Medicare Plans - Eligibility Requirements
General Eligibility Requirements (Basic Plan)
- You must be a resident of Washington state;
- You must be enrolled in Medicare Part A and Part B;
- You must provide evidence of rejection for medical reasons, a requirement of restrictive riders, an up-rated premium, or a pre-existing conditions limitation on a Medicare supplemental insurance policy, or not have comprehensive Medicare Supplement coverage available to you; and
- You must not have access to a reasonable choice of Medicare Advantage Plans (Part C).
Determining if You Have Reasonable Choice of Medicare Advantage Plans (Part C)
Under Washington law, to be eligible for coverage under WSHIP’s Medicare-eligible Basic Plan you must live in a Washington county where you do not have reasonable choice of comprehensive Medicare Advantage Plans (Part C).
Definition of Reasonable Choice
Reasonable choice of Medicare Advantage Plans means:
- You have a choice of health maintenance organization (HMO) or preferred provider organization (PPO) Medicare Advantage Plans offered by at least three different carriers that have had provider networks in your county of residence for at least five years.
- The benefit plan options include coverage at least as comprehensive as Plan F Medicare supplement plan combined with Medicare Parts A and B.
- The benefit plan options also provide access to adequate and stable provider networks that make up-to-date provider directories easily accessible on the carrier website, and will provide a hard copy, if requested.
- The health care provider with whom you have an established care relationship and from whom you have received treatment within the past twelve months is not a member of the available HMO or PPO Medicare Advantage Plan carrier networks.
Counties with Reasonable Choice
The Washington counties below have been determined to have reasonable choice of Medicare Advantage Plans. If you live in one of these counties you are not eligible for WSHIP unless your health care provider is not included as a member of at least one of the HMO or PPO benefit plans available to you.
Counties with reasonable choice of Medicare Advantage Plans in 2016:
Clark, Cowlitz, Island, King, Kitsap, Lewis, Pierce, Snohomish, Spokane, Thurston, Whatcom, Yakima
If you live in one of these counties, you are not eligible for WSHIP.