Medicare Advantage Eligibility Requirements & Rules

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Medicare Advantage eligibility happens when you have Parts A and B. Beneficiaries receive their benefits by Medicare or by a Medicare Advantage (MA) Plan.

You can call it a Part C plan, Advantage plan or MA Plan; these plans replace your coverage and provide benefits by private insurance companies.

The government pays a lump sum to the insurance company to have them assume responsibility of your claims

An Advantage plan will be responsible for your health care claims. At the doctor’s you’ll only need to show your MA plan card, no need to worry about your card.

Generally, these plans will include a Part D plan too, this makes tracking your healthcare a bit easier. Some plans will offer coverage for things like routine dental and routine eye care, which isn’t under Medicare.

Before choosing a plan, it’s important to understand how MA eligibility works.

Medicare Advantage Eligibility

MA Plans come in different types; the type of plan determines how the coverage works.

Additionally, MA eligibility is determined per where you live once you have Part A and Part B. If you reside in a different state or service area for part of the year – you should make sure the plan will provide coverage in both places.

If you have End-Stage Renal Disease typically, you won’t qualify for Advantage eligibility.

Qualifying for Medicare Advantage

Individuals qualifying for Part A and Part B qualify for MA plans. You must first have Medicare eligibility to have MA eligibility.

Meaning, you must first meet the eligibility requirements before Advantage eligibility starts.

To qualify for enrollment, you must first be a U.S. citizen or have permanent legal residency for a minimum of 5 consecutive years. You must also be 65 years old or older; eligibility may also occur because of disability.

Medicare Advantage Requirements

Once you’ve met the criteria for eligibility, you might be looking for additional coverage or an alternative way to get your benefits.

If you’ve been looking into MA Plan coverage, you’ll need to know Medicare Advantage eligibility requirements.

So, you enroll in Part A and Part B; then, you find an Advantage plan that makes you happy. The next step is to make sure the plan is available in your county.

On the other hand, you might not qualify for Advantage plans in certain situations. For example, if you have End-Stage Renal Disease, most Advantage plans won’t provide you coverage.

Sign Up for Medicare Advantage

Before you sign up for an Advantage plan you should know the best way. Prior to signing up, you should understand the plan’s rules and prices.

All MA Plans work in their own way, take some time to compare health plans in your area before deciding. Your plan should provide you with an option to enroll over the phone, on their website, or a paper enrollment form that you can mail in.

When you call a Medicare agent to help you compare plans you can apply over the phone. Just call the number above.

Make sure you have a couple of things handy before you call, you’ll want your Medicare number and the dates your Part A and Part B coverage date. These dates are on your card.

Medicare Advantage Enrollment

The first opportunity you’ll have for Advantage enrollment is during your Initial Enrollment Period (IEP). Your IEP is specific to your 65th birthday (or the 24th month of receiving disability benefits), this is when you’re first eligible.

During your IEP you’ll also have MA eligibility. Use this period to enroll in an Advantage plan if you need more coverage.

Unless you qualify for a Special Election Period (SEP), MA enrollment happens during 2 specific times each year. In most cases, once you join a plan, enrollment is for the duration of a year.

For those eligible, you may enroll or make changes during the MA Open Enrollment Period.

As of January 2019, the Open Enrollment Period is back. During this Open Enrollment Period, beneficiaries can change to another Advantage plan.

If their unhappy with their current coverage, and don’t want a different Advantage plan – beneficiaries can use this time to go back to Medicare and then join a Medicare Supplement plan.

Medicare Advantage Rules

As with any plan, MA eligibility has some rules to follow in order to receive coverage.

General rules include the following:

  • You must have Parts A and B
  • Must live in the service area of the MA plan you wish to join
  • You don’t have End-Stage Renal Disease (ESRD)

Following MA enrollment, if you were on any drug plans, you’ll automatically experience removal from the policy. Also, beneficiaries can’t have an Advantage plan and have a separate prescription drug plan; this is because some Advantage plans have drug coverage.

Contrarily, the exception to this is if a beneficiary has a PFFS Medicare Advantage plan. People with a Supplement insurance plan or Medicare need to purchase a sperate Part D policy to avoid paying out of pocket.

ESRD Medicare Advantage

Beneficiaries with ESRD typically won’t qualify for Medicare Advantage eligibility. However, patients with ESRD have a certain type of MA eligibility. ESRD patients can enroll in a special type of MA plan, known as a Special Needs Plan (SNP).

Medicare offers different types of SNPs; one type is specific for those with kidney failure. If you live in a service area where these SNPs are available, you may qualify to enroll.

Other Options than Medicare Advantage

MA plans aren’t your only option for help with coverage of healthcare costs should you become seriously ill. Medical expenses can potentially wipe out your bank account, it’s good to have a general understanding of your options so this doesn’t happen.

Another option besides MA is Medicare Supplement Insurance also a Medigap policy. Nevertheless, you should understand that Supplement Insurance coverage is different from MA coverage.

Supplement Insurance helps cover healthcare costs for things like copayments, coinsurance, and deductibles. If you have extensive healthcare needs and often are visiting the doctors, Medigap could be a great option for your Medicare coverage.

Let’s Help You Get Coverage

Still not sure what plan is right for you? Don’t worry seniors, we’re here to help!

Our agents are happy to provide quotes and compare plans for you, free of charge. Trying to compare plans, plan rates and understanding what option is best for your healthcare needs can be a daunting task without an agent.

Call one of our Medicare agents today! We can help take the stress of choosing a plan off your shoulders.

Can’t call right now? That’s okay; fill out an online rate form and discover the policy in your area with the most value.