Qualifications for Medicare Advantage Plans
If you’re considering a Medicare Advantage plan, then understanding the qualifications for Medicare Advantage plans will likely be your first step. Eligibility will likely be based on age or disability, your residence within a service area, and enrollment in Medicare Parts A and B.
While these are the basics, the nuances of each condition could also affect your ability to enroll. This article will guide you through these prerequisites and outline the subsequent steps for choosing and enrolling in a plan that might fit your needs.
Key Takeaways
- Individuals may be eligible for Medicare Advantage plans based on age, disability (including ESRD or receiving SSDI checks for 24+ months), residency within the plan’s service area, and enrollment in Medicare Parts A and B.
- Enrollment in Medicare Advantage plans can occur during three main periods: the 7-month Initial Enrollment Period around one’s 65th birthday, the Annual Enrollment Period from October 15th to December 7th, or the Special Enrollment Period for qualifying life events.
- Some Medicare Advantage plans may offer additional benefits over Original Medicare, such as prescription drug coverage and dental and vision care, with possible plan costs including variable premiums, deductibles, and out-of-pocket maximums.
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Eligibility Criteria for Medicare Advantage Plans
Joining the millions of Americans currently enrolled in a Medicare Advantage plan will likely require meeting certain eligibility criteria.
To enroll in a Medicare Advantage plan, one must meet the qualifications that will likely hinge on age, disability status, residency, and enrollment in Medicare Parts A and B.
Age and Disability Requirements
Typically, individuals qualify for a Medicare Advantage plan once they turn 65. However, there may be some exceptions. For instance, individuals under 65 who have received Social Security Disability Insurance (SSDI) checks for at least 24 months or who have been diagnosed with End-Stage Renal Disease (ESRD) may also be eligible.
Residency Requirements
Eligibility for a Medicare Advantage plan may also hinge on your geographic location, as members must reside within the plan’s service area. It’s worth noting that if you relocate outside of your plan’s service area and fail to notify your plan, you could be dropped from the plan.
However, you may qualify for a two-month Special Enrollment Period based on the remaining time in the planned year.
Frequent travelers should clarify their coverage options when outside the service area by consulting their plan.
Medicare Part A and B Enrollment
Qualifying for a Medicare Advantage plan may also necessitate enrollment in both Medicare Part A and Part B. Enrolling in both parts could make you eligible for the additional benefits that may be offered by certain Medicare Advantage plans.
Enrollment in these parts of Medicare can be done by contacting one of our licensed agents at 1-833-641-4938 (TTY 711), Mon-Fri 8 am-9 pm EST, at least 3 months before your 65th birthday. When enrolling in Medicare Part A, you have the option to concurrently apply for Medicare Part B.
These components of Medicare will likely form the basis of coverage that Medicare Advantage plans expand upon, possibly offering an alternative to Medicare Supplement insurance.
Enrollment Periods for Medicare Advantage Plans
Signing up for a Medicare Advantage plan can be done during three primary enrollment periods: the Initial, Annual, and Special Enrollment Periods. Each of these windows offers different opportunities to enroll in, switch, or drop a Medicare Advantage plan.
To enroll, call one of our licensed agents at 1-833-641-4938 (TTY 711), Mon-Fri 8 am-9 pm EST. They can provide comprehensive information, personalized guidance, and ongoing assistance to navigate the enrollment process for private insurance companies, making it easier for beneficiaries to make informed decisions about their healthcare.
Initial Enrollment Period
The Initial Enrollment Period spans a total of 7 months, starting 3 months before you turn 65, including your birthday month, and ending 3 months after. If you miss this window, you may have to wait until the General Enrollment Period to enroll, which could result in penalties.
Annual Enrollment Period
The Annual Enrollment Period, which runs from October 15 to December 7 each year, allows you to switch your plan or return to Original Medicare. You can also adjust your Medicare Advantage and Part D prescription drug coverage during this period.
Preparation may involve reviewing possible changes in your current plan’s coverage and costs, considering any alterations in your healthcare needs, and exploring the updated ‘Medicare & You’ handbook.
Special Enrollment Period
A Special Enrollment Period is granted for specific life events such as moving or losing employer coverage. This period, which lasts for 2 months, allows you to make changes to your Medicare Advantage plan outside of the usual enrollment periods.
Comparing Medicare Advantage Plan Options
Once you’ve determined your eligibility and the right enrollment period, the next step is to compare different Medicare Advantage plans.
Possible factors such as coverage differences, costs and premiums, and network providers should be considered when comparing plans.
Coverage Differences
When assessing Medicare Advantage plans, members may want to consider the possible types of services each plan may cover. Some plans may also include additional benefits, such as:
- Prescription drug coverage
- Dental and vision coverage
These benefits may not be part of Original Medicare coverage.
Potential Costs and Premiums
The costs for Medicare Advantage plans may vary significantly. Some potential factors that might influence these costs may include:
- Additional premium in addition to the monthly Part B premium
- Medicare spending
- Plan attributes
- Regional considerations
- Plan quality ratings
Network Providers
Verifying if your preferred healthcare providers are included in the plan’s network may also be crucial. Using out-of-network providers without the plan’s authorization could potentially result in higher out-of-pocket expenses.
Remember that the network of providers may change at any time throughout the year, so it’s crucial to stay informed.
Medicare Advantage Plan Costs
Comprehending the potential costs associated with Medicare Advantage plans, like premiums, deductibles, and out-of-pocket maximums, could aid in choosing a budget-friendly plan.
Premiums
Monthly premiums may vary for Medicare Advantage plans. However, in addition to the Medicare Advantage premium, you will likely need to continue paying the Medicare Part B premium.
Deductibles
A deductible is the amount you must pay for healthcare or prescriptions before your Medicare Advantage Plan begins to cover costs. The exact amount may vary.
Potential Benefits Offered by Medicare Advantage Plans
Some Medicare Advantage plans may go beyond Original Medicare by potentially providing more Medicare benefits.
These may include prescription drug coverage, dental and vision care, and hearing services.
Prescription Drug Coverage
Some Medicare Advantage plans may include prescription drug coverage. This coverage could aid with the potential cost of medications. If a plan doesn’t offer this coverage, you may also opt to enroll in a standalone Medicare Prescription Drug Plan.
Dental and Vision Care
Unlike Original Medicare, which may not cover routine dental or vision care, certain Medicare Advantage plans may offer these services. Some of these potential benefits may help cover the cost of:
- Exams
- Eyeglasses
- Contact lenses
- Preventive dental services
Switching Between Medicare Advantage Plans and Original Medicare
Medicare coverage may not be a permanent choice. Switching between Medicare Advantage plans and Original Medicare during enrollment periods is feasible.
Switching from Medicare Advantage to Original Medicare
If you’re currently in a Medicare Advantage plan and want to return to Original Medicare, you can do so during the Medicare Advantage Open Enrollment Period or the Annual Enrollment Period.
When you switch, you can also join a Medicare Prescription Drug Plan to add drug coverage.
Switching from Original Medicare to Medicare Advantage
If you’re currently enrolled in Original Medicare and want to switch to a Medicare Advantage plan, you can do so during the Initial or Annual Enrollment Periods. Before switching, you should consider the coverage, possible benefits, and potential costs of the Medicare Advantage plan.
To switch, call 1-833-641-4938 (TTY 711), Mon-Fri 8 am-9 pm EST.
Medicare Advantage Plans for Special Needs and Low-Income Individuals
Some Medicare Advantage plans may offer more than a one-size-fits-all solution, possibly boasting specific plans that could be designed for individuals with special needs or low income. Knowing when and how to switch Medicare Advantage plans could help you find the best option for your unique situation.
Special Needs Plans (SNPs)
Special Needs Plans are a type of Medicare Advantage Plan that has been designed for individuals with specific chronic conditions or disabilities. These plans will likely be designed to provide focused and specialized care to meet the needs of their members.
Assistance for Low-Income Individuals
Low-income individuals may qualify for assistance programs, such as Medicaid or the Low-Income Subsidy. Some of these programs could help cover some of the costs of prescription drugs and possibly reduce the expenses that may be associated with Medicare prescription drug coverage.
Enrolling in a Medicare Advantage Plan: Step-by-Step Guide
If you’re prepared to sign up for a Medicare Advantage plan and have considered all your options, you may also want to learn how to research, compare plans, verify your potential network providers, and complete the enrollment process.
Researching Plans
Members may want to begin by researching the potential Medicare Advantage plans available in their locality. By entering your zip code into any of the zip code boxes on this website, you can:
- Compare different Medicare Advantage and Prescription Drug Plans
- Focus on drug coverage and costs to find the perfect fit for your healthcare needs
- Input your information and sort through a variety of plans
- Weigh the pros and cons of each based on your situation
Compare the coverage, possible benefits, and costs of each hospital insurance and medical insurance plan to determine which one best meets your healthcare needs.
Verifying Network Providers
Before you enroll in a plan from a private insurance company, make sure your preferred healthcare providers are in the plan’s network. Check the plan’s provider directory on their website or call the plan directly to request a provider directory.
Completing Enrollment
Lastly, accomplish the enrollment process. You can enroll by calling one of our licensed agents at 1-833-641-4938 (TTY 711), Mon-Fri 8 am-9 pm EST.
Summary
Navigating the world of Medicare Advantage plans might seem complex, but with the right knowledge, you can confidently make the best healthcare decisions for your unique needs. Understanding the possible qualifications, enrollment periods, and potential costs for these plans could help you choose the plan that best suits your healthcare needs and budget.
Frequently Asked Questions
→ Can you be turned down for a Medicare Advantage plan?
No, you can’t be turned down for a Medicare Advantage plan. Once you’re eligible for Original Medicare, you cannot be denied enrollment into a Medicare Advantage plan.
→ Which of the following are eligibility requirements for enrollment in Medicare Advantage?
To enroll in a Medicare Advantage plan, you must have Medicare Parts A and B, live in the plan’s service area, and not be enrolled in a Medigap plan.
→ Can Medicare Advantage plans deny coverage for preexisting conditions?
Medicare Advantage plans may not reject enrollment based on pre-existing conditions, including end-stage renal disease.
This could mean that individuals with preexisting conditions can join a Medicare Advantage Plan without facing coverage denial.
→ When can I enroll in a Medicare Advantage Plan?
You can enroll in a Medicare Advantage plan during the Initial Enrollment Period, the Annual Enrollment Period, and the Special Enrollment Period. These are the main times when you can sign up for a Medicare Advantage plan.
ZRN Health & Financial Services, LLC, a Texas limited liability company
Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.