Advantage Eligibility

Cartoon artwork explaining Medicare and Advantage Eligibility​

Eligibility for Medicare Advantage Plans

Like other aspects of Medicare, there are certain eligibility requirements for Medicare Advantage plans. Your location will be a determining factor for which plans are available for you. We are going to discuss Medicare Advantage eligibility so that you can determine if you qualify for one of these plans.

Qualifications for Medicare Advantage Plans

To qualify for a Medicare Advantage plan, individuals must first be enrolled in Original Medicare – Parts A and B. This includes people younger than 65 who are eligible for Medicare for some other reason than age. Next, you must be current on payments of your Part B premiums. (Even if you choose to enroll in a Medicare Advantage plan, you must continue to pay the Medicare Part B premium.) Lastly, you must live in an area where Medicare Advantage plans are offered.

There are separate qualifications for financial assistance. Low-income individuals or those who qualify for both Medicare and Medicaid may be able to get help paying for the premiums, deductibles, copayments, and coinsurance expenses.

Individuals who have been diagnosed with End-Stage Renal Disease (ESRD) are eligible for Medicare Advantage plans, but their options are more limited. There are also Special Needs Plans available for those with chronic issues.

Regardless of your qualifications, Medicare Advantage plans are not available in all areas of the country. There may be none available in some areas, while others just have limited choices.

Eligibility Checklist for Medicare Advantage Plans

There are three things you must do to become eligible for a Medicare Advantage plan.

  1. Enroll in Medicare Parts A and B and have your Part B effective date
  2. Have your Medicare ID number
  3. Live in the plan’s service area

If you are unsure if you qualify for a Medicare Advantage plan, one of our licensed agents can assist you.

Rules and Requirements for Medicare Advantage Plans

Since Medicare Advantage plans are sold by private insurance companies, they will all come with their own rules and regulations. Not all Medicare Advantage plans are created equal, so it is very important that you understand how your plan works.

Most of the time, you will need to receive care from a doctor that is within your plan’s network. Going outside of the network will cause you to incur higher out-of-pocket costs, sometimes even the entire bill for services. You will likely also need to get a referral to see a specialist. Failure to do so may mean that the plan will not cover those expenses, regardless of whether the specialist is in your network or not.

Medicare Advantage Enrollments and Applications

As long as you are eligible for Medicare and have enrolled in Medicare Parts A and B, you can enroll in a Medicare Advantage plan if one is available in your area. Not all counties have these plans available, so this is one of the first things to check before you continue your enrollment.

There are several enrollment periods associated with Medicare Advantage plans. This first one you will be eligible for is your Initial Enrollment Period which begins around the time of your Part B effective date. One of the most important enrollment periods is the Annual Enrollment Period, which occurs every fall from October 15 to December 7.

You may also qualify for a Special Enrollment Period if you have a qualifying life event. One thing that can qualify you for a Special Enrollment Period is if your current Medicare Advantage plan leaves your area of residence. This gives you the right to switch policies when that occurs. You also have the ability to try a Medicare Advantage plan. During your trial period, you can decide if you’d like to keep the plan or switch back to Original Medicare. The trial period lasts for 12 months.

The easiest and most effective way to submit an application for a Medicare Advantage plan is through an insurance agent. The agent will make sure the plan you’ve chosen fits your needs and will assist you with all the necessary paperwork. They will also submit the application on your behalf, and follow up with you to make sure you have received your enrollment package.

Finding the best

Medicare Advantage Plan

A licensed agent can help you choose the best type of Medicare policy. We’ll ask you some questions about your lifestyle and health, and then can give you options that will fit those needs. We’ll be able to look at different plans across many carriers, so you can choose the best possible plan. After you choose, we’ll help you through the enrollment process and will file all the necessary paperwork. Our work doesn’t end there. We’ll reach out during important enrollment periods and make sure you still have the best plan available. All of these services come at no cost to you.

Questions to be advised on:

The Missouri Medicare Advisor website character Chris Mooneyham discussing Questions to be advised on.

While your plan options may be limited, there are now Medicare Advantage plans that offer coverage for individuals with ESRD.

No, there are no income limits on Medicare Advantage plans. If you are below a certain income, you may be eligible for a low-income subsidy or Medicaid assistance.

This is a personal decision – one that should not be taken lightly. There are many benefits to Medicare Advantage plans, but there are also limitations. Medicare supplements can provide more comprehensive coverage, but come with higher premiums. You will need to weigh the pros and cons of each choice.

Yes, you can switch back to Original Medicare during certain parts of the year. Do not leave your current policy until your new coverage is in plan, otherwise you could end up with little coverage and many medical expenses. Never have a lapse in coverage. If you switch back to Original Medicare, you should consider enrolling in a Medicare supplement and Part D prescription drug plan.

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