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Medicare Advantage Eligibility Requirements


It’s essential to understand Medicare Advantage eligibility terms and rules before seeking to enroll in a plan. Depending on your situation, a Medicare Advantage plan could be the coverage you need.

Your location determines which options are available to you. Eligibility can be a tricky thing to understand. We’re going to dive into Medicare Advantage eligibility and give you all the tools you need to make the best choice for you.

Who Qualifies for Medicare Advantage?

You’re eligible for a Medicare Advantage plan if you have Part A and Part B. Even those under 65 on disability may enroll!

Further, you must live in the plan’s service area and continue to pay your Part B premiums. You’ll pay the Advantage plan’s premium – if it has one – in addition to your Part B premium.

Low-income or Medicaid-eligible beneficiaries may qualify for extra help paying for premiums, deductibles, and copayments.

Those with End-Stage Renal Disease (ESRD) may qualify, too. For beneficiaries who enroll in Medicare with ESRD, coverage generally starts on the fourth month of dialysis. But there are instances in which coverage can start within the first month of dialysis:

  • If the beneficiary plans on completing home dialysis training to carry out self-dialysis treatments at home
  • Beneficiaries who start home dialysis training early (before the third month of their dialysis treatment)
  • Beneficiaries who participate in a home dialysis training program

If you have Medicare due to ESRD, your coverage stops under two conditions: 12 months after the month your dialysis treatments end or 36 months after receiving a kidney transplant.

There are also Special Needs Plans available for those with chronic issues. Depending on where you live, a Special Needs Plan may or may not be available.

Medicare Advantage Eligibility Checklist

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

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

Those unsure of Medicare eligibility can always call Social Security to ask.

What are the Requirements for Medicare Advantage Plans?

If you’re Medicare-eligible you can enroll in an Advantage plan in your area. Not all areas have Advantage plans; so, you’ll want to check before you get your heart set on a policy.

Several Medicare Advantage enrollment periods exist. These are instances when you’re eligible to change plans, such as the Annual Enrollment Period, the Medicare Advantage Open Enrollment Period, and during a Special Enrollment Period.

If you move out of the service area or the plan leaves Medicare, you can switch policies using Guaranteed Issue Rights.

Further, if you have a Medigap plan and want to try a Medicare Advantage plan, you have eligibility for trial rights. You get to try out the Advantage plan for up to 12 months.

Then, before the 12 months end, if you decide the Advantage plan isn’t right, you can switch back to Medigap. You must first see if your original policy is still available through your previous company.

If not, you can choose any policy of equal or lesser value with any company.

When Can I Apply for Medicare Advantage?

There are several times you can select a Medicare Advantage plan. First, the Initial Enrollment Period allows you to sign up when you first turn 65. Those that delay Part B qualify for the Initial Coverage Enrollment Period, which gives you Medicare Advantage eligibility when you do enroll in 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 make changes to Advantage plans.

Finally, there are Special Enrollment Periods that allow you to switch plans during life-changing or policy-changing situations.

How to Enroll in a Medicare Advantage Plan

Before you enroll, you’ll want to research the best Medicare Advantage plans in your area. It’s always a good idea to consult an agent about your options. Our agents are Medicare experts.

It’s important to consider if your doctor is in-network, note that you’ll need a referral to see specialists, and whether your prescriptions are on the plan’s formulary. Further, you’ll want to compare costs.

Our agents work with the top carriers in the nation for Medicare. We can compare Medigap to Advantage and answer all your questions.

What are the Medicare Advantage Rules?

There is a reason people ask why Medicare Advantage plans are bad. In fact, there are a few reasons why people leave Advantage plans. For instance, many are unsatisfied with the dental benefits their Advantage plans provide them with.

Something to keep in mind is that you HAVE to use the network of doctors they allow. So, if you live in New York and you’re visiting family in Florida, a doctor’s visit could be 100% your responsibility. Or, if you see a specialist that isn’t in the network, the cost is all on you.

While there are many reasons to say Medigap is more comprehensive than Advantage, but some coverage is always better than no coverage. With that said, it’s important to understand the differences between the types of plans.

FAQs

Can I join a Medicare Advantage plan if I have End-Stage Renal Disease?
Yes, Medicare Advantage plans are now available to those with End-Stage Renal Disease.

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, there may be a Special Needs Plan in your area that caters to low-income individuals.
Should I get a Medicare Advantage plan?
If you don’t qualify for Medigap or it’s too far out of your budget, you may consider a Medicare Advantage plan. Whether you choose Medigap or Advantage, it’s always better to have some extra coverage. than none. You don’t want to find yourself in a situation where you owe tens of thousands of dollars in healthcare costs. The Advantage plan will at least provide some protection.
Can you go back to Original Medicare from an Advantage plan?
Yes; during certain times of the year, you can drop your Advantage plan and return to Medicare. But, you should have a policy in place. Medicare, by itself, can be costly. Never leave your policy until you have a new plan in place. You never want to have a lapse in coverage. If you rely on an Advantage plan to give you Part D benefits, don’t forget to enroll in a stand-alone policy.
Who is qualified for Medicare Advantage?
You can join Medicare Advantage if you already have Original Medicare and there are Advantage plans in your area. People under 65 with certain disabilities may also qualify.
Can you be turned down from a Medicare Advantage plan?
Beneficiaries who have Part A and Part B generally won’t be refused Medicare Advantage coverage.

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Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

4 thoughts on “Medicare Advantage Eligibility Requirements

  1. 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?

  2. 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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