Who is Eligible for Medicare Advantage?

Signing up for a Medicare Advantage (also called MA or Part C) plan can be a great option for many seniors, but understanding eligibility for it can be a challenge. Medicare Advantage plans provide a way to get Medicare coverage from a quality private insurance company rather than directly from the government. By shopping on the Medicare Advantage marketplace, those with a variety of lifestyles can find plans that suit their budgets and needs. According to a recent study by J.D. Powers, enrollment in Medicare Advantage plans increased by almost 10% between 2018 and 2019. The idea of having a privately-offered choice in Medicare coverage is gaining popularity with retirees. Still, many seniors struggle to understand if they are eligible for a Medicare Advantage plan, when they can sign up, and what steps they need to take before enrolling. 

Eligibility for Medicare Advantage plans heavily overlaps with eligibility for Original Medicare (Parts A and B), but it isn’t precisely the same. Likewise, there are some important differences between enrollment periods for Original Medicare and Medicare Advantage. To make these topics more clear, this article contains important eligibility information, a step-by-step guide to enrollment with a helpful chart, and answers to some of the most commonly asked questions.

Understanding Medicare Advantage Eligibility

Eligibility for Medicare Advantage is, at its most basic level, controlled by the eligibility standards of Original Medicare. However, eligibility for Medicare Advantage is also moderated by a small list of other considerations. Below you can learn about both general Medicare eligibility and eligibility standards that are specific to Medicare Advantage.

General Medicare Eligibility

No one can enroll in Medicare Advantage unless he or she is already enrolled in Medicare Parts A and B. Medicare Advantage Plans ask new applicants for their Medicare number and Parts A and B enrollment dates. There are multiple paths to eligibility for Original Medicare, and, therefore, for Medicare Advantage as well. Read more about each of these paths to eligibility below.

• Age: The simplest determinant of Medicare eligibility is age. Generally, those 65 and older are automatically eligible and can apply three months before the month of the 65th birthday, the month of the birthday, or up to three months after the birthday month (a seven month period, total). Age-based eligibility does not translate to automatic enrollment for all, though for some seniors it does. You can learn more about automatic enrollment vs. enrollment by application later in this article. 
• Disability: Regardless of age, some people qualify for Medicare because of disability.  Those who have been getting disability benefits from Social Security for more than 24 months are automatically enrolled in Medicare Parts A and B. These people will get a Medicare Card in the mail up to three months before their 25th month of disability. 
• Specific Conditions: Medicare addresses two specific health conditions in its eligibility standards: Amyotrophic Lateral Sclerosis (commonly called ALS or Lou Gehrig’s Disease) and End-Stage Renal Disease. These are both disabling conditions, and those who have ESRD or ALS can begin receiving Medicare without waiting for their 25th month of collecting disability.

Eligibility Limitations Specific to Medicare Advantage

The basic criteria of eligibility for Medicare apply to Medicare Advantage as well, with a few exceptions and restrictions which we explore below. 

Location Restrictions

With Original Medicare, everyone gets the same coverage regardless of location. However, Medicare Advantage plans only apply to specific areas. The number of plans offered in different areas can vary greatly. As of March 2020, in New York City there are 50 Medicare Advantage plan choices. Options in less populous areas are likely to be far more limited, with moderately populated locations offering perhaps 20 to 25 options. Some extremely rural areas may have only one or two plan options. 

To find out which plans are available to seniors in your area, you can use the Health Plan Finder. This tool allows you to search for Medicare Advantage plans, Prescription Drug plans (which often come with Medicare Advantage), and Medigap plans (which are not Medicare Advantage and which can only be used with Original Medicare). When you use this tool, you’ll be shown available plans based on your zip code.  

Special Needs Plans Restrictions

Another restriction on Medicare Advantage eligibility is that some Medicare Advantage plans are designated Special Needs Plans (SNPs) that have very specific eligibility standards. SNPs exist because Medicare allows insurance companies to create plans catering to specific groups of people with complex health and/or financial needs. These plans can often serve some patients more efficiently than a plan for general use can. Of course, to use an SNP a senior must actually have the need to which the plan caters. Insurance companies are never required to offer SNPs, so their availability can vary dramatically by region.

Medicare allows for the creation of three basic SNP types. Below you can explore each in detail. 

• Institutional SNP (I-SNP): Institutional SNPs exist to meet the unique needs of those who live in a nursing home or other institutional setting on a long-term basis (90+ days). Some I-SNPs serve residents of only one facility, while others serve residents of multiple facilities in the same geographical area. The Centers for Medicare and Medicaid Services (CMS) provides more details on what qualifies as an I-SNP facility. 
• Dual Eligible SNP (D-SNP): Many low-income and/or disabled seniors are simultaneously eligible for both Medicare and Medicaid. These individuals are referred to as “dual eligible.” They can sign up for a Dual Eligible SNP (D-SNP) that is uniquely designed to help them understand their coverage under both programs. A D-SNP typically provides care coordination, that is, special advice and medical/financial planning resources for plan members. It may also provide a variety of other perks such as very low costs and extensive coverage for things like hearing, dental, and vision. 
• Chronic Condition SNP (C-SNP): A Chronic Condition SNP (C-SNP) is, as its name implies, designed to serve those with a specific chronic condition. The conditions served are typically severe and/or disabling. Conditions include but are not limited to: stroke, heart failure, cancer, autoimmune diseases, addictions, liver disease, mental illnesses, diabetes, dementia, and more. Typically C-SNPs have healthcare networks that include specialists for the chronic condition served. They may offer tests and medical services typically involved in treating the condition at a more affordable than average rate, or they may have a greater capacity than average to provide appointments that cater to the condition.

It’s important to note that, in general, anyone with a preexisting condition can still get a Medicare Advantage plan. However, those with the preexisting condition ESRD may not be eligible for any Medicare Advantage plan except for a C-SNP. Those who don’t have access to a C-SNP that accepts ESRD patients will most likely need to use Original Medicare instead of Medicare Advantage.

Technical Eligibility vs. True Suitability 

It’s possible to be eligible for a Medicare Advantage plan in the short-term but to find it an untenable option in the long-term. There are a few scenarios that seniors should be aware of when it comes to the suitability of a plan.

• Unsuitable networks: Location eligibility typically goes by county. If you’re eligible for a plan by virtue of your residence in a county, that doesn’t mean that services you need will be nearby. The network of some plans may be limited to only a small area within the county, and you may need to drive an unreasonable distance to see the providers you need. 
• Unsustainable costs: You may be eligible for some plans that have costs that you’ll be unable to keep up with over time. Unfortunately, some insurance providers will be more focused on signing you up than they will be on advising you on plan costs based on your income.

For the reasons above, it’s important to think critically about whether or not a plan will actually work for you and if Medicare Advantage is a better long-term option than Original Medicare.

The Enrollment Process for Medicare Advantage

If you’ve determined that you are eligible or nearing eligibility for Medicare, then you should start thinking about enrollment in Medicare Advantage. One cannot enroll just anytime; there are specific enrollment periods. The steps below will help you understand how the enrollment process works.

Step 1: Decide If Delaying Medicare Enrollment Is Right for You

As mentioned earlier, before enrolling in Medicare Advantage plans seniors need to enroll in Medicare Parts A and B. For a small portion of the population, it can be beneficial to delay enrollment in Medicare for a few years. This applies primarily to those who are nearing 65 but who still work (or who have a spouse that still works). It cannot be stressed enough that enrolling late in Medicare can carry steep, recurring fees for many people, so delaying coverage is only a good option for those who have a fee exemption. Having a fee exemption is most likely, though not guaranteed, for those who fit the profile below.

A senior who’s nearing age 65 may have a fee exemption if:

• The senior (or a spouse) receives health coverage through work
• The workplace includes more than 20 employees
• The senior (or spouse) plans to work beyond age 65 or the company offers retiree coverage

Essentially, someone in this situation may be able to and may want to delay starting their Medicare coverage because they decide that their work-provided coverage meets all of their needs at a low cost. However, no one should decide this without consulting with their company’s benefits manager. When asked, a benefits manager should be able to provide information on whether or not the provided health coverage is considered “group coverage” by the IRS. Seniors in qualified plans can delay coverage without a late enrollment fee later.

In general, only members of group health plans are eligible to delay coverage without dealing with a late enrollment fee when they do decide to enroll in Medicare. There are some exceptions to this, such as those who currently have insurance through a program called COBRA. If in doubt about your eligibility for a waived late fee, look at further details on exemptions on the official Medicare website or use this contact form to reach out to Medicare directly for more information.

Step 2: Enroll in Medicare Parts A and B When the Time Is Right

Seniors who are ready to switch to Medicare Advantage need to start by making sure they are enrolled in Medicare Parts A and B. Some people are automatically enrolled, but others need to apply. Both situations are explained below.

• Automatic Enrollment: If you’re getting Social Security or Railroad Retirement Board Benefits (RRB) at least three months prior to turning 65, then you’ll be automatically enrolled in Medicare Parts A and B. You’ll also be automatically enrolled if you have been getting disability benefits for more than 24 months or if you have ALS or ESRD and have started receiving disability (enrollment occurs immediately in this case). Note that ESRD patients are always eligible for Original Medicare but may not be eligible for most Medicare Advantage plans except for some Special Needs Plans.   
• Enrollment by Application: If you don’t meet one of the requirements listed in the previous point, then you’ll need to actively apply for Medicare. If you’re still unsure of your eligibility or enrollment status, you can use this tool that Medicare provides. The tool can also help you calculate your Parts A and B premiums. 

For those who need to apply for Parts A and B, enrollment periods can be found in detail on the official Medicare website. Note that there is some overlap between enrollment periods for Parts A and B and for Medicare Advantage, but the enrollment periods are considered distinct. In general, those turning 65 can sign up for Parts A and B beginning 3 months before the month they turn 65 through three months after the month they turn 65 (a seven month period). Those who miss or delay their initial enrollment period for Parts A and B can utilize the annual “open enrollment period” every year between January 1–March 31, but they may face a late enrollment fee in some cases. 

If you are automatically enrolled or if you apply when first eligible then you’ll get a Medicare number and card as early as three months before your Parts A and B coverage begins. You’ll use the enrollment dates and Medicare member number on your card to enroll in a Medicare Advantage plan when you have a Medicare Advantage enrollment period.

Step 3: Plan for Your Medicare Advantage Enrollment Period

Once you’re enrolled in Parts A and B, you can enroll in the Medicare Advantage plan of your choice, provided that you are in a qualified enrollment period. We have split the major enrollment periods into two different categories. The focus of this step is on joining a Medicare Advantage plan for the first time, but you’ll also find plenty of information on switching between plans and making other changes to coverage.

Open Enrollment Periods

The most straightforward enrollment periods are called “open enrollment,” and there are two of these. The first open enrollment period is from October 15th-December 7th of every year. The second open enrollment period is from January 1st-March 31st. When added together, open enrollment periods account for roughly 4.25 months of each year. 

The two different open enrollment periods have slightly different rules. During the first one seniors can join a Medicare Advantage plan for the first time, switch from one plan to another, or switch back to Original Medicare.  In the second enrollment period, seniors cannot join a Medicare Advantage plan for the first time (also called “switching from Original Medicare to Medicare Advantage”), but they can switch from Medicare Advantage plan to another, and they can also switch from Medicare Advantage back to Original Medicare. 
These open enrollment periods also allow seniors to make some changes to their drug coverage if they have a drug coverage (Part D) plan that is separate from Medicare Advantage. For information on joining, dropping, and switching drug plans, you can read more details here.

Enrollment Periods Based on Individual Circumstances

Aside from open enrollment periods, there are several other time periods in which a senior or other Medicare beneficiaries can join or make changes to their enrollment in a Medicare Advantage plan. Each of the enrollment periods in their section is conditional, with eligibility for the period based on the actions and/or status of the person at a specific time.

The first three enrollment periods in the chart below are based on birthdays and/or on disability status, making them perfect for those who want to enroll in a Medicare Advantage plan as early as possible. These first three periods are perhaps the most commonly utilized, but the other periods listed provide opportunities to enroll for those who missed their initial enrollment. As with the open enrollment periods, some of these enrollment periods also apply to prescription drug plans. Check the Medicare article listed earlier for complete information on drug plans.

Note: In most or all cases, the senior needs to already be enrolled in Medicare Parts A and B in order to join an MA plan.

Making Changes to Coverage Outside of Enrollment Periods

In addition to the enrollment periods detailed above, there are some other times during which you can alter coverage. Medicare lists 25 “special circumstances” when changes are possible, including circumstances related to moving, changes in employment, insurance companies abruptly dropping plans, and a variety of other scenarios, some of which are comparatively unusual. You may wish to familiarize yourself with all special circumstances in advance so that you know what your rights are. However, you can also simply refer to the list any time that you experience a life change that makes you want to alter your coverage.

Medicare also allows plan changes due to the “5-star special enrollment period.” Every year between December 8th and November 30th seniors can move from a Medicare Advantage plan they already have to a 5-star Medicare Advantage plan if one is offered in their area. All Medicare Advantage plans are rated on a scale of 1-5 stars based on customer satisfaction surveys and other factors, and plans that perform exceptionally well benefit from this special enrollment period that lower-performing plans don’t enjoy. Note that this enrollment period is focused on moving between plans, not enrolling for the first time in a Medicare Advantage plan.

Frequently Asked Questions