Medicare Plans - Eligibility Requirements
General Eligibility Requirements (Basic Plan)
- You are a resident of Washington state;
- You are enrolled in Medicare Part A and Part B;
- You were rejected for coverage by a health carrier, offered substantially reduced coverage on a Medicare supplemental insurance policy, or you do not have comprehensive Medicare supplemental coverage available to you; and
- You do not have access to a reasonable choice of Medicare Advantage Plans (Part C). NOTE: This includes persons who reside in a county that is not designated by WSHIP as having “reasonable choice” of Medicare Advantage Plans and persons with End Stage Renal Disease (ESRD) since persons with ESRD typically cannot enroll in a Medicare Advantage Plan.
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, or you have End Stage Renal Disease (ESRD) since persons with ESRD typically cannot enroll in a Medicare Advantage Plan.
Counties with reasonable choice of Medicare Advantage Plans in 2018 & 2019:
Clark, Cowlitz, King, Pierce, Snohomish, Spokane, Thurston
If you live in one of these counties, you are not eligible for WSHIP.