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.
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. There 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 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.
What are the 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
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