Comparing Medicare plans in Washington
Medicare Part C—almost universally known as Medicare Advantage—is the private, carrier-insured alternative to the federal government’s traditional Medicare program. If you are approaching age 65 or preparing to retire in Washington state, deciding how to receive your Medicare benefits is the single most consequential healthcare choice you will make. You can either stay with the federal government’s Original Medicare (and likely purchase supplementary policies to fill its gaps), or you can transfer the administration of your benefits to a private insurance carrier through a Part C plan.
In Washington, Medicare Advantage is not a one-size-fits-all product. There are currently 124 real Medicare Advantage plans available across the state, offered by 11 different major insurance carriers. This guide provides a comprehensive, end-to-end breakdown of what Part C actually is, how the private carrier model works, the specific costs and networks you will encounter in Washington, and how to evaluate whether a carrier-insured plan is the right fit for your medical needs and financial situation.
To understand Part C, you first have to understand what it replaces. Original Medicare is a fee-for-service program managed entirely by the federal government. When you go to the hospital (Part A) or see a doctor (Part B), the federal government pays your healthcare provider directly. However, Original Medicare has significant financial gaps: it covers roughly 80% of your outpatient medical costs, leaving you responsible for the remaining 20%, with absolutely no cap on how high that 20% can reach if you face a catastrophic illness.
Medicare Part C was created by Congress to offer an alternative. When you enroll in a Medicare Advantage plan, you do not lose your Medicare. You are still in the Medicare program, you still have the same fundamental rights and protections, and you must still pay your monthly Part B premium.
However, instead of the federal government paying your medical bills directly, the government pays a set monthly fee (a process known as capitation) to a private insurance company—such as UnitedHealthcare, Humana, or Kaiser Permanente. That private carrier then becomes legally responsible for managing your care, processing your claims, and paying your doctors.
Because the carrier is taking on the financial risk of your healthcare, they are allowed to establish their own cost-sharing structures, require you to use their specific networks of doctors and hospitals, and implement managed care rules like prior authorizations. In exchange for you agreeing to these network rules, the carriers often charge low (or even $0) monthly premiums and bundle in extra benefits that the federal government does not offer.
A standard Medicare Advantage plan is often described as an “all-in-one” solution because it packages several distinct modules of coverage into a single ID card. By law, any carrier offering a Part C plan in Washington must provide coverage that is at least as good as Original Medicare. Here is how the benefits break down:
Your Part C plan assumes total responsibility for the services normally covered by Medicare Part A. This includes inpatient hospital care, skilled nursing facility stays, hospice care, and some home health services. Instead of paying Medicare’s standard deductible for a hospital stay, a Part C plan will typically charge you a daily copayment for the first several days you are admitted to the hospital (for example, $350 per day for days 1 through 5, and $0 thereafter).
Your plan also covers the outpatient services normally handled by Part B: primary care physician visits, specialist visits, preventive screenings, outpatient surgeries, diagnostic lab work, MRIs, and durable medical equipment (like CPAP machines or wheelchairs). Rather than paying a flat 20% coinsurance for all of these services as you would under Original Medicare, Part C plans typically assign predictable, fixed-dollar copayments. For instance, you might pay $0 to see your primary care doctor and $40 to see a specialist.
The vast majority of Part C plans in Washington are “MA-PD” plans, meaning Medicare Advantage Prescription Drug plans. The carrier embeds a Part D formulary (a list of covered medications) directly into the medical policy. You do not need to purchase a separate standalone drug plan. The carrier organizes medications into different “Tiers”—typically Tier 1 for preferred generics up to Tier 5 for specialty drugs—and assigns a specific copayment or coinsurance to each tier.
Original Medicare strictly limits its scope to medical necessities, meaning it entirely excludes routine dental care, vision exams, hearing aids, and fitness memberships. Private carriers use supplemental benefits to compete for your enrollment. Most Medicare Advantage plans in Washington include preventative dental (cleanings and X-rays), routine eye exams and allowances for glasses, hearing aid coverage, and memberships to fitness programs like SilverSneakers or Renew Active. Some even offer allowances for over-the-counter (OTC) pharmacy items or transportation to medical appointments.
The appeal of Medicare Advantage often lies in its predictable cost structure, but it is vital to understand exactly how the money works before enrolling. “Zero premium” does not mean “free healthcare.”
First and foremost, enrolling in a Part C plan does not absolve you of the federal Medicare Part B premium. For 2026, the standard Part B premium is paid directly to the government (usually deducted from your Social Security check). If you stop paying your Part B premium, the government will disenroll you from Medicare entirely, which automatically terminates your Part C plan.
Once the Part B premium is paid, you then look at the Part C plan’s own premium. Many plans in Washington advertise a $0 monthly premium. The carrier can afford to do this because the federal government is already paying them hundreds of dollars every month to manage your care. If you choose a plan with a richer benefit package or a broader network, you might pay a separate monthly premium to the carrier (e.g., $35 or $75 a month) on top of your Part B premium.
When you actually use healthcare services, you pay copayments (a flat dollar amount, like $45 for a specialist) or coinsurance (a percentage of the total cost, like 20% for chemotherapy drugs). Because Part C plans use copayments for most routine services, you know exactly what a doctor’s visit will cost before you walk into the office.
The most important financial feature of a Medicare Advantage plan is the Maximum Out-of-Pocket (MOOP) limit. This is a strict, federally mandated ceiling on how much you can spend on covered in-network medical services in a calendar year.
If your plan has a MOOP of $4,500, you will pay your copays and coinsurance for doctor visits, surgeries, and hospital stays as normal. But the moment your total spending hits $4,500 in that calendar year, the carrier steps in and pays 100% of your covered medical costs for the rest of the year. (Note: Prescription drug costs do not count toward the medical MOOP; Part D has its own separate out-of-pocket caps mandated by federal law). Original Medicare has no MOOP, which is why a Part C plan provides vital protection against catastrophic medical debt.
| Feature | Original Medicare (A & B) | Part C (Medicare Advantage) |
|---|---|---|
| Administration | Federal Government | Private Insurance Carrier |
| Provider Network | Any doctor in the U.S. who accepts Medicare | Restricted to carrier's local HMO or PPO network |
| Maximum Out-of-Pocket (MOOP) | None (Unlimited financial risk without a Medigap plan) | Required by law (Caps your annual medical spending) |
| Prescription Drugs (Part D) | Must purchase a separate standalone plan | Usually included automatically (MA-PD) |
| Routine Dental/Vision/Hearing | Not covered | Frequently included as extra benefits |
| Cost Predictability | Often 20% coinsurance for major services | Usually fixed dollar copayments |
The trade-off for the low premiums, extra benefits, and out-of-pocket caps is that Medicare Advantage plans require you to use their specific networks of doctors and hospitals. In Washington, you have 11 different carriers—including Regence BlueShield, Premera, Kaiser Permanente, Providence, and UnitedHealthcare—all building their own local networks.
Before enrolling in any plan, you must verify that your preferred primary care doctors, specialists, and hospitals (such as UW Medicine, Swedish, MultiCare, or Providence) are in-network for that exact plan name. Networks function in three primary ways:
An HMO plan requires you to use only in-network providers, except in absolute emergencies. If you see a doctor outside of the HMO network, the carrier will pay nothing, and you will be responsible for the entire bill. HMOs typically require you to designate a Primary Care Physician (PCP) who coordinates your care, and you often need a formal referral from that PCP before you can see a specialist. Because HMOs are highly restrictive, they usually offer the lowest costs and the richest extra benefits.
A PPO plan offers much more flexibility. You can see any provider in the plan’s network, usually without needing a referral to see a specialist. Furthermore, a PPO allows you to see out-of-network providers, provided that the doctor is willing to accept the plan’s terms. However, if you go out-of-network, your share of the cost will be significantly higher. For example, the AARP Medicare Advantage from UHC WA-0001 (PPO) allows you to bypass referrals and see out-of-network doctors, making it an excellent choice for Washingtonians who travel frequently or spend winters in other states.
An HMO-POS is a hybrid model. It functions primarily like an HMO—requiring you to use a core network of providers—but it includes a “Point of Service” benefit that allows you to go out-of-network for certain specific services, often at a higher cost. Plans like the AARP Medicare Advantage Essentials from UHC WA-7 (HMO-POS) offer this blend, giving enrollees slightly more flexibility than a rigid HMO without the higher premiums typically associated with a full PPO.
To maintain low premiums and offer broad benefits, private carriers actively manage the care you receive. When you move from Original Medicare to Part C, you will encounter two primary managed care mechanisms that you must be prepared to navigate:
Prior Authorization: For many non-emergency procedures, expensive diagnostic tests (like MRIs or CT scans), and hospital admissions, your doctor must submit a request to the insurance carrier for approval before the service is rendered. The carrier’s medical directors review the request to ensure the procedure is medically necessary. If they deny the prior authorization, the plan will not pay for the service.
Step Therapy: This rule often applies to prescription drugs and occasionally to certain medical treatments. Step therapy requires you to try a less expensive, proven treatment first before the plan will agree to cover a more expensive or newer alternative. For instance, if your doctor prescribes an expensive brand-name arthritis medication, the carrier may require you to try a generic equivalent first. Only if the generic fails to work will they approve the brand-name drug.
Medicare Advantage is guaranteed issue, meaning you cannot be denied for health reasons, but you must meet strict administrative requirements to enroll.
You cannot simply sign up for or drop a Medicare Advantage plan whenever you want. The federal government strictly regulates the periods during which you can alter your Medicare coverage.
Your first opportunity to enroll in a Part C plan happens when you first turn 65. This is a seven-month window that includes the three months before your 65th birthday month, the month of your birthday, and the three months after. If you are retiring past age 65 and losing employer coverage, you will be granted a Special Enrollment Period to sign up without penalty.
The most important window for existing Medicare beneficiaries runs from October 15 through December 7 every year. During AEP, you can join a Medicare Advantage plan, switch from one Part C plan to a different one, or drop your Part C plan entirely and return to Original Medicare. Any changes made during AEP take effect on January 1 of the following year. Because plan networks, premiums, and drug formularies change annually, you must review your coverage every single AEP.
Running from January 1 through March 31 every year, this window is exclusively for people who are already enrolled in a Medicare Advantage plan on January 1. If you discover you dislike your current Part C plan, the MA-OEP allows you one opportunity to switch to a different Medicare Advantage plan, or drop it and return to Original Medicare. You cannot use this period to move from Original Medicare into a Part C plan; it is only for correcting a Part C choice you already made.
When you transition to Medicare, you are fundamentally choosing between two parallel tracks:
Track 1: Original Medicare + Medigap + Part D. Under this track, you stay with the government program and buy a private Medicare Supplement (Medigap) policy to cover the 20% coinsurance, plus a standalone drug plan. This track offers ultimate freedom—you can see any doctor in the country who accepts Medicare, without referrals or network restrictions. However, it requires paying high, fixed monthly premiums (often $150 to $250+ per month for the Medigap plan alone), and it does not include extra perks like dental or vision.
Track 2: Medicare Part C (Advantage). Under this track, you consolidate everything into one private plan. You accept network restrictions, prior authorizations, and copayments as you go, but in return, you enjoy much lower monthly premiums and gain extra benefits like dental, vision, and fitness memberships.
The choice comes down to cash flow, risk tolerance, and travel habits. If you travel extensively outside of Washington or have complex medical conditions requiring out-of-state specialists, a Medigap plan provides unmatched geographic freedom. But if you prefer lower fixed monthly costs, want all your benefits handled by a single ID card, and are comfortable receiving care within a regional Washington health system (like Kaiser or UW Medicine), a Part C plan is often the more efficient choice.
With 11 carriers offering 124 plans in Washington, deciding on a single policy requires careful evaluation. Do not simply look for the lowest premium. When comparing your options, assess the following:
Compare the 124 Medicare Advantage plans available in Washington, verify your doctor networks, and find the right coverage for your lifestyle.
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.