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Medicare Advantage Eligibility

Summary: Medicare Advantage Eligibility requirements are standard in all 50 states. You must be enrolled in Original Medicare, live in your selected plans service area, and enroll during a qualifying enrollment period. Estimated Read Time: 5 min

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Table of Contents:

  1. Medicare Advantage Eligibility Requirements
  2. Who Qualifies for Medicare Advantage?
  3. Medicare Advantage Qualifications
  4. When Can I Apply for Medicare Advantage?
  5. Can You Be Denied a Medicare Advantage Plan?
  6. What Are the Medicare Advantage Rules?
  7. How to Determine Medicare Advantage Eligibility

It is essential to understand Medicare Advantage eligibility rules before enrolling in a plan. Depending on your situation, a Medicare Advantage (Medicare Part C) plan might be the most suitable coverage option to fit your needs. If this is the case, it is important to understand if you are eligible before you enroll.

Medicare Advantage plans are offered by private insurance companies and benefits can vary by location, but eligibility rules are standard throughout for all plans and carriers nationwide.

Medicare Advantage Eligibility Requirements

Medicare Part C eligibility is determined by your enrollment in Original Medicare. If you are enrolled in Original Medicare, you can enroll in a Medicare Advantage plan. Not all counties nationwide offer the same Medicare Advantage plans. Thus, costs and benefits do vary based on where you live.

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.

Who Qualifies for Medicare Advantage?

To qualify for Medicare Advantage, you must be a resident of the United States who is enrolled in Medicare Part A and Medicare Part B. If you are only enrolled in one part of Original Medicare or are eligible for Original Medicare but have not yet enrolled, you are not eligible for Medicare Advantage.

If you are enrolled in Original Medicare and Medicaid benefits, you are also eligible for a Medicare Advantage plan. Dual Eligible Medicare Advantage plans are available specifically for individuals enrolled in Medicare and Medicaid to help compliment the health benefits already in place.

In the past, most individuals with End Stage Renal Disease were not eligible for Medicare Part C benefits. However, due to a provision in the 21st Century Cures Act, individuals with ESRD are eligible for Medicare Advantage coverage and cannot be limited to specific plans beginning in 2021. Due to this provision, 2021 saw a relative increase of 50.8% in Medicare Advantage enrollment among those with ESRD from 2020.

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Medicare Advantage Qualifications

Medicare Advantage qualifications are straightforward. There are a few things you must do to qualify for a Medicare Advantage plan.

  1. Know your Medicare Part A and Part B effective date
  2. Have your Medicare card number handy
  3. Live in the plan’s service area

When working with a licensed insurance agent to enroll in a Medicare Advantage plan, it is important to have all of your qualifications ready to go as they are necessary to submit the application.

When Can I Apply for Medicare Advantage?

To enroll in a Medicare Advantage plan, you must have a valid enrollment period. There are several Medicare Advantage enrollment periods available for qualified beneficiaries. Whether you have been enrolled in a Medicare Advantage plan previously or are new to Medicare, there is a specific Medicare Advantage enrollment period for you.

Can You Be Denied a Medicare Advantage Plan?

Beneficiaries with Original Medicare Part A and Part B cannot be refused enrollment to a Medicare Advantage plan. Unlike with Medicare Supplement plans, there are no health questions you must answer during the enrollment process, and your pre-existing conditions do not play a role in admission.

However, just because enrollment is simple, does not always mean a Medicare Advantage plan is the most suitable option for you. It is important to always review the plans coverage and compare that to your healthcare needs.

If you tend to visit the doctor more frequently, you may need a plan that provides lower copayments and deductibles than someone who only goes to the doctor once a year for an annual checkup. The plan you choose to enroll in should make the most sense for your needs. After reviewing your options, if the plan is a match, then you should begin the enrolling process.

However, if you feel there may be a better plan available for you, it is important to check qualifications to ensure you are able to enroll.

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What Are the Medicare Advantage Rules?

Medicare Advantage plans often come with rules that dictate the providers you can see, facilities you can receive care at, and the services you may need a pre-approval or referral for. Compared to other supplemental Medicare options, Medicare Advantage plans are typically more strict regarding how you can use their benefits.

It is also important to ensure you receive care inside of the plans service area. For example, 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.

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 extremely knowledgeable on all things Medicare and are 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 a plan that fits  your needs. Call the number above to review available plans in your area or complete our online rate form to see what is available today!

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.

  1. Medicare Advantage Plans, Medicare. Accessed August 2022.
    https://www.medicare.gov/health-drug-plans/health-plans
  2. Understanding Medicare Advantage Plans, Medicare. Accessed August 2022.
    https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf
  3. Medicare Advantage in 2021, KFF. Accessed August 2022.
    https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2021-enrollment-update-and-key-trends/
  4. What is Medicare Part C?, HHS. Accessed August 2022.
    https://www.hhs.gov/answers/medicare-and-medicaid/what-is-medicare-part-c/index.html
Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare educator serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

8 thoughts on "Medicare Advantage Eligibility"

  1. 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?

    1. 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.

  2. 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.

  3. 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?

  4. 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.

    1. 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.

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