Medicare Advantage
Eligibility
Medicare Advantage plans have specific eligibility requirements that you need to meet. The first requirement is that you must be enrolled in Medicare Parts A and B. Additionally, you must live in the service area of the plan you want to enroll in. If you have end-stage renal disease (ESRD), you generally cannot enroll in a Medicare Advantage plan. However, there are some exceptions to this rule, such as if you already have a Medicare Advantage plan when you develop ESRD or if you receive a kidney transplant. It’s important to note that eligibility requirements can vary depending on the specific plan and the insurance company offering it. Working with a licensed agent can help you understand the requirements and determine if you qualify for a Medicare Advantage plan.
Available Medicare Advantage Plans
HMO Plans
HMO-POS Plans
PPO Plans
PFFS Plans
Special Needs Plans
MAPD Plans
Qualifications for Medicare Advantage Plans
To be eligible for a Medicare Advantage plan, one must first enroll in Original Medicare, which includes Parts A and B. This applies to people under the age of 65 who qualify for Medicare due to a disability or medical condition. Additionally, it is necessary to stay current with payment of Part B premiums, even if one chooses to enroll in a Medicare Advantage plan. Finally, one must live in an area where Medicare Advantage plans are offered.
For those with limited financial means, there are additional qualifications for financial assistance. Those who are low-income or qualify for both Medicare and Medicaid may be eligible for help with 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 limited. Special Needs Plans are also available for individuals with chronic conditions.
However, it is important to note that Medicare Advantage plans are not available in all areas of the country. In some areas, there may be no plans available, while in others, the options may be limited.
Eligibility Checklist for Medicare Advantage Plans
There are three things you must do to become eligible for a Medicare Advantage plan.
- Enroll in Medicare Parts A and B and have your Part B effective date
- Have your Medicare ID number
- 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 & Requirements for Medicare Advantage Plans
As Medicare Advantage plans are offered by private insurance companies, each plan will have its own set of rules and regulations. Therefore, it is crucial that you have a clear understanding of how your plan operates, as not all Medicare Advantage plans are the same.
Generally, your health care services must be provided by a doctor within your plan’s network to avoid higher out-of-pocket costs or even the full bill for services rendered. You may also need to obtain a referral to see a specialist, and failing to do so could result in the plan not covering those expenses, even if the specialist is within your network.
Medicare Advantage Enrollments & Applications
If you are eligible for Medicare and have enrolled in Medicare Parts A and B, you can sign up for a Medicare Advantage plan if one is offered in your area. However, not all counties have these plans available, so it’s important to check before enrolling.
There are several enrollment periods related to Medicare Advantage plans. Your Initial Enrollment Period will start around your Part B effective date. The most significant enrollment period is the Annual Enrollment Period, which takes place every fall from October 15 to December 7.
If you experience a qualifying life event, you may be eligible for a Special Enrollment Period. One example of a qualifying event is if your current Medicare Advantage plan is no longer offered in your area, which allows you to switch policies. You can also try a Medicare Advantage plan during a 12-month trial period and decide whether to keep the plan or switch back to Original Medicare.
To apply for a Medicare Advantage plan, it is best to work with an insurance agent. An agent will ensure that the plan you select meets your requirements and assist you with all necessary paperwork. They will also submit your application and follow up with you to ensure that you receive your enrollment package.
