It is essential to understand Medicare Advantage eligibility rules before enrolling in a plan. Depending on your situation, a Medicare Advantage plan might be the best coverage to fit your needs. However, in other circumstances, there may be another option of which you are not aware.
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Medicare Advantage plans vary by location, but eligibility rules are standard. In this article, we dive into Medicare Advantage eligibility and give you all the tools you need to make the best coverage choice.
Who Qualifies for Medicare Advantage?
You are eligible for a Medicare Advantage plan if you have Original Medicare (Part A and Part B). Even those on Medicare under 65 due to disability may enroll. You may sign up for a Medicare Advantage policy if you live in your chosen plan’s service area.
When you enroll in a Medicare Advantage plan, you will pay your chosen plan’s monthly premium in addition to your Medicare Part B premium.
Low-income or Medicaid-eligible beneficiaries may qualify for extra help paying for premiums, deductibles, and copayments. Extra Help qualification is based on your annual income and can change anytime.
Those with End-Stage Renal Disease (ESRD) may also qualify for Medicare Advantage. For beneficiaries who enroll in Medicare with ESRD, coverage generally starts on the fourth month of dialysis. However, in some instances, coverage can begin within the first month of dialysis:
- If the patient plans on completing home dialysis training to carry out self-dialysis treatments at home
- ESRD Patients who start home dialysis training early (before the third month of their dialysis treatment)
- Patients who participate in a home dialysis training program
If you have Medicare due to ESRD, your Medicare coverage can stop under two conditions:
- 12 months after the month your dialysis treatments end
- 36 months after receiving a kidney transplant.
Special Needs Plans are also available for those with chronic issues. Depending on where you live, a Special Needs Plan may or may not be available.
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What Are the Medicare Advantage Eligibility Requirements?
If you are Medicare-eligible, you can enroll in a Medicare Advantage plan in your area. Not all locations have Medicare Advantage plans, so you should check plan availability before you decide on a policy.
There are several Medicare Advantage enrollment periods. An enrollment period is a window when you can select, drop, or change coverage. Examples include the Annual Enrollment Period, Medicare Advantage Open Enrollment Period, and a Special Enrollment Period.
If you move out of your Medicare Advantage plan’s service area or the plan leaves Medicare, you can switch policies using a Special Enrollment Period. Further, if you have a Medicare Supplement (Medigap) plan and want to try Medicare Advantage, you qualify for trial rights. With these trial rights, you can try out the Medicare Advantage plan for up to 12 months.
If you decide the Medicare Advantage plan is not suitable for you before 12 months, you can switch back to Medigap. However, you must ensure your original Medicare Supplement policy is still available through your previous company. If not, you can choose any policy of equal or lesser value with any company.
Medicare Part C Eligibility
To be eligible for Medicare Part C you must:
- Enroll in Medicare Part A
- Enroll in Medicare Part B
- Live in the service area of your selected plan
- Have a valid Medicare Advantage Enrollment Period.
To enroll in a Medicare Part C plan, there are no health questions, and you cannot be denied coverage for any reason.
After January 1, 2021, even those with end-stage renal disease (ESRD) are eligible for any Medicare Part C plan in their area. Prior to 2021, those diagnosed with ESRD were only eligible for Special Needs Plans. Now, those with ESRD are eligible for a broader range of plans with different coverage options.
Medicare Advantage Eligibility Checklist
You must do a few things to qualify for a Medicare Advantage plan.
- Know your Medicare Part A and Part B effective date
- Have your Medicare card number handy
- Live in the plan’s service area
Those unsure of Medicare eligibility can always call Social Security to inquire.
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When Can I Apply for Medicare Advantage?
You have several opportunities to select a Medicare Advantage plan. First, the Initial Enrollment Period allows you to sign up when you first turn 65. Those who delay Medicare Part B qualify for the Initial Coverage Enrollment Period, which gives you Medicare Advantage eligibility when you enroll in Medicare Part B.
The Annual Enrollment Period is every fall, from October 15 through December 7. Then, the Medicare Advantage Open Enrollment Period is one last chance to change your existing Medicare Advantage plans from January through March.
Finally, Special Enrollment Periods allow you to switch plans during life-changing or policy-changing situations.
Can You Be Denied a Medicare Advantage Plan?
Beneficiaries with Medicare Part A and Part B will not be refused Medicare Advantage coverage. Unlike with Medigap, there are no health questions you must answer when enrolling in Medicare Advantage, and your pre-existing conditions do not play a role in admission.
However, just because the plan is easy to sign up for does not automatically make it the best coverage for your needs. We always recommend comparing your options before enrolling in a Medicare Advantage plan.
How to Enroll in a Medicare Advantage Plan
If you meet Medicare eligibility, you will want to research the best Medicare Advantage plans in your area before you enroll. It is always a good idea to consult an agent about your options.
Our licensed agents are Medicare experts who review each plan side-by-side, so you will be confident when choosing the proper coverage.
It is essential to consider if your doctor is in-network and whether your prescriptions are on the plan’s formulary. Further, you’ll want to compare costs.
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Our agents work with the top carriers in the nation for Medicare. We can compare Medigap to Medicare Advantage and answer all your questions.
What Are the Medicare Advantage Rules?
Compared to other supplemental Medicare options, Medicare Advantage plans are typically stricter regarding how you can use their benefits. There are a few
A vital factor to consider is that you must adhere to a doctor network to receive coverage in many cases. So, if you live in New York and you’re visiting family in Florida, a doctor visit could be 100% your responsibility. Or, if you see a specialist that isn’t in the network, the cost is all on you.
Additionally, if you need to visit a specialist for care, you may need a referral first. A practitioner could delay your care if you cannot obtain a referral promptly. On the other hand, Medicare Supplement plans are accepted wherever doctors take Medicare.
What Are the Medicare Advantage Income Limits?
There are no income limits for Medicare Advantage. But, if you qualify for a low-income subsidy or Medicaid, a Special Needs Plan may be available in your area that caters to low-income individuals.
FAQs
How to Determine Medicare Advantage Eligibility
Having a Medicare expert in your corner is essential whether you are new to Medicare or have been enrolled with the health care program for a while. Our licensed agents are Medicare experts, ready to help with all your questions, anytime.
Whether you are looking for your first Medicare Advantage plan or are looking to review your options for the new year, our agents will help you find the best plan for your needs. Call the number above to review available plans in your area or complete our online rate form for a side-by-side policy comparison.
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Sources:
MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.
- Medicare Advantage Plans, Medicare. Accessed August 2022.
https://www.medicare.gov/types-of-medicare-health-plans/medicare-advantage-plans - Understanding Medicare Advantage Plans, Medicare. Accessed August 2022.
https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf - Medicare Advantage in 2021, KFF. Accessed August 2022.
https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2021-enrollment-update-and-key-trends/ - What is Medicare Part C?, HHS. Accessed August 2022.
https://www.hhs.gov/answers/medicare-and-medicaid/what-is-medicare-part-c/index.html
I have a chronic condition which requires a $5,000 treatment every 14 days. This cost is currently covered by my employer provided health plan. Will I be covered under Medicare upon retirement? Is there a preexisting condition exclusion in Medicare? How about Medicare Advantage?
John, thank you for reaching out! If your doctor deems treatment medically necessary, you will be covered under Medicare. However, you could be responsible for copayments or deductibles depending on the plan you enroll in. When enrolling in Medicare, pre-existing conditions are not considered, so you are eligible to enroll in any plan. I recommend speaking with a licensed agent to review all your coverage options during your initial enrollment to determine the best plan for your needs.
We live in West Virginia. Are there any Advantage Plans for this area? I thought you had to be under a certain income level to qualify for an Advantage Plan in the first place.
Kent, great question! Advantage plans are available to any Medicare beneficiary nationwide.
I am enrolled in Parts A and B and also have a supplement. I moved to Florida and would like to enroll in a Medicare Advantage plan. Is moving from another state considered a life event which would allow me to make this change in the middle of the year?
Hi Elizabeth! You will only qualify for a Special Enrollment Period if your current plan is not available where you moved. In this case, your Medigap plan will travel with you. You just need to contact the carrier to update your address. If you want to leave your Medigap plan for a Medicare Advantage plan, you’ll have to wait until the Annual Enrollment Period in the fall.
I am totally confused about Medicare Plan B? I read that if you buy a Medicare Advantage plan (Plan B), you will be reimbursed from Social Security on your monthly Premiums. This will be from my own doctor where I live who is listed on the Medicare Advantage plan. I will have Governmental original Plan B Medicare (I already have Plan A) starting March 1, 2021. I already have an employee FEHB plan from Blue Cross and Blue Sheild Anthem coverage in Virginia Beach currently.
Hi Ernest! Medicare Advantage plans are known as Part C. To get a Medicare Advantage plan, you must still enroll in Part B. Some Medicare Advantage plans have what’s called a premium reduction benefit. This is only available in some states. You’re reimbursed through your Social Security check. You will see a reduced amount taken out for the premium. Your doctor is not the one who reimburses you. Normally, those enrolled in FEHB do not need to enroll in a Medicare Advantage plan. It’s recommended to have Part B & FEHB, but not necessary to have FEHB, Part B, and Medicare Advantage.