Requirements for Medicare Advantage Eligibility

by David Bynon, last updated

Anyone enrolled in Medicare Part A and Part B (Original Medicare) can join a Medicare Advantage plan in their area. This includes individuals who have Medicare due to a disability, regardless of their age.

This article’ll explain who qualifies for Medicare Advantage, including Special Needs Plans, what private health plans cover, how much they cost, and how to enroll.

Key Takeaways

  • There are three requirements to join a Medicare Advantage plan.
  • You must be enrolled in both Medicare Part A and Part B;
  • You must live in a plan’s service area; and
  • You must enroll during an authorized enrollment period.

Who is Eligible?

Generally speaking, everyone with Medicare Part A and Part B benefits is eligible for Medicare Advantage. What restricts most people from getting a plan is availability.

Although plans are available in about 3,000 counties and territories, they are not available in all. For example, no HMO or PPO plans are available in Alaska.

Also, not everyone qualifies for all types of plans. For instance, Special Needs Plans (SNPs) are only available to individuals who meet the specific requirements of the SNP. For this reason, we organize SNPs separately.

You can find a complete list of Medicare Advantage plans in your area using our Plan Finder tool.

How Do Medicare Advantage Plans Work?

Medicare Advantage plans are sold by private insurance companies. They are an alternative to Original Medicare coverage.

What is Covered?

Original Medicare (Part A and Part B) provides hospital coverage and medical coverage. On average, it pays about 80% of your major medical costs. However, it does not cover outpatient prescriptions, routine dental and vision, hearing aids, or non-emergency medical transportation. That’s where Medicare Advantage comes in.

All Medicare Advantage plans are required to cover all of the same benefits as Medicare Part A and Part B. They can also include extra benefits that Original Medicare does not cover. Routine dental, vision, and hearing benefits are common extras, as is prescription drug coverage.

Although Medicare Advantage plans are required to provide all of the same services as Medicare Part A (hospital coverage) and Part B (medical coverage), they are not required to cover them in the same way. Specifically, plans have the right to set their own deductibles, copayments, and coinsurance on Part A and Part B benefits.

How Much Do They Cost?

The price you see next to a Medicare Advantage plan is the additional monthly premium you will pay to be in the plan, if any. Plans are not all-inclusive. Plans also have out-of-pocket costs when you use healthcare services. And, you will need to keep paying your monthly Medicare Part B premium.

Under Medicare Part B, beneficiaries pay a 20% coinsurance after they have paid the annual Part B deductible. But, a Medicare Advantage plan may choose to charge more or less than a 20% coinsurance on specific services. Many plans charge copayments (a flat fee), and some services may have no out-of-pocket costs at all.

The same is true with Part A services. Although it is widely believed that Medicare Advantage plans save money, many plans have higher out-of-pocket costs for inpatient care than Original Medicare. Savings are typically realized when a beneficiary can take full advantage of a plan’s extra benefits and rarely uses Part A services.

Restrictions and Provider Networks

In addition to setting their out-of-pocket costs, plans also have the right to require referrals and preauthorization. This is often the case when a specialist is involved (referral) or a certain type of test or procedure is needed (preauthorization).

Finally, most Medicare Advantage plans use local provider networks. You will be required to use providers in the network or you pay all costs (HMO plan) or higher costs (PPO plan).

When to Enroll in a Medicare Advantage Plan

You can join a Medicare Advantage plan in your area during several enrollment periods.

Initial Enrollment Period (IEP)

When first eligible for Medicare at age 65, or 24 months after drawing your first Social Security Disability Income (SSDI) check, you will have an Initial Enrollment Period. During this period you can choose your Medicare plans.

Your IEP is a 7-month period of time. It begins 3 calendar months before your 65th birthday (or 25th month of SSDI) and ends 3 calendar months after.

Fall Open Enrollment Period (OEP)

If you don’t join a Medicare Advantage plan during your IEP, your next available opportunity is during the fall Medicare Open Enrollment Period. During this time you can signup for a Medicare Advantage plan and/or a Medicare Part D prescription drug plan. This is also the time when you can drop your plan and go back to your Original Medicare benefits.

Fall OEP begins October 15th and ends December 7th each year. Just prior to this time, Medicare will send you a new copy of their “Medicare & You Handbook.”

Special Enrollment Period (SEP)

Under certain circumstances, you may be eligible for a Special Enrollment Period. This happens when you have a qualifying life event, such as moving out of your plan’s service area or being released from jail.

You can call 1-855-728-0510 (TTY 711) to speak with an advisor to determine if you are eligible for a Special Enrollment Period.

How To Enroll

To join a Medicare Advantage plan you will need to go through a licensed insurance agent. MedicareWire has partnered with HealthCompare, a nationwide Allstate company, to offer free enrollment services with the major carriers, including AARP/UnitedHeathcare, Humana, Aetna, Blue Cross Blue Shield, Cigna, and many more.

Give HealthCompare a call at 1-855-728-0510 (TTY 711).



Was this article helpful?

Related Articles