Medicare Advantage Eligibility Requirements & Rules
Medicare Advantage eligibility terms and rules are essential for you to understand. Depending on your situation, a Medicare Advantage plan could be the coverage you need.
Your location determines which options are available to you. For example, someone in Wyoming may have fewer Advantage plan options than someone in Pennsylvania.
In some cases, Medigap is more beneficial than Advantage. But, sometimes, you won’t qualify for Medigap. Eligibility can be a tricky thing to understand.
Today 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 may be eligible for a Medicare Advantage plan if you have Part A and Part B. Even those under 65 on disability could enroll!
Further, you must live in the plan’s service area and continue to pay your Part B premiums. You’ll pay for the Advantage plan and Part B.
Low-income or Medicaid eligible beneficiaries may qualify for extra help paying for premiums, deductibles, and copayments.
Those with End-Stage Renal Disease may not qualify for a Medicare Advantage plan. But, there are Special Needs Plans for those with chronic issues.
Depending on where you live, a Special Needs Plan may or may not be available. If there’s an ESRD Special Needs Plan in your area, you may qualify.
While End-Stage Renal Disease currently prohibits beneficiaries from enrolling in Medicare Advantage, this rule may change in 2021 or 2022.
Medicare Advantage Eligibility
There are a few things you must do to qualify for a Medicare Advantage plan.
Here is a Checklist for Medicare Advantage Eligibility:
- You need to know your Part A and B effective date
- Have your Medicare card number
- You need to live in the plan’s service area
- In most cases, you CAN’T have End-Stage Renal Disease
Tip: Those unsure of Medicare eligibility can always call Social Security to ask.
Medicare Advantage Requirements
If you’re on Medicare, you’re eligible for 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.
If you move out of the service area or the plan leaves Medicare, you can switch policies using Special Enrollment 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” the Advantage plan for up to 12 months.
Then, before the 12 months, 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 15th through December 7th. 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
Once you find the right policy enrolling is the next step. 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, your specialist, and your drugs have coverage. Further, you want to compare those costs.
Also, these plans change each year. So, the best plan for you in 2020 might be a joke in 2021.
Our agents work with the top carriers in the nation for Medicare. We can compare Medigap to Advantage and answer all your questions.
Tip: Enrolling yourself into a plan may cost you more, contact an agent to be sure you’re getting the policy that brings you the most value.
Medicare Advantage Rules
There is a reason people ask “why Medicare Advantage plans are bad?” The thing is, you HAVE to use the network of doctors they allow.
So, if you’re visiting family in Florida, a doctor’s visit could be 100% your responsibility. Or, if you have a specialist that isn’t in the network, if you see that doctor, the cost is all on you.
On top of following the doctor network, you may need a referral every time you want to see a specialist. With Medigap, a referral is a thing of the past.
While there are many reasons to say Medigap is more comprehensive than Advantage, some coverage is always better than no coverage.
Tip: If you’re unsure about the policy that’ll benefit you the most, give one of our agents a call.
Medicare Advantage Eligibility FAQ’s
Can I Join a Medicare Advantage Plan if I have End-Stage Renal Disease?
Once you have a medical determination that you no longer have End-Stage Renal Disease, like you have a successful kidney transplant, you can join a Medicare Advantage plan.
As mentioned earlier, if there is an ESRD Special Needs Plan in your area, you can enroll in that while having ESRD. Also, if you already had an Advantage plan and you develop ESRD, you may be able to join another policy with the same company.
What are the Medicare Advantage Income Limits?
There are no income limits for Medicare Advantage; you can make as much or as little as you want.
But, if you qualify for 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, please consider a Medicare Advantage plan. Whether you choose Medigap or Advantage, it’s always better to have some coverage.
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?
Absolutely, 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.
Tip: Before you switch plans, talk to an agent about ALL your options and make sure it’s the best choice for you.
Get Help Finding Your Policy Match
Whether you’re new to Medicare or you’ve dealt with it a while, you need an expert in your corner. Our agents are Medicare experts, ready to answer ALL your questions.
Instead of trying to locate each quote online, alone, call an agent and let them walk you through everything. The agent can educate you on Medicare, and provide quotes for the top carriers in your area.
Don’t waste time trying to figure it out on your own. We have an expert ready to help you every step of the way. From education to enrollment, we know how to make the process easy.
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