Who Qualifies for Medicare Advantage Plans?

Fact Checked
Published: 12/30/2020
Contributing Expert: Ron Elledge
Reviewed by: Caren Lampitoc


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.

caren headshot
Caren Lampitoc
Medicare Consultant
Caren Lampitoc
Medicare Consultant

Caren Lampitoc is an educator and Medicare consultant for Medicare Risk Adjustments and has over 25 years of experience working in the field of Medicine as a surgical coder, educator and consultant.

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, but it’s also worth considering Medicare Advantage, also known as Part C. Having a Medicare Advantage plan may work in your favor in many instances.

Medicare Advantage plans are offered by private companies, as opposed to Original Medicare, which is a function of the U.S. government. These private insurers work with the national Medicare program to provide the benefits of Original Medicare — and often more. In addition to offering Medicare Part A and Part B benefits, they may offer vision and dental benefits, for example.

So 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, or ESRD. This is permanent kidney failure, and it usually means you will be on dialysis or in need of a transplant.
  • You have amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s disease

You also need to be a citizen or permanent resident of the United States, have worked long enough (or your spouse has 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.

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?

Part A of Original Medicare 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, which may include part-time nursing care, physical therapy, or more.

This coverage is mandated by federal and state laws as well as 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 builds on the benefits of Part A by providing the following coverages:

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

Note that 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 drugs, before Medicare picks up the rest.

Who qualifies for Medicare Advantage?

It’s simple: 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, there may be other additions, such as the inclusion of vision, dental, and hearing coverage. There may also be cost benefits, including lower out-of-pocket costs, depending on who your plan administrator is.

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 may not qualify for a certain plan if you do not live in the coverage area that that company services. You can find out if a plan operates in your area by checking out the government’s Medicare site.

Another limitation exists if you have end-stage renal disease (ESRD). Many Medicare Advantage plans will not cover you if you have permanent kidney failure that requires regular dialysis, or if you’ve had a kidney transplant. You’ll need to talk to a membership coordinator at the company you’re interested in working with to see if they will cover you, if you are in this situation.

But even here there are options: Medicare Special Needs Plans (SNPs) are Medicare Advantage plans designed to serve those with chronic conditions, such as autoimmune disorders, dementia, and ESRD. There are different versions of the plan designed for each illness, and most include coverage for drugs that are commonly used in the treatment of that illness or disease.

How do I enroll in a Medicare Advantage Plan?

Every Medicare Advantage plan has its own requirements and processes, and thus there’s no single way to sign up. Your first task is to find out what coverage plans are accessible 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 it and obtain an enrollment form, which you will fill out and return. You can also call Medicare itself 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 your Medicare Part A and Part B coverage, just as if you have Original Medicare. The only part of the Original Medicare coverage that is not necessarily covered by Medicare Advantage is hospice care, but don’t worry: even if you’re with Medicare Advantage, you can still access the Original Medicare hospice coverage.

Many plans, but not all, offer additional benefits such as vision, hearing, or dental 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?

Fees and charges for Medicare Advantage plans are set once a year, starting on January 1, by the administering company, rather than the government’s Medicare division. There is no premium for Part A, but there is for Part B. In 2019, that was set at a standard of $135.50 or higher, depending on income level.

In addition to any premiums that are due, you may also have to pay a deductible, that varies according to your plan, and a copayment or coinsurance, which may also vary. This cost may be impacted by whether your doctor or medical supplier accepts assignment. This merely means that your medical provider agrees to accept the Medicare-approved amount as full payment for the services. If they do not accept assignment, you may have to pay the difference between what Medicare will pay and what the provider charges.

Sources