Medicare is a federal program, but the decisions that surround it are anything but uniform. When to enroll, whether to delay Part B while still working, whether to choose a Medicare Advantage plan or a Medicare Supplement (Medigap) policy, and how to challenge a denial all turn on timing and on state insurance rules. Holmes Law helps clients as a Washington Medicare planning attorney, looking at Medicare in the context of the whole plan: retirement, long-term care, Apple Health, and estate planning.
Washington has some of the most consumer-friendly Medigap rules in the country. Under RCW 48.66.045, a person who already has a Medigap policy can generally switch to another plan at any time without new medical underwriting, within the plan categories the statute allows. The state also runs a well-established free counseling program through the Office of the Insurance Commissioner. Michael Holmes is admitted in Washington and works remotely with clients across the state. This page explains the rules that most often cause problems; it is general information, not legal or insurance advice for your situation, and Holmes Law does not sell insurance.
How Medicare Fits Into a Washington Elder Law Plan
Medicare pays for hospital care, physician services, prescription drugs, and short-term skilled care. It does not pay for long-term custodial care, which is why Medicare decisions are only one part of planning for later life. For care needs that last months or years, the relevant programs are Apple Health (Medicaid), the WA Cares Fund, private long-term care insurance, and VA benefits; see the WA long-term care page. But mistakes in Medicare enrollment can create lifetime penalties and coverage gaps, and a Washington Medicare planning attorney can spot the traps before they become permanent.
Medicare’s Parts in Brief
- Part A (hospital insurance) covers inpatient hospital care, a limited period of skilled nursing facility care after a qualifying inpatient stay, hospice, and some home health care. Most people pay no premium for Part A because of their work history.
- Part B (medical insurance) covers physician services, outpatient care, durable medical equipment, and preventive services, and it carries a monthly premium.
- Part C (Medicare Advantage) plans are offered by private insurers approved by Medicare. They bundle Part A and Part B coverage, usually include Part D, and use provider networks and prior authorization.
- Part D covers outpatient prescription drugs through private plans. Beginning in 2025, Part D includes an annual cap on out-of-pocket drug costs, and enrollees can choose to spread their out-of-pocket costs across the year through the Medicare Prescription Payment Plan.
This page deliberately does not list premium, deductible, or cap amounts, because they change every year. Current figures are published by the Centers for Medicare & Medicaid Services.
Enrollment Windows
Initial Enrollment Period
The Initial Enrollment Period is the seven-month window that includes the three months before the month a person turns 65, the birthday month, and the three months after. People already receiving Social Security retirement benefits are generally enrolled in Parts A and B automatically. Everyone else must apply through the Social Security Administration. Enrolling in the months before the birthday month avoids a gap; enrolling later in the window can delay the start of coverage.
General Enrollment Period
Someone who misses the Initial Enrollment Period and has no special enrollment right can enroll during the General Enrollment Period from January 1 through March 31 each year. Coverage begins the month after enrollment, and a late enrollment penalty may apply for as long as the person has Part B.
Annual and Medicare Advantage open enrollment
Each fall, from October 15 through December 7, beneficiaries can change Medicare Advantage and Part D plans for the following year. From January 1 through March 31, people already in a Medicare Advantage plan can switch to another Medicare Advantage plan or return to Original Medicare with a Part D plan. Returning to Original Medicare does not by itself create a right to buy a Medigap policy without underwriting, which is why the Medigap rules below are so important.
Part B Special Enrollment Period Traps
Many Washington residents keep working past 65, especially in technology, health care, and public employment. A person covered by a group health plan based on current employment, his or her own or a spouse’s, may delay Part B without penalty and later enroll during a Special Enrollment Period, which lasts eight months after the employment or the coverage ends, whichever happens first. The traps:
- COBRA is not coverage based on current employment. The eight-month clock starts when employment ends, not when COBRA ends. People who wait for COBRA to run out can miss the window and face a penalty.
- Retiree health coverage is also not based on current employment.
- Small employers. When an employer has fewer than 20 employees, Medicare is usually primary, and the group plan may pay little or nothing for someone who should have enrolled in Part B.
- Health savings accounts. Once enrolled in any part of Medicare, a person cannot contribute to an HSA. Because Part A enrollment after 65 can be retroactive up to six months (but not before the month of eligibility), HSA contributions should stop before applying.
- Part D. A person without creditable drug coverage who delays Part D faces a separate late enrollment penalty. Employers are required to tell employees whether their drug coverage is creditable; keep those notices.
Social Security has additional special enrollment periods for exceptional circumstances, such as a natural disaster or an employer’s or health plan’s error. Documentation from the employer is essential in every case.
Medigap in Washington
A Medigap policy supplements Original Medicare by paying some or all of the deductibles, coinsurance, and copayments Original Medicare leaves behind. Medigap plans are standardized by letter nationally. Plans C and F are available only to people who were first eligible for Medicare before January 1, 2020.
Federal open enrollment and guaranteed issue
Federal law gives every beneficiary a six-month Medigap open enrollment period that begins the first month the person is both 65 or older and enrolled in Part B. During that period, an insurer cannot refuse to sell a policy or charge more because of health. Federal law also provides guaranteed issue rights in specific situations, such as when a Medicare Advantage plan leaves the area or when a person tries Medicare Advantage for the first time and returns to Original Medicare within the trial period.
Washington’s switching rule
Washington goes further than most states. Rather than a narrow “birthday rule” that gives a short window each year, RCW 48.66.045 requires Medigap issuers to accept a Washington resident who is replacing an existing Medigap policy without evidence of insurability, within the plan categories the statute permits. According to the Office of the Insurance Commissioner, a person with a Medigap plan B through N can switch at any time to another plan B through N, and a person with Plan A can switch to another Plan A, without a health screening questionnaire. The permitted replacement plans depend on when the original policy was issued.
The key limitation: this right belongs to people who already have a Medigap policy. Someone moving from Medicare Advantage or employer coverage to Medigap outside open enrollment or a guaranteed issue situation may have to pass a health screening questionnaire.
Under-65 access
People under 65 who have Medicare because of disability or end-stage renal disease face more limited choices. Washington’s Medigap statute addresses these beneficiaries, but the Office of the Insurance Commissioner cautions that people under 65 may not be able to buy the Medigap plan they want, or any Medigap plan, until they turn 65. When they reach 65, they receive a new Medigap open enrollment period. Medicare Advantage, and for those with limited income, Apple Health and the Medicare Savings Programs, may be alternatives in the meantime.
SHIBA: Washington’s Free Medicare Counseling
Washington’s State Health Insurance Assistance Program is called SHIBA (Statewide Health Insurance Benefits Advisors) and is operated by the Office of the Insurance Commissioner. SHIBA volunteers provide free, unbiased counseling on plan choices and enrollment, and they can be reached through the OIC’s SHIBA line at 800-562-6900. SHIBA is a valuable resource for comparing plans; Holmes Law focuses on the legal side, such as coordinating Medicare with Apple Health eligibility, special needs trusts, powers of attorney, and appeals.
IRMAA: Income-Related Premium Surcharges
Higher-income beneficiaries pay an Income-Related Monthly Adjustment Amount (IRMAA) on top of the standard Part B and Part D premiums. The Social Security Administration determines IRMAA using modified adjusted gross income from the tax return filed two years earlier. That lag creates problems for recent retirees whose income has dropped, and for people who had a one-time spike from selling a business, a Roth conversion, or a large capital gain. Washington has no personal income tax on wages, but federal income from a home sale or investment sale still counts toward IRMAA.
A beneficiary whose income has dropped because of a life-changing event, such as retirement, reduced work hours, death of a spouse, divorce, or loss of income-producing property, can ask Social Security to use more recent income by filing Form SSA-44 with supporting documentation. Estate and trust planning can also affect IRMAA, since distributions from certain trusts and retirement accounts count as income.
Help With Costs: Apple Health and Medicare Savings Programs
Washington residents with limited income and resources may qualify for Medicare Savings Programs, administered through Apple Health, which can pay Part B premiums and, for some people, Medicare cost-sharing. People who qualify are also generally deemed eligible for the federal Extra Help program for Part D costs. Full Apple Health eligibility can cover services Medicare does not, including long-term care. See WA Medicaid planning for how Washington counts income and resources.
Medicare Appeals
Medicare denials can be appealed, and many are overturned. Original Medicare appeals move through five levels: redetermination by the Medicare Administrative Contractor, reconsideration by a Qualified Independent Contractor, a hearing before an Administrative Law Judge, review by the Medicare Appeals Council, and judicial review in federal district court. Each level has its own deadline and, at the higher levels, an amount-in-controversy requirement. Medicare Advantage and Part D plans have parallel processes that begin with the plan itself.
Two situations deserve special mention:
- Fast-track appeals. When a hospital plans to discharge a patient, or a skilled nursing facility, home health agency, or hospice plans to end covered services, the patient can request an expedited review by the Beneficiary and Family Centered Care Quality Improvement Organization. The deadline is very short, usually by noon of the day after receiving the notice.
- The “improvement standard.” Medicare coverage of skilled nursing and therapy does not depend on the patient improving. Under the Jimmo v. Sebelius settlement, skilled care to maintain a condition or slow decline can be covered. Denials that say a patient has “plateaued” deserve a careful look.
An agent under a durable power of attorney or a health care agent can pursue appeals for a beneficiary who cannot do so. The WA incapacity and powers of attorney page explains how to set that up.
Moving to or From Washington With Medicare
Retirees move in and out of Washington often, and a move can change Medicare coverage. A Medicare Advantage or Part D plan is tied to a service area, so a permanent move out of the plan’s service area creates a special enrollment period to choose a new plan, and failing to act can leave a person without drug coverage. Original Medicare works nationwide, and a Medigap policy generally stays in force after a move, although premiums may change and Washington’s switching rule applies only to policies governed by Washington law. People moving into Washington who want to use the state’s switching rule should confirm with the insurer and with SHIBA how their current policy is treated.
A move also affects Apple Health and the Medicare Savings Programs, which are state programs; eligibility must be re-established in the new state. For snowbirds who split time between Washington and another state, Original Medicare with a Medigap policy is often more practical than a network-based Medicare Advantage plan.
Working With a Washington Medicare Planning Attorney
Holmes Law does not sell insurance or recommend specific plans. A Washington Medicare planning attorney helps with the legal pieces: documenting employer coverage for a Part B special enrollment, preparing an IRMAA reconsideration request, coordinating Medicare with Apple Health and special needs trusts, preparing powers of attorney so an agent can handle appeals, and reviewing facility discharge notices.
Frequently Asked Questions
Can I switch Medigap plans any time in Washington?
If you already have a Medigap policy, Washington law generally lets you switch to another plan within the categories allowed by RCW 48.66.045 without a health screening. Moving to Medigap from Medicare Advantage or another type of coverage is different and may require underwriting.
Do I have to sign up for Part B at 65 if I am still working?
Not if you have group health coverage based on current employment (yours or your spouse’s) from an employer large enough for that coverage to be primary. Confirm with the employer, keep documentation, and enroll within eight months after employment or coverage ends.
Is COBRA enough to delay Part B?
No. COBRA is not coverage based on current employment, and the special enrollment window runs from the end of employment.
Where can I get free help comparing plans in Washington?
SHIBA, the Statewide Health Insurance Benefits Advisors program run by the Office of the Insurance Commissioner, provides free counseling.
Can I reduce my IRMAA surcharge after retiring?
Often. If your income dropped because of a life-changing event such as retirement, you can ask Social Security to use more recent income by filing Form SSA-44 with documentation.
Does Medicare pay for a nursing home?
Only for a limited period of skilled care after a qualifying inpatient hospital stay. Long-term custodial care is generally paid privately, by long-term care insurance, by the WA Cares Fund for eligible people, or by Apple Health.
Speak With a Washington Medicare Planning Attorney
Medicare decisions ripple into long-term care, Apple Health, and estate planning. Holmes Law can review your situation and coordinate your Medicare choices with the rest of your plan. Visit the Washington elder law hub, or contact Holmes Law to speak with Michael Holmes.