Who is Eligible for Medicare Advantage Plans?
Navigating Medicare options can be challenging, particularly when determining who is eligible for Medicare Advantage plans. These plans are available to those enrolled in Medicare Parts A and B, living within a plan’s service area, and not currently on a Medigap policy.
This article lays out the clear-cut guidelines, considers special conditions that might affect eligibility, and offers insight into the enrollment process. Find out if you, or a loved one, are eligible and learn what steps to take next.
Key Takeaways
- Medicare Advantage Plans, provided by private insurers, include all services under Original Medicare except hospice care, often with added benefits such as prescription drug coverage, as well as dental, vision, and hearing services.
- Eligibility for Medicare Advantage Plans requires enrollment in Medicare Parts A and B and residency within the plan’s service area, while exclusion from eligibility applies to those who are currently enrolled in a Medigap plan.
- Enrollment periods for Medicare Advantage Plans include the Initial Enrollment Period, Annual Enrollment Period, Open Enrollment Period, and Special Enrollment Periods, each with specific timeframes and conditions for eligibility.
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Medicare Advantage Plan Basics
Medicare Advantage Plans, also known as Part C, are an alternative to Original Medicare. These plans are provided by private insurance companies and offer additional benefits and coverage options.
These plans encompass all services covered under Medicare Part A and Part B, except for hospice care. They also provide coverage for emergency and urgent care and offer protection for emergency services beyond the plan’s designated service area within the United States.
Before selecting a plan, one should consider various factors including your doctor’s network coverage, whether your prescriptions are included in the plan’s formulary, and the plan’s associated costs.
The benefits offered by these plans are regulated by the federal government, which dictates what benefits are permitted. However, each plan has the flexibility to offer a different combination of these government-approved services.
What is a Medicare Advantage Plan?
Medicare Advantage Plans, often known as Part C, offer the following benefits:
- Coverage of Medicare Parts A and B
- Extra benefits such as vision, hearing, and dental coverage
- Coverage for all services covered by Parts A and B, excluding hospice care
- Coverage for emergency and urgent care, even beyond the plan’s service area within the United States.
These plans come in various categories including Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Medicare Savings Account (MSA), and Private Fee-for-Service (PFFS), all of which contribute to a comprehensive health plan.
How do Medicare Advantage Plans work?
Medicare Advantage Plans function with a network system of doctors, hospitals, and other healthcare providers, guaranteeing that beneficiaries receive care from approved providers.
Some of these plans, such as HMO Plans, may require a referral to consult a specialist. If an individual consults a specialist who is not within the plan’s network, they might be responsible for the entire cost.
Key differences between Original Medicare and Medicare Advantage Plans
Notable differences exist when comparing Original Medicare and Medicare Advantage Plans.
Here are some key differences to consider:
- Original Medicare covers most medically necessary services and supplies in hospitals, doctors’ offices, and other healthcare facilities.
- Medicare Advantage plans, provided by private companies, typically feature specific provider networks, and may present reduced costs if you utilize doctors within the plan’s network.
- Medicare Advantage plans have average annual out-of-pocket costs almost $2,000 lower than those of Original Medicare.
- Medicare Advantage plans impose an annual limit on out-of-pocket expenses, while Original Medicare does not.
Medicare Advantage Plans often provide extra benefits, not covered by Original Medicare, such as prescription drug coverage, vision, hearing, dental coverage, and wellness programs.
Eligibility Criteria for Medicare Advantage Plans
The eligibility criteria for Medicare Advantage Plans are quite simple. The main requirements are enrollment in Medicare Parts A and B and residency in the plan’s service area. Notably, those enrolled in a Medigap plan are not eligible for Medicare Advantage Plans.
Enrollment in Medicare Parts A and B
To be eligible for a Medicare Advantage Plan, you need to:
- Be enrolled in both Medicare Parts A and B.
- These plans are an alternative to traditional Medicare coverage.
- This can be done online if individuals already have Part A or by completing and mailing the Application for Enrollment in Medicare Part B (CMS-40B) to their local office.
Residency in the plan’s service area
When considering a Medicare Advantage Plan, one should make sure to reside in the plan’s service area. This area is a geographic region within which the health insurance plan admits members and restricts membership based on residency.
If you relocate outside of your plan’s service area for more than six months, you may be disenrolled from most plans.
Exclusion of Medigap plans
If you are currently enrolled in a Medigap plan, you should be aware that you are not eligible to enroll in a Medicare Advantage Plan. This is because of potential issues when switching from a Medicare Advantage Plan to traditional Medicare.
It is also worth noting that Medigap plans do not provide the additional coverage benefits that Medicare Advantage Plans do.
Special Circumstances Affecting Eligibility
Certain special circumstances might impact your eligibility for Medicare Advantage Plans. These include having End Stage Renal Disease (ESRD), being a beneficiary of the Railroad Retirement Board, or receiving disability benefits.
Knowing whether one qualifies for Medicare Advantage is essential for making informed decisions about healthcare coverage.
End Stage Renal Disease (ESRD)
Starting in 2021, individuals with End-Stage Renal Disease (ESRD) have become eligible to enroll in Medicare Advantage Plans. These individuals receive coverage for all covered services, not limited to those related to kidney disease.
There are also special Medicare Advantage Plans, known as Special Needs Plans (SNPs), designed specifically for individuals with ESRD.
Railroad Retirement Board beneficiaries
Being a beneficiary of the Railroad Retirement Board does not affect your eligibility for Medicare Advantage Plans.
If you meet the requirements of being at least 65 years old and being eligible to receive railroad retirement or social security benefits, you can enroll in a Medicare Advantage Plan.
Disability benefits recipients
Those receiving disability benefits may also qualify for Medicare Advantage Plans. Eligibility requires having received Social Security Disability benefits for a period of 24 months.
There are also Special Needs Plans (SNPs) tailored to cater to the requirements of individuals receiving disability benefits.
Enrollment Periods for Medicare Advantage Plans
There are several enrollment periods for Medicare Advantage Plans. Some of these periods include:
- Initial Enrollment Period
- Annual Enrollment Period
- Medicare Advantage Open Enrollment Period
- Special Enrollment Period
Each of these periods has a specific timeframe and criteria for enrollment.
Initial Enrollment Period
The Initial Enrollment Period for Medicare Advantage Plans lasts for seven months. This period commences three months prior to an individual’s Medicare eligibility and concludes three months after their enrollment.
This period allows individuals to enroll in a Medicare Advantage Plan with drug coverage or a separate Medicare drug plan.
Annual Enrollment Period
The Annual Enrollment Period for Medicare Advantage Plans is from October 15 to December 7 each year. This period allows for plan changes and new enrollments.
However, if changes are not made during this period, the option to switch plans or make changes to coverage may not be available until the next Annual Enrollment Period, unless specific qualifying events occur.
Open Enrollment Period
The Open Enrollment Period for Medicare Advantage Plans lasts from January 1st to March 31st.
This period provides an opportunity for Medicare Advantage enrollees to modify their plans or transition to traditional Medicare. During this period, individuals have the option to switch from one Medicare Advantage Plan to another, with or without drug coverage.
Special Enrollment Periods
Special Enrollment Periods allow for enrollment or plan changes due to specific life events or circumstances, such as moving outside of a plan’s service area or losing other coverage.
These periods typically last for 2 months, but if employment or employer coverage ends, individuals have an eight-month period to sign up for a Medicare Advantage Plan.
Costs Associated with Medicare Advantage Plans
The costs related to Medicare Advantage Plans can differ, including premiums, deductibles, and out-of-pocket costs. Slightly more than 50% of Medicare Advantage plans that offer prescription drug coverage do not have a monthly premium.
The average projected Medicare advantage plans cost in 2021 is $21, and the average deductible amount in 2021 was $203.
Notably, all Medicare Advantage Plans impose an annual limit on out-of-pocket expenses for Parts A and B services.
Monthly premiums
Not all Medicare Advantage Plans require a monthly premium; certain plans are offered with a monthly premium of $0. However, premiums for plans can differ by location, with each county potentially presenting varying premiums based on the plans offered in that area.
The inclusion of coverage options within Medicare Advantage Plans, such as joining a Medicare drug plan (Part D), can also impact monthly premiums.
Deductibles
Deductibles in Medicare Advantage Plans refer to the amount individuals are required to pay for healthcare or specific services before their plan begins covering the costs. While certain plans have their own deductibles, others may provide a $0 deductible option.
The deductible may be applicable to a range of services provided by Original Medicare and, generally, Medicare Advantage Plans, such as doctor office visits, and some plans may also encompass drug, vision, hearing, dental, or wellness coverage.
Out-of-pocket costs
Out-of-pocket costs under Medicare Advantage Plans can include copayments and coinsurance, which vary by plan.
On average, individuals enrolled in Medicare Advantage Plans may be responsible for $18 per month in out-of-pocket expenses, with an average out-of-pocket maximum of $4,835 for in-network services.
Additionally, there are mandated maximum limits, with the out-of-pocket maximum not exceeding $8,300 for in-network services and $12,450 for both in-network and out-of-network services in 2023.
Additional Benefits Offered by Medicare Advantage Plans
Compared to Original Medicare, Medicare Advantage Plans generally offer additional benefits including:
- Vision
- Hearing
- Fitness
- Dental
- Prescription drugs
- Other related services
Prescription drugs are potentially covered in Medicare Advantage Plans, and if a plan does not provide drug coverage, individuals have the option to enroll in a Medicare Prescription Drug Plan for coverage.
Preventive services included in Medicare Advantage Plans’ coverage encompass exams, shots, lab tests, screenings, programs for health monitoring, counseling, and education.
Prescription drug coverage
Prescription drug coverage in Medicare Advantage Plans is typically provided as Medicare Part D. If a plan does not include drug coverage, individuals have the option to enroll in a separate Medicare drug plan to obtain it.
The expenses for prescription drug coverage in Medicare Advantage Plans may include:
- A premium, sometimes as low as zero in many plans
- Annual deductibles
- Copayments or coinsurance
- Expenses in the coverage gap if applicable.
Preventive services
Preventive services in Medicare Advantage Plans encompass:
- Exams
- Shots
- Lab tests
- Screenings
- Programs for health monitoring
- Counseling
- Education
They are important in healthcare management as they aid in disease prevention, particularly chronic diseases, resulting in extended lifespan and facilitating early detection and treatment of health issues.
Medicare Advantage Plans cover many preventive services, such as screenings and vaccines, at no out-of-pocket cost, like Original Medicare where most preventive services are covered with no cost when seeing a participating provider.
Other additional benefits
Other benefits offered by Medicare Advantage Plans include coverage for routine dental services, such as oral exams, cleanings, dental x-rays, and occasionally fluoride treatments.
Vision coverage may include annual exams, eyeglass frames with prescription lenses, and prescription contact lenses, primarily for individuals with specific diagnosed medical conditions and those at high risk. These additional offerings are part of the Medicare benefits provided by Medicare Advantage.
Medicare Advantage Plans also frequently provide additional benefits, including coverage for hearing aids, as well as coverage for fitting exams for hearing aids, which are not usually included in Original Medicare.
Navigating the Medicare Advantage Plan Marketplace
While navigating the Medicare Advantage Plan marketplace might seem overwhelming, it doesn’t have to be. By comparing coverage options, evaluating costs, and consulting a Medicare expert, you can make the process easier and more efficient.
Comparing coverage options
When you’re ready to start comparing Medicare Advantage Plans, you can just use our website by entering your zip code on this page. Or call us today at 1-833-641-4938.
Each type of Medicare Advantage Plan offers distinct coverage options and imposes specific network restrictions.
Evaluating costs
Besides comparing coverage options, it’s vital to evaluate the costs associated with each hospital insurance plan, including medical insurance. This involves considering premiums, deductibles, and out-of-pocket expenses.
The typical monthly premium for a Medicare Advantage Plan is approximately $18.50, which ranges by company, plan, and area.
Consulting a Medicare expert
Consulting a Medicare expert can prove highly beneficial in guiding and assisting you in selecting the right plan.
A Medicare expert, such as a Medicare Advisor, can help guide you through the available options and assist you in selecting the most suitable Medicare Advantage Plan for your specific needs and preferences.
Special Needs Plans: Tailored Coverage for Specific Conditions
Special Needs Plans (SNPs) are a category of Medicare Advantage Plan explicitly designed for specific groups of people, such as those with diseases or characteristics.
They provide customized benefits, networks, and drug formularies to best meet the specific needs of the groups they serve.
Types of Special Needs Plans
There are three types of Special Needs Plans: Chronic Condition Special Needs Plans (C-SNPs), Dual Eligible Special Needs Plans (D-SNPs), and Institutional Special Needs Plans (I-SNPs).
Each type of SNP is designed to provide tailored care and coverage for specific groups of people, such as those with certain chronic diseases or conditions, those eligible for both Medicare and Medicaid, or those living in certain institutions (like nursing homes) or requiring nursing care at home.
Summary
To wrap up, understanding Medicare Advantage Plans and their eligibility requirements is crucial for making informed decisions about your healthcare coverage. By comparing coverage options, evaluating costs, and consulting with a Medicare expert, you can find a plan that best suits your needs.
Remember, your health is your wealth, so take the time to find a plan that will provide you with the coverage you need.
Frequently Asked Questions
→ Which of the following are eligibility requirements for enrollment in a Medicare Advantage?
To be eligible for enrollment in a Medicare Advantage plan, you must have Medicare Parts A and B and reside in the plan’s service area. Individuals with End-Stage Renal Disease generally cannot join a Medicare Advantage Plan.
→ When will 2025 Medicare Advantage plans be available?
Medicare Advantage plans for 2025 are will available to enroll in starting on October 15th 2024.
→ What is the biggest disadvantage of Medicare Advantage?
The biggest disadvantage of Medicare Advantage is the limited choice of doctors and medical offices compared to Original Medicare, along with potentially higher costs for complex medical needs.
→ Why are people leaving Medicare Advantage plans?
People are leaving Medicare Advantage plans due to excessive prior authorization denial rates and slow payments from insurers. These issues are causing dissatisfaction among members.
→ Do Medicare Advantage plans have to accept everyone?
Yes, Medicare Advantage plans must accept all Medicare-eligible enrollees, but costs may increase due to copayments and out-of-pocket expenses.
Customers can switch back to Original Medicare during the annual open enrollment period.
→ What are Medicare Advantage Plans?
Medicare Advantage Plans, also known as Part C, offer additional benefits and coverage options through private insurance companies, serving as an alternative to Original Medicare.
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.