Medicare in the District of Columbia: At a glance
Medicare enrollment in Washington, DC
92,890 DC residents were covered by Medicare as of the end of 2018. That’s about 13 percent of the District’s population, versus more than 18 percent of the United States population enrolled in Medicare.
Most Medicare beneficiaries are eligible for coverage because they’re at least 65 years old. But Medicare eligibility is also triggered when a person has been receiving disability benefits for 24 months. Nationwide, 16 percent of all Medicare beneficiaries are eligible due to disability. It’s a little higher in DC, where 17 percent of Medicare beneficiaries enrolled due to a disability.
Medicare Advantage in Washington, DC
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 11 Medicare Advantage plans available for purchase in DC in 2019. Fifteen percent of the District’s Medicare beneficiaries were enrolled in Advantage plans as of 2017. Nearly 19 percent of DC’s Medicare population had private coverage as of the end of 2018; most were enrolled in Medicare Advantage plans, but there are also some enrollees in DC who have Medicare Cost plans, which is another form of private Medicare coverage.
Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the opportunity to switch between Medicare Advantage and Original Medicare and/or add or drop a Medicare Part D prescription plan. As of 2019, 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 Washington, DC
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 2016, there were 9,927 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 the District’s rate review tool indicates that at least eight insurers offer Medigap plans in DC (CareFirst Blue Cross Blue Shield, Physician’s Mutual, Humana, Banker’s Life and Casualty, Mutual of Omaha, Pennsylvania Life Insurance, Genworth, and TransAmerica).
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 C, Plan F, 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 DC Medicare beneficiaries 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. A search of Medigap quotes indicates that at least CareFirst does offer Medigap Plan A to DC residents under age 65.
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). 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.
Medicare Part D in Washington, DC
Original Medicare 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 that includes Part D prescription drug coverage.
Insurers in the District of Columbia are offering 25 stand-alone Part D plans for sale in 2019, with premiums that range from about $14 to $97/month.
As of late 2018, there were 56,543 Medicare beneficiaries in DC with Part D prescription coverage. The majority (nearly 40,000 people) had stand-alone Part D plans, while the rest had Medicare Advantage plans with built-in Part D coverage.
Medicare spending in Washington, DC
In 2017, Original Medicare’s average per-beneficiary spending in DC was $9,496, based on data that were standardized to eliminate regional differences in payment rates (the data did not include costs for Medicare Advantage). Nationwide, average per beneficiary Original Medicare spending was $9,761 per enrollee, so Medicare spending in DC was a little lower than the national average.
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 healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.