How do Medicare Advantage plans differ from Original Medicare?

Original Medicare lets you see any provider who accepts Medicare nationwide but has no annual out-of-pocket maximum and usually requires separate Part D and optional Medigap. Medicare Advantage typically uses HMO or PPO networks, includes an annual out-of-pocket maximum, and may bundle drug and extra benefits.

Who should consider a Medicare Advantage plan in Washington?

Consider Medicare Advantage if you want consolidated coverage, predictability with an annual out-of-pocket cap, and access to added benefits. It can be a strong fit if your preferred doctors are in-network and you do not need frequent out-of-state routine care.

When can I enroll or switch Medicare Advantage plans in Washington?

You can enroll during your Initial Enrollment Period around your 65th birthday, during the Annual Enrollment Period (October 15–December 7), or switch MA plans/go back to Original Medicare during the Medicare Advantage Open Enrollment Period (January 1–March 31). Certain life events may qualify you for a Special Enrollment Period.

What do Medicare Advantage plans cost in Washington?

Monthly premiums vary by county and plan and can be as low as $0 in addition to your Part B premium. You will also have copays or coinsurance for services and an annual in-network out-of-pocket maximum, after which covered costs are paid by the plan for the remainder of the year.

Do Medicare Advantage plans include prescription drug coverage?

Most Washington Medicare Advantage plans include Part D drug coverage. If a plan you choose does not include Part D, you may need a separate Part D plan—verify that your medications and pharmacies are covered before enrolling.

Are my doctors and hospitals covered under Medicare Advantage?

Coverage depends on the plan’s network. HMOs usually require in-network care and referrals for specialists, while PPOs offer some out-of-network coverage at higher cost. Always confirm that your primary care provider, specialists, and hospitals participate before enrolling.

What extra benefits can Washington Medicare Advantage plans include?

Depending on the carrier and county, plans may include dental, vision, hearing, telehealth, fitness programs, over-the-counter allowances, transportation, and wellness services. Specific benefits and limits vary by plan.

Can I have a Medigap policy with a Medicare Advantage plan?

No. Medigap is designed to supplement Original Medicare only. If you enroll in Medicare Advantage, you cannot use a Medigap policy with that plan.

What if I travel or live part-time outside Washington?

Medicare Advantage plans cover emergencies anywhere in the U.S., but routine care is tied to the plan’s service area and network. If you spend extended time out of state or need nationwide provider flexibility, consider whether Original Medicare with Medigap may better suit your situation.

How do I decide between Medicare Advantage and Original Medicare with Medigap?

Compare networks, total annual costs, travel needs, prescriptions, and extra benefits. Medicare Advantage can offer lower premiums and added perks but requires using network providers. Original Medicare with Medigap may have higher premiums but provides broad nationwide access and fewer utilization rules.

Where can I get local help reviewing Washington Medicare Advantage plans?

Work with a licensed Washington broker who represents multiple carriers and can compare plans in your county, verify your doctors and drugs, and assist with enrollment and yearly reviews.

How do I apply for Washington health insurance?

You can apply for coverage through Washington Healthplanfinder or with help from Advisor Health Benefits Group. Our licensed brokers guide you through comparing plans, applying online, and completing enrollment.

When is open enrollment for Washington health insurance?

The 2026 Washington Healthplanfinder open enrollment runs November 1, 2025, through January 15, 2026. Medicare’s Annual Enrollment Period runs October 15 through December 7, 2025.

Does Advisor Health Benefits help with Medicare in Tri-Cities, WA?

Yes. We provide Medicare Advantage, Medigap, and Part D guidance for residents in Richland, Kennewick, Pasco, and across Washington.

Is there a cost to use a Washington health insurance broker?

No, there is no extra cost to you. Advisor Health Benefits is paid by the carriers, so you receive expert guidance at no additional charge.

What documents do I need to apply for health insurance in Washington?

Gather proof of income, Social Security numbers for all household members, immigration status if applicable, and a list of current prescriptions and doctors to compare plan networks.

What Is a Medicare Advantage Plan in Washington and Should I Consider One?

Q: What is a Medicare Advantage plan in Washington?

A Medicare Advantage plan (Part C) is a private insurance alternative to Original Medicare that provides Part A and Part B benefits and often includes Part D prescription drug coverage plus extras like dental, vision, and fitness. You must have Medicare Parts A and B and live in the plan’s Washington service area.

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November 13th, 2025
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Kevin Husted, Washington Medicare Broker — Advisor Health Benefits Group

When you turn 65 or become eligible for Medicare in Washington, you face a big decision: should you stay with Original Medicare or choose a Medicare Advantage plan (also known as Medicare Part C)? Both provide important benefits, but they work differently. Choosing the right one can affect your budget, your doctors, and your peace of mind.

In this article, I’ll explain what a Medicare Advantage plan in Washington is, how it works, who it’s right for, and what to consider before enrolling. As a licensed Washington Medicare broker, I’ve helped hundreds of people compare their options and find the right plan — and I’ll give you the same guidance here.

Understanding Medicare Advantage (Part C)

What a Medicare Advantage Plan Is

A Medicare Advantage plan is an alternative way to get your Medicare Part A (hospital) and Part B (medical) benefits. These plans are offered by private insurance companies approved by Medicare.

When you join one:

You still have Medicare, but your benefits come through the plan instead of directly from the government.
Most plans also include prescription drug coverage (Part D).
Many offer extra benefits such as dental, vision, hearing, transportation, and fitness programs.

These plans are regulated by Medicare, but each company sets its own rules for provider networks, referrals, copays, and coverage extras.

How Medicare Advantage Plans Work in Washington

Availability and Plan Types

In Washington State, Medicare Advantage plans are available in nearly every county, with dozens of options from major carriers. Depending on where you live, you may have access to:

HMO (Health Maintenance Organization) plans, which use local provider networks and often require referrals.
PPO (Preferred Provider Organization) plans, which allow out-of-network care at higher cost.
PFFS (Private Fee-for-Service) plans, less common but offering flexible doctor choice.

You can review plan options and updates for the upcoming year on our guide to Washington Medicare Plan Options 2026.

Enrollment Windows

You can join, switch, or drop a Medicare Advantage plan during certain times:

Initial Enrollment Period: The 7-month window around your 65th birthday.
Annual Enrollment Period (AEP): October 15 – December 7 each year.
Medicare Advantage Open Enrollment (MA OEP): January 1 – March 31, if you’re already in an MA plan.

Each period allows specific changes, so timing is key.

Costs in Washington

Medicare Advantage premiums in Washington range from $0 to about $80 per month, depending on your county and plan.
Remember, you still pay your Part B premium ($174.70/month in 2025 for most people).

You’ll also have:

Copays for doctor visits or hospital stays
Coinsurance for some services
An out-of-pocket maximum (MOOP) — once you reach it, your plan pays 100% for covered services for the rest of the year

For 2026, the average Washington plan’s MOOP is around $6,700 in-network.

Advantages of Choosing a Medicare Advantage Plan in Washington

1. Comprehensive, All-in-One Coverage

Medicare Advantage bundles your hospital, medical, and often drug coverage into one plan. You carry one card and work with one insurance company — a simpler experience than juggling separate Part A, B, D and Medigap policies.

2. Predictable Costs and Annual Limits

Original Medicare doesn’t have a spending cap, but Medicare Advantage plans do. Once you reach your annual out-of-pocket maximum, the plan pays 100% of covered costs. That provides financial peace of mind if you face a serious illness.

3. Extra Benefits

In Washington, many plans include valuable extras that Original Medicare doesn’t cover:

Preventive and routine dental, vision, and hearing care
Prescription drug coverage (Part D)
Fitness memberships such as SilverSneakers
Telehealth, meal delivery, or transportation assistance

These perks can add up to hundreds of dollars in value each year.

4. Competitive Premiums — Sometimes $0

Some Washington MA plans have no additional premium beyond your Part B payment. Others charge modest monthly fees for richer benefits. Either way, many residents find MA plans cost-effective compared with pairing Original Medicare with Medigap and Part D.

5. Local Coordination and Managed Care

For people who prefer having one coordinated system — where your doctors, specialists, and hospitals are connected — a Medicare Advantage HMO or PPO can streamline your care.

Potential Drawbacks to Consider

1. Network Limitations

Most plans require you to use in-network providers (especially HMOs). Going outside the network can mean higher costs or no coverage except in emergencies. If you travel frequently or live in multiple states, this could be restrictive.

2. Prior Authorizations and Plan Rules

Medicare Advantage plans can require pre-approval for certain tests, procedures, or specialists. You’ll want to review each plan’s rules and how responsive they are before enrolling.

3. Annual Changes

Plans renew their contracts each year. Premiums, copays, drug formularies, and even provider networks can change. Reviewing your plan every fall during the Annual Enrollment Period is crucial.

4. Limited Flexibility if Switching Back

If you leave Medicare Advantage and return to Original Medicare, you might not be guaranteed acceptance into a Medigap supplement later. Washington offers some protections, but timing still matters.

Comparing Medicare Advantage vs. Original Medicare in Washington

Feature	Original Medicare	Medicare Advantage
Provider Choice	Any U.S. provider accepting Medicare	Usually limited to plan network
Prescription Drug Coverage	Separate Part D plan needed	Often included
Out-of-Pocket Limit	None	Yes, capped annually
Extra Benefits (Dental, Vision, Fitness)	Not included	Often included
Monthly Premiums	Part B + optional Medigap + Part D	Part B + may include $0 plan premium
Nationwide Coverage	Yes	Emergency coverage only outside service area

Each path has pros and cons — the best choice depends on your health needs, travel habits, and budget.

How to Decide if a Medicare Advantage Plan Is Right for You

Ask Yourself:

Do I want simple, all-in-one coverage?
→ MA plans may be ideal.
Do I travel often or split time between states?
→ Original Medicare offers more flexibility.
Do I want dental, vision, and fitness benefits?
→ These extras are usually part of MA plans.
Am I comfortable staying within a provider network?
→ If yes, MA plans often save you money.
Do I want predictable annual costs?
→ The built-in MOOP can provide reassurance.

For a personalized checklist, review our Medicare Checklist Before 65. It’s a great starting point for comparing your options.

Choosing a Washington Medicare Advantage Plan

Step 1: Check Eligibility

You must be enrolled in both Medicare Part A and Part B, and live within the plan’s Washington service area.

Step 2: Review Available Plans by County

Contact Advisor Health Benefits Group to look at your 2026 options. You can also explore our Washington Medicare Plans page for current plan categories and updates.

Step 3: Compare Key Features

Premiums and out-of-pocket limits
Doctor and hospital networks
Prescription coverage and formularies
Extra benefits like dental, vision, and fitness
Quality star-ratings (the higher, the better)

Step 4: Verify Your Doctors and Medications

Always confirm your primary care doctor, specialists, and preferred pharmacies are in-network and your prescriptions are covered.

Step 5: Enroll During the Right Period

Enroll online, through a broker, or directly with the insurance carrier during your eligible period. If you need help, contact us at Advisor Health Benefits.

Why Work With a Local Washington Medicare Broker?

Choosing a plan isn’t just about finding the cheapest premium — it’s about matching your needs to the right carrier and network.

As a Washington-based Medicare broker, I:

Represent multiple top-rated insurers statewide
Provide unbiased advice (I work for you, not the carriers)
Help compare costs, benefits, and provider networks side-by-side
Assist with enrollment, paperwork, and annual reviews

You don’t pay extra for working with a broker — it’s built into the plan. Many Washington residents find this guidance invaluable, especially with annual plan changes.

Learn more about me and our agency at About Advisor Health Benefits and my profile page.

Common Questions About Medicare Advantage in Washington

Is Medicare Advantage popular in Washington?

Yes. More than half of Washington’s Medicare beneficiaries are enrolled in MA plans, and options expand every year.

Can I change plans if mine isn’t working?

Yes — you can switch during the Annual Enrollment Period (Oct 15–Dec 7) or the MA Open Enrollment (Jan 1–Mar 31).

Can I get help paying for Medicare?

Yes, Washington has programs to assist low-income beneficiaries. Contact the Statewide Health Insurance Benefits Advisors (SHIBA) program or your local broker for guidance.

What about prescription drugs?

Most MA plans include Part D coverage. If you choose one that doesn’t, you’ll need a separate drug plan. Be sure to confirm coverage for your current medications.

Can I have both Medicare Advantage and Medigap?

No. You can have one or the other — not both. Medigap only supplements Original Medicare.

Real-World Example: Who a Medicare Advantage Plan Fits Best

Meet Susan, a 67-year-old retiree living in Spokane. She’s healthy, takes one daily prescription, and likes her local doctor. She wants dental and vision coverage without juggling multiple plans.

After reviewing options, she enrolls in a $0-premium HMO plan that includes:

Part D drug coverage
$25 doctor visit copays
$6,500 MOOP
Free dental cleanings and eye exams

Her total yearly costs are predictable, and she’s satisfied knowing her plan coordinates all her care locally. For someone like Susan, a Washington Medicare Advantage plan is a smart choice.

Final Thoughts — Should You Consider a Medicare Advantage Plan in Washington?

In short: yes, you should at least consider one.

A Medicare Advantage plan can be an excellent fit if you want:

Streamlined coverage that bundles medical, hospital, and prescription benefits
Added perks like dental, vision, and fitness programs
Predictable annual spending limits
A trusted local network of providers

But it’s not right for everyone. If you value full provider flexibility, travel often, or require specialized care across state lines, Original Medicare + Medigap + Part D might suit you better.

The key is personalization. Every Washington county, health situation, and budget is unique — and that’s where expert guidance makes a difference.

I invite you to connect with me directly at Advisor Health Benefits Group to compare plans side-by-side, review rates, and ensure you’re covered with confidence.

Also, explore these helpful resources:

About Kevin Husted
Kevin Husted is an independent Medicare and health insurance broker serving Washington State. Through Advisor Health Benefits Group, he helps individuals, families, and small businesses compare coverage options, understand Medicare, and enroll in the best plans for their needs.

Trusted Medicare Resources for Washington Residents

Before making your decision, it’s important to learn from verified, non-commercial sources. These resources help you understand how Medicare Advantage works without steering you toward specific plans:

Medicare.gov – Understanding Medicare Advantage
The official federal guide explains what Medicare Advantage covers, how it differs from Original Medicare, and what to consider before enrolling.
Washington State Office of the Insurance Commissioner – Medicare Information
A Washington-specific government resource that outlines your rights, enrollment help, and state assistance programs such as SHIBA.
Social Security Administration – Medicare Enrollment Basics
Learn how to apply for Medicare, manage enrollment periods, and link your Social Security benefits with Medicare coverage.

After reviewing these official resources, reach out to a local Medicare broker for one-on-one guidance that’s tailored to your health and budget.
👉 Contact Advisor Health Benefits Group to discuss your options with a Washington Medicare expert.

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