Who is Eligible for Medicare Advantage Plans?
Navigating the potential Medicare options may 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 will lay out the guidelines, consider special conditions that might affect eligibility, and offer 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, and may even offer added benefits such as prescription drug coverage, and 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 time frames 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, will likely offer some of 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 will likely function with a network system of doctors, hospitals, and other healthcare providers, possibly allowing beneficiaries to 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.
Possible Differences Between Original Medicare and Medicare Advantage Plans
Some notable differences may exist when comparing Original Medicare and Medicare Advantage Plans.
Some differences to consider:
- Original Medicare will likely cover most medically necessary services and supplies in hospitals, doctors’ offices, and other healthcare facilities.
- Medicare Advantage plans, provided by private companies, may feature specific provider networks, and could also present reduced costs if you utilize doctors within the plan’s network.
- Certain Medicare Advantage plans may have average annual out-of-pocket costs that may be lower than those of Original Medicare.
- Some Medicare Advantage plans may impose an annual limit on out-of-pocket expenses, while Original Medicare does not.
Some of the Medicare Advantage Plans may also provide extra benefits, not covered by Original Medicare, such as prescription drug coverage, vision, hearing, and dental coverage.
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. An area is a geographic region within which the health insurance plan admits members and could restrict 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 some Medigap plans may 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.
End Stage Renal Disease (ESRD)
Individuals with End-Stage Renal Disease (ESRD) are 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 who may be 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 time frame and criteria for enrollment.
Initial Enrollment Period
The Initial Enrollment Period for Medicare Advantage Plans lasts for seven months. This period commences three months before 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.
To enroll, call one of our licensed agents at 1-833-641-4938 (TTY 711), Mon-Fri 8 am-9 pm EST.
Our licensed agents 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.
Possible Costs Associated with Medicare Advantage Plans
The costs related to Medicare Advantage Plans may differ, including premiums, deductibles, and out-of-pocket costs.
Notably, a majority of Medicare Advantage Plans may also impose an annual limit on out-of-pocket expenses for Parts A and B services.
Monthly Premiums
However, not all Medicare Advantage Plans require a monthly premium. However, premiums for certain plans may differ by location, with each county potentially presenting varying premiums based on the plans offered in that area.
The possible inclusion of coverage options within some Medicare Advantage Plans, such as joining a Medicare drug plan (Part D), may 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.
The deductible may apply 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, or dental coverage.
Potential Out-of-Pocket Costs
Out-of-pocket costs under certain Medicare Advantage Plans may include copayments and coinsurance, which could vary by plan.
Possible Benefits Offered by Medicare Advantage Plans
Compared to Original Medicare, some Medicare Advantage Plans may offer additional benefits including:
- Vision
- Hearing
- Dental
- Prescription drugs
Prescription drugs may be covered in some Medicare Advantage Plans, but if a plan does not provide drug coverage, individuals have the option to enroll in a Medicare Prescription Drug Plan for coverage.
Preventive services may also be included in certain Medicare Advantage Plans’ coverage encompassing exams, shots, lab tests, screenings, programs for health monitoring, counseling, and education.
Prescription Drug Coverage
Prescription drug coverage in Medicare Advantage Plans will likely be provided as Medicare Part D. If a plan does not include drug coverage, individuals could have the option to enroll in a separate Medicare drug plan to obtain it.
The possible expenses for prescription drug coverage in Medicare Advantage Plans may include:
- A premium
- Annual deductibles
- Copayments or coinsurance
- Expenses in the coverage gap if applicable.
Preventive Services
Preventive services in Medicare Advantage Plans will likely encompass:
- Exams
- Shots
- Lab tests
- Screenings
- Programs for health monitoring
- Counseling
- Education
These could be important in healthcare management as they could aid in disease prevention, particularly chronic diseases, which may facilitate early detection and treatment of health issues.
Some Medicare Advantage Plans may also cover many preventive services, such as screenings and vaccines, similar to how some preventive services with Original Medicare may be covered with no cost when seeing a participating provider.
Other Additional Benefits
Other benefits that could be offered by some Medicare Advantage Plans may 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 could be part of the Medicare benefits provided by Medicare Advantage.
Some Medicare Advantage Plans may also frequently provide additional benefits, including coverage for hearing aids, as well as coverage for fitting exams for hearing aids, which may not be 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 use our website by entering your zip code on this page. Or call one of our licensed agents today at 1-833-641-4938.
Each type of Medicare Advantage Plan offers distinct coverage options and imposes specific network restrictions.
Evaluating Potential Costs
Besides comparing coverage options, it will likely be vital to evaluate the costs that may be associated with each hospital insurance plan, including medical insurance. This could involve considering premiums, deductibles, and out-of-pocket expenses.
Consulting a Medicare Expert
Consulting a Medicare expert could 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) will likely be 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 has been 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
Understanding Medicare Advantage Plans and their eligibility requirements could be crucial for making informed decisions about your healthcare coverage. By comparing the potential coverage options, evaluating costs, and consulting with a Medicare expert, you can find a plan that best suits your needs.
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 Medicare Advantage plans be available?
Medicare Advantage plans will be available to enroll in starting on October 15th of every year.
→ What is the biggest advantage of Medicare Advantage?
One of the biggest advantages of Medicare Advantage could be the broad range of choices for doctors and medical offices compared to Original Medicare, along with potentially lower costs for complex medical needs.
→ Why are people choosing Medicare Advantage plans?
People may choose Medicare Advantage plans due to a lack of prior authorization and quick payments from insurers.
→ 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, could offer additional benefits and coverage options through private insurance companies, possibly 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.