Who Qualifies for Medicare Advantage?

Who Qualifies for Medicare Advantage?

As you approach age 65, it's time to start thinking about your long-term healthcare in retirement. For many, that's Medicare. With a few plans to choose from — including Original Medicare, Medicare Advantage and other supplemental insurance plans — you'll want to explore your options to determine the best path for you.

For many, Medicare Advantage is an attractive option. It's an alternative way to receive Medicare through a private insurer. However, if you're considering going that route, it's important to first understand how these plans work and who qualifies for Medicare Advantage. Here's what you need to know.

What is Medicare Advantage?

Original Medicare has two primary parts: Part A covers emergency care, and Part B covers doctor's visits. Medicare Advantage is also known as Medicare Part C, and it covers the services that fall under both Part A and Part B.

Medicare Advantage is administered through a private insurer approved to provide Medicare. Depending on the plan, you may also receive some additional benefits covered under Medicare Advantage, such as dental care, vision care or prescription drug coverage.

How Does Medicare Advantage Work?

With a couple of different options for coverage, you might wonder why someone would pick one type of Medicare over the other. There are a few reasons Medicare Advantage may fit better than Original Medicare for some.

One reason is Medicare Advantage plans tend to offer more coverage. For example, you may receive routine dental and vision care, wellness programs and prescription drug coverage depending on the plan. Currently, none of these are covered by Original Medicare.

Out-of-pocket costs are a factor, too. Medicare Parts A and B typically cover around 80% of your health care costs. The remaining 20% needs to be covered out-of-pocket or through Medigap plans, which contribute to some of these additional costs. Medicare Advantage has an out-of-pocket spending limit, which can also help reduce some of these costs. However, some Medicare Advantage plans may have you pay a monthly premium.

Do I Qualify for Medicare Advantage?

Knowing who qualifies for Medicare Advantage is important. Luckily, the list of necessary qualifications is very simple. You qualify for Medicare Advantage if:

  • You are enrolled in Original Medicare.
  • You live in an area where a Medicare Advantage insurer provides services.
  • The private insurance company is accepting applications for new members during the enrollment period.

Medicare Advantage insurers cover service areas — specific geographic locations where hospitals, doctors and service providers operate within a network. When enrolling in a Medicare Advantage plan, your location can dictate your coverage options. You may have multiple plans to choose from or no providers offering coverage in your area.

Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) are common options for Medicare Advantage plans. Depending on what's available to you and what you choose, you may need to stay within a local network determined by your provider to have your care covered.

If you choose a Medicare Advantage plan and then move out of your region, you may no longer qualify for that plan and be disenrolled.

When Can I Enroll in a Medicare Advantage Plan?

If you decide that Medicare Advantage is the best option for your needs and you qualify, you'll need to wait for an enrollment period. Medicare offers a variety of enrollment options throughout the year.

  • You can sign up during an initial enrollment period during the three months before and after the month you turn 65.
  • Medicare offers an open enrollment period from October 15 through December 7 during which can sign up, switch or leave any Medicare plan.
  • Medicare offers a general enrollment period from January 1 through March 31 during which you can sign up for Original Medicare plans.
  • A Medicare Advantage enrollment period also runs from January 1 to March 31 during which you can switch or leave Medicare Advantage plans.
  • In some instances, like losing your current insurance or moving locations, you may qualify for a special enrollment.

You can also check with Medicare.gov for specifics on sign-up periods these enrollment dates approach.

The main takeaway? Before you decide which type of Medicare is best for your needs, explore all your options.

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