Who Qualifies for Medicare Advantage Plans?

Fact Checked
Contributing expert: Ron Elledge, Medicare Consultant
Reviewed by: Kelly Blackwell, Certified Senior Advisor®
Updated: March 15, 2022

ron headshot
Ron Elledge
Medicare Consultant and Author
Ron Elledge
Medicare Consultant and Author

Ron Elledge is a seasoned Medicare consultant and author of “Medicare Made Easy.” As a Medicare expert, he regularly consults beneficiaries on Medicare rules, regulations, and strategies.

Kelly Blackwell - Small Profile Image
Kelly Blackwell
Certified Senior Advisor (CSA)®
Kelly Blackwell
Certified Senior Advisor (CSA)®

Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.

Navigating the complexities of Medicare doesn’t have to be difficult. It’s important to understand what the major plan components — Parts A, B, and D — provide. It’s also worth considering Medicare Advantage, also known as Part C, as an alternative way to get your Original Medicare Parts A and B benefits. Having a Medicare Advantage plan may work in your favor in many instances.

Medicare Advantage Plans are offered by private insurance companies, unlike Original Medicare, which is adminstered by the U.S. government. The private insurers are approved and regulated by Medicare to provide the benefits of Original Medicare Part A and Part B.  In addition, Medicare Advantage Plans typically offer perscription drug coverage (Part D), vision, hearing, and dental benefits.

Who qualifies for Medicare Advantage? We’ll take a look at that and more below.

Who Qualifies for Original Medicare?

To begin with, let’s consider who is eligible for Medicare in any of its forms. Generally, you can get Medicare if one of these conditions applies:

  • You are at least 65 years old
  • You are disabled and receive Social Security Disability Insurance (SSDI) or Railroad Retirement disability payments
  • You have End-Stage Renal Disease (ESRD) and require dialysis or a kidney transplant
  • You have amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease

You must be a citizen or permanent resident of the United States. You are eligible for premium-free Part A if you or your spouse have worked long enough to be eligible for Social Security or Railroad Retirement Board (RRB) benefits, or been a government employee who has paid into the Medicare system. If you are not eligible for premium-free Part A, you may be able to buy it.

For some people, such as those who have paid into the Social Security system and are receiving benefits, there’s no need to sign up for Medicare. Medicare is linked to your Social Security or RRB benefits, so once you start receiving those benefits at 65 (or earlier, if you have a disability), you are automatically signed up for Medicare Parts A and B.

If you are not receiving Social Security or RRB benefits at least four months before you turn 65, you’ll need to contact Social Security to sign up. In many cases, you can apply online. If you are younger than 65 but have a disability, your Medicare benefits should begin after you’ve received Social Security or RRB benefits for 24 months.

What is Medicare Part A?

Medicare Part A (hospital insurance) covers the following:

  • Inpatient care if you are hospitalized
  • Skilled nursing care in a nursing facility
  • Nursing home care (not custodial or long-term)
  • Hospice care
  • Home health care, may include part-time nursing care, physical therapy, or more.

This coverage is mandated by federal and state laws and by coverage decisions made by Medicare or by companies that process Medicare claims at both the national and local levels. You can find out if a test, medical item, or service is covered by Medicare at the government’s Medicare site.

What is Medicare Part B?

Medicare Part B (medical insurance) builds on the benefits of Part A by providing services such as:

  • Doctor visits
  • Lab tests
  • Ambulance services
  • Preventive care
  • Durable medical equipment, like blood sugar monitors, crutches, or wheelchairs
  • Outpatient mental health care, including partial hospitalization
  • Some limited outpatient prescription drugs, including those you would get in a hospital or outpatient setting instead of those you’d give yourself. This includes flu shots and other vaccinations, as well as transplant drugs, and those for end-stage renal disease.

Medicare may not pay for the entire cost of your medical needs. You’ll be required to pay a certain percentage, such as 20% for doctor’s visits, before Medicare picks up the rest.

Who Qualifies for Medicare Advantage?

If you qualify for and are already enrolled in Medicare Parts A and B, you are eligible to get your coverage via Medicare Advantage, or Medicare Part C.

There are several reasons why the all-in-one coverage of Medicare Advantage may be a better choice for you. In addition to receiving Parts A and B benefits, there may be other inclusions, such as vision, dental, and hearing coverage. There may also be cost benefits, including lower out-of-pocket costs, depending on who your plan administrator is and how much you access your benefits.

Who Doesn’t Qualify for Medicare Advantage?

First, you must be enrolled in Original Medicare Part A and Part B to be eligible for Medicare Part C. Second, because Medicare Advantage Plans are administered by private companies, you must reside in the plan’s service area. You can find out if a plan operates in your area by checking out the government’s Medicare site.

You cannot purchase a Medicare Advantage Plan and a Medigap (Medicare supplemental insurance) plan at the same time.

How Do I Enroll in a Medicare Advantage Plan?

Every Medicare Advantage Plan has its own requirements and processes, thus there’s no single way to sign up. Your first task is to find out what coverage plans are available in your area and compare the benefits of the plans with the benefits you’d have in Original Medicare.

For many plans, it’s possible to complete the enrollment process through the Medicare website. For some plans, you may need to contact the company that administers them and obtain an enrollment form, which you will fill out and return. You can also call Medicare at 1-800-MEDICARE for assistance in choosing your plan.

When you join Medicare Advantage, you’ll need to give your Medicare number and the date your Part A and B coverage began. Medicare plan providers are not allowed to call you unless you’ve specifically requested a call, and they should never ask for financial information such as a credit card number over the phone. If someone claiming to be from Medicare does ask for financial information from you, hang up immediately — it is most likely a scam.

What Do Medicare Advantage Plans Cover?

Medicare Advantage Plans cover all Medicare Part A and Part B services except hospice care. If you need hospice care, Medicare Part A will cover it, even if you are enrolled in a Medicare Advantage Plan..

Many plans, but not all, offer additional benefits such as vision, hearing, dental coverage, and prescription drug coverage. Another plus is that there is a yearly limit on what you pay out-of-pocket for your Parts A and B services. Once you reach that limit, you won’t have to pay anything additional for that year.

All Medicare Advantage Plans include emergency and urgent care. You are also eligible for emergency coverage outside of the plan’s service area, though that’s only within the U.S.

How Much Do Medicare Advantage Plans Cost?

The administering private insurance company sets fees and charges for Medicare Advantage plans once a year. Updated costs start on January 1. There is no premium for Part A for most Medicare beneficiaries, but there is for Part B. In 2022, the Part B standard monthly premium is $170.10.

In addition to any premiums your plan may have, you may also have to pay an annual deductible. Cost-sharing in the form of deductibles, coinsurance, and copays varies depending on your plan. Your costs are lowest if you use in-network providers and adhere to the plan’s rules about how you obtain services. For instance, you may need a referral to see a specialist or obtain prior authorization for certain procedures and medications.

Learn More From Our Sources