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Who Qualifies for Medicare Advantage Plans?

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Since Medicare Advantage plans are offered by private insurance companies, some people may worry that they won’t qualify for Medicare Advantage plans.

Qualifying for a Medicare Advantage plan is actually not too different from qualifying for Original Medicare, Part A and Part B.

Who qualifies for Medicare?

First, let’s briefly summarize how you can qualify for Original Medicare, Part A and Part B. Stay with us, because you need to be eligible for Part A and Part B in order to qualify for Medicare Advantage.

To qualify for Original Medicare, you must be:

  • An American citizen or permanent legal resident of at least 5 years in a row
  • Aged 65 or older, or eligible due to disability

Who qualifies for Medicare Advantage?

In most cases, here’s all you need to qualify for a Medicare Advantage plan. You must:

  • Be enrolled in Medicare Part A and Part B, or be eligible for them
  • Live within the plan’s service area. That means that when you find a plan you’d like to sign up for, make sure the plan serves the county where you live. Read more on this later in this article.

Please note: You might not qualify for a Medicare Advantage plan in certain cases. See below.

Who might not qualify for Medicare Advantage?

If you have end-stage renal disease, you might not qualify for most Medicare Advantage plans. End-stage renal disease (ESRD) is permanent kidney failure that requires you to get dialysis regularly, or have a kidney transplant.

Do you have ESRD, but still want to enroll in a Medicare Advantage plan? You can:

  • Contact the plan you’re hoping to enroll in, and ask if your particular situation disqualifies you for a Medicare Advantage plan. It never hurts to ask.
  • Enroll in a special type of Medicare Advantage plan called a Special Needs Plan (SNP). There are a few different types of SNPs, and one of them is specifically designed for people with ESRD. You may qualify for this type of Medicare Advantage plan if there’s one in your area.

How can you know if you live within a Medicare Advantage plan’s service area?

Here’s one way you can find out, and it’s easy. Just enter your ZIP code in the box on this page and click the button. eHealth’s plan finder will display a list of Medicare Advantage plans in your area. Not only that – you can enter your medications and even your doctor to see what plans might cover your medications, and might have your doctor in the plan’s network.

Of course you are always welcome to contact a licensed eHealth insurance agent.

A plan’s formulary may change at any time. When required by law, you will receive notice from your plan of changes to the formulary.

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