Medicare Advantage Eligibility Requirements

There are 3 general eligibility requirements to qualify for a Medicare Advantage plan (Medicare Part C):

1. You must be enrolled in Original Medicare (Medicare Part A and Part B).

2. You must live in the service area of a Medicare Advantage insurance provider that is accepting new users during your application period.

3. You do not have End Stage Renal Disease (ESRD).

Who is eligible for Medicare Part C?

Anyone who is enrolled in Original Medicare (Part A and Part B) may be eligible to sign up for a Medicare Advantage (Part C) plan. This includes people under the age of 65 who have qualified for Medicare because of a disability. 

People who have End-Stage Renal Disease (ESRD) may not be able to enroll in a Medicare Advantage plan. If you have ESRD, you may be able to enroll in a Medicare Special Needs Plan (SNP).

A Special Needs Plan is a certain type of Medicare Advantage plan that is designed for people with specific health care conditions or circumstances. 

You cannot have a Medicare Advantage plan and a Medicare Supplement Insurance (Medigap) policy at the same time.

In some cases, you may be able to have a Medicare Advantage plan and a Medicare Part D prescription drug plan at the same time, as long as your Medicare Advantage plan does not include prescription drug coverage.

How does Medicare Part C work?

Medicare Part C plans are sold by private insurance companies as an alternative to Original Medicare. Medicare Part C plans are required by law to offer at least the same benefits as Medicare Part A and Part B. 

There are several different types of Medicare Advantage plans, such as HMO plans and PPO plans. Each type of plan may feature its own network of participating providers. 

What is covered under Medicare Part C?

Medicare Part C plans provide all of the same benefits as Original Medicare. Most Medicare Advantage plans also offer prescription drug benefits, which Original Medicare doesn't cover.

Some Medicare Advantage plans may also offer a number of additional benefits that can include coverage for things like:

How much does Medicare Part C cost?

​Some Medicare Advantage plans may require you to pay a monthly premium. In 2019, the weighted average Medicare Advantage plan premium was $29 per month.1

There were more than 2,700 Part C plans available throughout the country in 2019, and 45 percent of those featured a $0 premium.

Nearly 6 out of 10 Medicare Advantage beneficiaries were enrolled in a $0 premium plan in 2019.

The average deductible for a Medicare Advantage plan in 2019 was $95.20 per year, and the average annual out-of-pocket limit was $4,794.

Medicare Advantage plans are required to include an annual out-of-pocket spending limit, which limits how much you will have to pay in Medicare deductibles, coinsurance and other out-of-pocket costs in a single year.

Medicare Part A and Part B don't include an out-of-pocket spending limit. Medicare out-of-pocket costs​ can add up quickly if you're faced with a long-term inpatient hospital stay or undergo extensive medical care that requires high coinsurance or copay costs.

When can I enroll in a Part C plan?

If you are eligible for a Medicare Advantage plan and there is a plan available in your service area, you still need to wait for an enrollment period to join.

This Medicare enrollment guide can help you navigate the various Medicare enrollment periods.

Initial Enrollment Period (IEP)

When you first become eligible for Medicare, you will be given an Initial Enrollment Period (IEP).

Your IEP lasts for seven months. It begins three months before you turn 65 years old, includes the month of your birthday and continues on for three more months.

Annual Enrollment Period (AEP)

The Annual Enrollment Period is also referred to as the fall Medicare Open Enrollment Period for Medicare Advantage plans

The Medicare AEP lasts from October 15 to December 7 each year. During this time, you may be able to sign up for, change or disenroll from a Medicare Advantage plan.

Special Enrollment Period (SEP)

You could potentially qualify for a Medicare Special Enrollment Period (SEP) at any time throughout the year if you experience a qualifying life event.

These qualifying events can include situations such as moving to a new plan service area, being released from jail, moving into or out of a skilled nursing facility and more.

A licensed insurance agent can help determine if you are eligible for a Special Enrollment Period.

You can also call to speak with a licensed agent to find out more about Medicare Advantage plans in your area and learn when you may be able to enroll.

 

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Or call TTY Users: 711 24/7 to speak with a licensed insurance agent.