Medicare Advantage Plans Eligibility

Most people who are eligible for Medicare also qualify for a Medicare Advantage Plan. Unlike most private insurance plans you will not need to go through a medical screening or underwriting to join a Medicare Advantage Plan. Anyone who has Part A and Part B and lives in the service area of the Medicare Advantage Plan is able to join as long as they do not have ESRD (see below).

Your eligibility for Medicare Advantage Plans is determined by your eligibility and participation in Medicare Part A and Part B. To qualify for an Advantage plan you must already have Part and Part B or be eligible to sign up for both of them during your Initial Enrollment Period (the 7 months around the time that you turn 65).

Legal residents of the United States 65 years old and older who have resided in the country for at least 5 consecutive years are eligible for Medicare Benefits. People who have contributed FICA taxes to Medicare for more than 10 years (40 quarters) are eligible to receive Part A Medicare benefits without paying a monthly premium. Residents that are eligible but have not met the 10-year requirement are eligible for Medicare when they turn 65 but they will have to pay a premium for these benefits. Permanently disabled individuals and individuals with either ESRD or ALS are eligible for Medicare coverage before they are 65. Most ESRD patients will not qualify for Medicare Advantage Plans.

Medicare Advantage Plans are usually area specific; to qualify for an Advantage Plan you must live within the plan's service area. Advantage Plans rely on area specific networks of medical doctors and providers. Generally, you can see doctors outside of the area but your costs will usually be higher. Each plan is unique and you will have to look at the plan carefully to determine what is and isn't covered if you do not see one of their preferred providers.

ESRD stands for End-Stage Renal Disease (kidney failure). If you have ESRD you will not be allowed to join an Advantage Plan unless you are already part of an Advantage Plan when you are diagnosed with ESRD. Rare exceptions to this rule exist. For example, successful transplant recipients may be able to join an Advantage Plan. People with excellent retiree benefits may also sometimes be able to join an Advantage Plan. Furthermore, some Advantage SNP (Special Needs Plans) covers ESRD. To check your particular situation, contact your local ESRD Organization.

In summary, to qualify for a Medicare Advantage Plan you must have Part A and Part B and live within the plan's service area. People with ESRD are excluded from Advantage except under special circumstances.