Who Qualifies for Medicare Advantage Plans?

checkmark Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: September 14, 2020

What You Should Know

  • 1 Medicare Advantage plans cover the same services as the federal government’s Medicare Parts A and B and provide additional benefits
  • 2 You can sign up for Medicare Advantage during your initial enrollment period for Medicare Part A and Part B.
  • 3 Most people with permanent kidney failure requiring dialysis or transplant aren’t eligible for Medicare Advantage plans.
  • 4 You may also be eligible for a special enrollment period if you retire after age 65 and are no longer covered by a company health insurance plan.

Medicare Advantage plans are private health insurance policies that let you choose how you receive your Medicare coverage. These plans cover the same services as the federal government’s Medicare Parts A and B and provide additional benefits.  

You can sign up for a Medicare Advantage plan if:

  • You’re already enrolled in Medicare Parts A and B
  • You reside in an area served by the Medicare Advantage plan you want to subscribe to
  • You don’t have permanent kidney failure (although you may qualify for a Special Needs Plan)  

It can be complicated to understand Medicare eligibility and navigate between different types of plans and costs. This guide provides information about who qualifies for Part C plans, what they cover, how to enroll, and the associated costs. 

Who Qualifies for Medicare?

Original Medicare is the federal government’s health insurance program comprising Part A and Part B. 

In most cases, you qualify for Medicare if you’re 65 years of age and either a U.S. citizen or have been a legal permanent resident for five consecutive years.

If you’re younger than 65, you may qualify for Medicare if you:

  • Have received disability benefits for at least two years through Social Security or the Railroad Retirement Board
  • Have been diagnosed with end-stage renal disease or Lou Gehrig’s disease 

You can check if you qualify for Medicare using the federal government’s online eligibility tool.

What is Medicare Part A?

Medicare Part A is a hospital insurance program. It helps cover costs if your doctor determines you need inpatient care in a hospital or medical facility. This includes:

  • Hospital care for a surgical procedure, illness, or injury
  • Short-term care in a skilled nursing facility after a hospital stay, including treatment for a condition that developed while in the hospital, such as an infection
  • Long-term stay of more than 25 days in an acute care facility, usually for past intensive or critical care patients who need comprehensive rehabilitation, treatment for head trauma, or a ventilator
  • Home health, including part-time skilled nursing care, physical therapy, occupational therapy, and speech-language pathology services
  • Hospice and respite care

What is Medicare Part B?

Medicare Part B covers medically necessary services, such as:

  • Care through a doctor or health care provider
  • Ambulance transportation to a hospital
  • Emergency department services
  • Kidney dialysis and supplies
  • Occupational and physical therapy
  • Speech-language pathology
  • Cardiac and pulmonary rehabilitation
  • Mental health care
  • Durable medical equipment prescribed by a doctor for home use, such as oxygen equipment, blood sugar monitors and test strips, nebulizers, CPAP devices, canes, walkers, wheelchairs, and patient lifts
  • Medical tests, screening, and preventive services like mammograms, screening for HIV or diabetes, bone density measurements, EKGs, flu shots, glaucoma tests, and hepatitis B shots

Who qualifies for Medicare Advantage?

You can qualify for Medicare Advantage if:

  • You live in a region that’s served by the Medicare Advantage plan in which you want to enroll
  • You’re already registered in Original Medicare Parts A and B and have a Medicare number
  • You don’t have permanent kidney failure, although some insurance companies may cover end-stage renal disease through a Special Needs Plan
  • You’re not receiving Medigap benefits

Who doesn’t qualify for Medicare Advantage?

Most people with permanent kidney failure requiring dialysis or transplant aren’t eligible for Medicare Advantage plans, except through Special Needs Plans. These plans are specifically tailored to those with chronic conditions, including end-stage renal disease.

How do I enroll in a Medicare Advantage Plan?

There are several ways to enroll in a Medicare Advantage plan.

  • Complete an online enrollment form on the plan provider’s website.
  • Complete a hard copy of the enrollment form and mail it to the provider.
  • Call the insurance company support line.
  • Call Medicare at 1-800-633-4227.

When can I enroll in a Medicare Advantage Plan? 

Initial enrollment period

You can sign up for Medicare Advantage during your initial enrollment period for Medicare Part A and Part B. This seven-month-long period begins three months before the month you turn 65 and ends three months after the month you turn 65.

Other enrollment periods

If you sign up for Medicare Parts A and B during the general enrollment period of January 1st to March 31st, you receive a special enrollment period to register in a Medicare Advantage plan.

You may also be eligible for a special enrollment period if you retire after age 65 and are no longer covered by a company health insurance plan.

You can join or switch Medicare Advantage plans during the annual open enrollment period between October 15th to December 7th. 

If you’re already enrolled in a Medicare Advantage plan, you can drop or switch plans during the Medicare Advantage Open Enrollment Period of January 1st to March 31st.

What do Medicare Advantage Plans cover?

Medicare Advantage plans must provide coverage for the same services as traditional Medicare.

  • Part A hospital insurance
  • Part B medical insurance

Many Medicare Advantage plans also offer additional benefits not included in Original Medicare. The federal government determines what benefits are permitted, and each plan covers a different mix of services. 

When choosing a Medicare Advantage product, consider which benefits are important to you and understand how the plan determines eligible expenses. You can choose plans that cover:

  • Routine dental visits, such as cleanings
  • Basic vision care 
  • Hearing exams and hearing aids
  • Fitness programs, such as SilverSneakers or Silver and Fit
  • Transportation to medical appointments
  • Meal delivery
  • Cooking classes and nutrition education
  • Bathroom safety devices 
  • In-home support
  • Telemonitoring
  • Caregiver support
  • Adult day care services
  • Health and wellness services

Some Special Needs Plans are also customized for those with chronic conditions.

How much do Medicare Advantage Plans cost?

The average Medicare Advantage plan premium is estimated at $23 per month in 2020. About half of the plans that provide prescription drug coverage have no monthly premium, except for the Part B premium.

What are the out-of-pocket costs of a Medicare Advantage plan?

Some plans have higher initial costs but may cost less when you access the benefits. Other plans may have low monthly premiums or no premiums but charge a higher fee when you use them.

When comparing Medicare Advantage plans, it’s important to consider all of the costs that you may end up paying.

  • Monthly premiums
  • Part B premiums, if your plan does not pay for all or part of them
  • Annual deductibles
  • Additional deductibles for certain benefits
  • Copayments or cost-sharing that requires paying a portion of the cost of a service each time you use it
  • Out-of-network costs if you use a provider that is not part of the plan’s network

Unlike Original Medicare, Medicare Advantage plans must limit your annual out-of-pocket costs. Once you’ve reached the plan’s annual limit, you can’t be asked to pay more.  Monthly premiums are typically not considered an out-of-pocket cost.The federal government has an online tool to help you find a plan in your service area and compare benefits and costs.

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Contributing Expert:

Roseann Birch, Medicare Consultant

With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.

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Reviewed by:

Leron Moore, Medicare Consultant

With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.