your coverage history (CMS-L564) to prove you are exempt from the late enrollment penalty.
Medicare Part B is the anchor of your outpatient healthcare security. Getting it right means knowing exactly when your enrollment window opens and deciding how you will protect yourself from the 20% coinsurance.
Your next steps depend entirely on your current situation:
Navigating Medicare deadlines, avoiding penalties, and comparing the 124 Advantage plans against Medigap options in Washington requires precision. Take the time to map out your timeline, check your doctor’s Medicare status, and structure a policy that protects your health and your retirement savings.
Speak with a licensed producer to compare Washington Medicare Advantage and Medigap options tailored to your doctors 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.