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Who Qualifies for Medicare Advantage Plans?


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Medicare Advantage plans are an alternative way for people to receive their Medicare Part A (hospital) and Part B (medical) benefits from private insurance companies approved by Medicare. A person who qualifies for Medicare Advantage may find these plans an attractive option because many Medicare Advantage plans provide additional benefits such as routine dental, routine vision, wellness programs, and prescription drug coverage. Medicare Advantage plans also may have lower out-of-pocket costs than Original Medicare has and provide out-of-pocket maximums.

What are the basic characteristics of someone who qualifies for a Medicare Advantage plan?

  1. You must qualify for Medicare Part A and Part B coverage.

It is important to remember, Medicare Advantage doesn’t replace Medicare Part A and Part B coverage. It is simply another way to receive these Medicare benefits—and sometimes additional benefits—through a plan sponsored by a Medicare-approved insurance company. To enroll in a Medicare Advantage plan, you must be eligible for, or already have, Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage. Most people qualify for Medicare Part A and Part B when they turn age 65 or have received disability benefits from the Social Security Administration or Railroad Retirement Board for 24 months.

  1. You must live within the service area of the plan.

Medicare Advantage plans have service areas or designated regions where they are licensed by a state and approved by Medicare to provide coverage. Frequently Medicare Advantage plans also have networks of contracted health-care facilities and professionals who deliver covered services to the plan’s members. Therefore, you must sign-up for a Medicare Advantage plan that is available where you live.

What are other characteristics of someone who qualifies for a Medicare Advantage plan?

  1. You must pay the Medicare Part B premium.

Typically, you are still responsible for paying your Medicare Part B premium when you enroll in a Medicare Advantage plan. An exception may exist for people with limited incomes that qualify them for a Part B premium government subsidy. In addition to the Medicare Part B premium, you may pay a premium to the Medicare Advantage plan you choose, depending upon the plan and coverage it provides. Medicare Advantage plans can have premiums as low as $0.

  1. In some cases, you can’t have permanent kidney failure (ESRD)

Generally people who have ESRD are covered by Medicare Part A and Part B, and do not qualify for Medicare Advantage enrollment. If you have this condition, however, you may be able to enroll in a particular type of Medicare Advantage plan, a Special Needs Plan, designed to support many of the unique coverage needs of individuals with certain chronic health conditions, including ESRD.

Do you qualify for a Medicare Advantage plan? To begin searching for Medicare Advantage plans in your area, just enter you zip code on this page.

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