Who Qualifies for Medicare Advantage Plans?

Learn about Medicare eligibility, who qualifies for Medicare Advantage plans, and when to enroll.

For many Medicare-eligible seniors, a Medicare Advantage plan offers comprehensive health coverage, including prescription drug coverage, often with no monthly premium. As individuals age, they focus more and more on health care. Finding the right health insurance plan is essential to helping seniors cover coinsurance and other out-of-pocket costs, but the health plan must also be affordable.

Under the federal Medicare program, seniors choose how they want to receive their Medicare benefits:

Medicare eligibility is the same for Original Medicare and Medicare Part C. However, with a Medicare Advantage plan, you must live in the plan’s service area. Original Medicare is accepted nationwide.

Another part of your Medicare coverage is Medicare Part D, which covers prescription drugs. With Original Medicare, you must buy a separate prescription drug plan. However, many Medicare Advantage plans include Part D coverage, one reason Advantage plans are increasingly popular.

Each insurance company offering Medicare Part C plans is approved and regulated by the federal government. Some Medicare Part C plans require a monthly premium in addition to your Part B premium.

How to Determine Medicare Advantage Eligibility

If you qualify for Original Medicare, then you qualify for a Medicare Advantage plan. Because Medicare Part C is simply another way to receive your Medicare benefits, eligibility requirements include enrolling in Part A and Part B.

You qualify for Part A and Medicare Part B if you are a U.S. citizen or permanent resident.

Medicare eligibility requirements also include meeting one of the following conditions:

  • You are 65
  • You have ESRD (end-stage renal disease)
  • You have ALS (amyotrophic lateral sclerosis)
  • You are disabled and receive either Social Security (SS) or Railroad Retirement (RR) disability benefits

If you qualify for and are receiving SS or RR benefits, you’re automatically signed up for Medicare. However, you’ll have to sign up through a Social Security office or online if you aren’t already receiving benefits.

Medicare Part A Enrollment

You won’t pay for Medicare Part A if you or your spouse worked enough hours to qualify for Social Security or Railroad Retirement or if you’re a government employee who’s paid into Medicare.

Part A is hospital insurance that covers these services:

  • Inpatient care
  • Skilled nursing in a care facility
  • Hospice
  • Nursing home care
  • Home health care

Medicare Part B Enrollment

Medicare Part B is medical insurance that covers doctors’ visits and other outpatient services such as the following:

  • Durable medical equipment
  • Ambulance transportation
  • Preventive care
  • Laboratory tests

Remember that even though you meet the requirements for Medicare eligibility, Medicare doesn’t pay 100% of your costs. You’ll have coinsurance, deductibles, and copayments for Medicare Part A and Medicare Part B. Medicare beneficiaries who are low-income or eligible for Medicaid might qualify for extra help paying these out-of-pocket costs.

Who Doesn't Qualify for Medicare Advantage?

Every Medicare-eligible individual qualifies for Medicare Advantage.

There are, however, a few circumstances that can cause disqualification from Medicare Advantage:

  • If you stop paying your Part B premium
  • If you have Medicare Supplement Insurance
  • If you don’t live in the plan’s service area

How Do I Enroll in a Medicare Advantage Plan?

In addition to Medicare Part A and Medicare Part B benefits, Medicare Advantage plans frequently offer additional benefits such as gym memberships and routine dental or vision care.

Plan options include:

  • HMO (Health Maintenance Organization)
  • PPO (Preferred Provider Organization)
  • SNP (Special Needs Plans)

Eligibility requirements for Advantage plans require beneficiaries to live in the plan’s service area. So if you live in different parts of the country during the year, ask the insurance company if you’re covered in both locations.

You can join Medicare Advantage during one of the following enrollment periods.
Initial Enrollment Period

Your Initial Enrollment Period begins when you first meet the requirements for Medicare eligibility.

The IEP:

  • Lasts for seven months
  • Starts three months before your 65th birthday
  • Includes your birthday month
  • Ends three months after your 65th birthday

Annual Enrollment Period

The Annual Enrollment Period is the same as the Medicare Open Enrollment Period.

The AEP:

  • Runs from October 15 to December 7
  • Allows you to enroll in Medicare Advantage, withdraw from Medicare Advantage, or change Medicare Advantage plans

Open Enrollment Period

If you already have an Advantage plan, you can also make changes during the Medicare Advantage Open Enrollment Period.

The OEP:

  • Runs from January 1 through March 31
  • Is when you can switch Advantage plans
  • Is when you can drop Medicare Advantage and return to Original Medicare

Special Enrollment Periods

Special Enrollment Periods are for life-changing situations that occur.

Circumstances that trigger a SEP include the following:

  • Moving out of your plan’s service area
  • The insurance company providing your plan discontinues the plan
  • Moving into or out of a nursing facility

Our insurance agents are happy to explain the eligibility requirements for each enrollment period and walk you through the process.

Resource links

Our agents can help you determine when you qualify for Medicare Part C, compare costs, and navigate the maze of Medicare plans available. The following links provide additional Medicare information.

Ready to learn more?

Choosing between Medigap and Medicare Advantage plans is not an easy decision. However, educating yourself about the differences between the two types of insurance coverage, comparing different plans and policies, and talking to a licensed insurance agent will help you make the right choice.