Who Qualifies for Medicare Advantage Plans?

Eligibility requirements for a Medicare Advantage plan are the same as the eligibility requirements for Original Medicare (Parts A and B). Medicare Advantage plans do work differently, though, as we will explore below.

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

• Original Medicare (Part A and Part B)           – or – 
• Medicare Advantage (also known as Medicare Part C; this replaces your A & B coverage, often with additional benefits such as prescription drugs, vision, dental, or wellness programs)

Private insurance companies offer Medicare Advantage (or Part C Medicare) plans, and each company is approved and regulated by the federal government. Some Medicare Part C plans require a monthly premium in addition to your assigned Part B premium.

Another part of your Medicare coverage is Medicare Part D, which covers prescription drugs. With Original Medicare, you must buy your Part D prescription drug plan separately from Parts A and B. However, many Medicare Advantage plans include Part D coverage, which is one reason Advantage plans are becoming increasingly popular.

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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, you must first enroll in Medicare Part A and Medicare Part B, and then you can switch to a Medicare Advantage plan.

You qualify for Medicare Part A and Medicare Part B if you are a U.S. citizen (or permanent resident) and also meet one of the following conditions:

• You are age 65 or older
• You have ESRD (end-stage renal disease)
• You have ALS (amyotrophic lateral sclerosis)
• You are disabled and have received either Social Security (SS) or Railroad Retirement (RR) disability benefits for 24 months or more

If you have received SS or RR benefits for at least 24 months, you are automatically signed up for Medicare. If you are not disabled but meet one of the other criteria, you will need to sign up through a Social Security office or online.

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 (this equates to roughly ten years).

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 carries a monthly premium that is standardized by income, which usually must be paid in addition to the Medicare Advantage (Part C) premium (some exclusions apply).

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

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

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

Remember that even if you meet the requirements for Medicare eligibility, Medicare doesn’t pay 100% of your costs. You will 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 a Medicare Advantage plan.

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

• If you stop paying your Part B premium
• If you have Medicare Supplement insurance (you cannot have a Medicare Supplement and Medicare Advantage plan)
• If you don’t live in the plan’s service area

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.

How Do I Enroll in a Medicare Advantage Plan?

You can join a Medicare Advantage plan during one of the following enrollment periods.

• Initial Enrollment Period (IEP)

  Your Initial Enrollment Period begins when you first meet the requirements for Medicare eligibility.  Your IEP begins three months before your 65th birthday month and ends three months after your 65th birthday month.

• Annual Enrollment Period (AEP)

  The Annual Enrollment Period (AEP) runs from October 15th through December 7th of each year. During the AEP each year, you may enroll in a Medicare Advantage plan, withdraw from a Medicare Advantage plan, or change Medicare Advantage plans.

• Open Enrollment Period (OEP)

  The Medicare Advantage Open Enrollment Period (OEP) runs from January 1st to March 31st of each year.  During this time, if you are already enrolled in a Medicare Advantage plan, you may switch plans or revert back to Original Medicare.  You can also purchase separate Part D prescription drug coverage at this time. You may only make one change of this kind per year.

• Special Enrollment Periods (SEPs)

  Special enrollment periods (SEPs) are rare and only apply when triggered by a life-altering event.  Examples include:

  • moving out of your plan’s service area
  • your insurance company discontinues your plan
  • moving into or out of a nursing facility
  • you gain or lose Medicaid coverage
  • various other situations, as explained in detail on Medicare.gov

If you would like further assistance understanding the various enrollment periods, our licensed and experienced insurance agents are available anytime to walk you through the process.

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Choosing the right Medicare Plan is not a decision that should be taken lightly. With Policy Guide’s assistance, you will have access to the knowledge and expertise of professional agents who can help you compare different health plans, prices, and policies to ensure that you make an informed decision. Let us guide you through this process, so that your chosen plan best suits your needs.

Resource Links

• Understanding Enrollment Periods for Medicare Advantage Plans
• Prescription Drug Coverage
• Applying for Medicare