Who is eligible for Medicare Part C (Medicare Advantage)?

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In general, a person must meet certain eligibility requirements to qualify for Medicare Part C (Medicare Advantage). These requirements include:

• They must have already enrolled in Original Medicare (parts A and B).
• They must live in an area where an insurance provider offers a Medicare Advantage plan with the coverage they require.
• The plan must be available during their application or enrollment period.

People can enroll in Original Medicare if they are 65 years old or over. They must also be citizens of the United States or have been legal permanent residents for at least 5 years.

Specific rules apply to those under 65 years old who have certain health conditions or disabilities.

Read more about eligibility under age 65.

How to check eligibility

The government has a calculator that people can use to determine whether they are eligible for Medicare coverage and, if so, the likely premium.

People can use the calculator at Medicare.gov.

Medicare Part C (Medicare Advantage) provides an alternative way for individuals with Medicare Part A and Part B to receive their benefits.

Medicare contracts private insurance companies to administer Medicare Part C plans.

The plans feature the same coverage as Medicare parts A and B, and many include prescription drug coverage. Medicare Advantage plans often have additional benefits, too, such as:

• vision care
• hearing aids
• dental care
• gym membership

Some people find that a Medicare Part C plan is less expensive than Original Medicare and limits their maximum out-of-pocket expenses.

However, Medicare Advantage plans generally require people to see in-network healthcare professionals.

Read about the pros and cons of Medicare Advantage plans.

People with certain illnesses may be entitled to Medicare Part A and Part B, but they may not be eligible for Part C (Medicare Advantage).

These illnesses include:

• Amyotrophic lateral sclerosis (ALS): People with ALS, which is also known as Lou Gehrig’s disease, automatically receive parts A and B once they receive Social Security Disability Insurance (SSDI) benefits.
• End-stage renal disease (ESRD): People with ESRD are eligible for parts A and B. Typically, Medicare Part C (Medicare Advantage) plans exclude those with ESRD, but individuals can enroll in a Special Needs Plan (SNP).

Read more about ESRD and Medicare.

Disabilities and Medicare eligibility

Specific rules apply to Medicare relating to disabilities. An individual is eligible for Original Medicare if they have received SSDI or Railroad Retirement Board (RRB) payments for the past 24 months.

They must also be U.S. citizens or have been legal permanent residents for at least 5 years.

Common types of Medicare Advantage plans include:

• Health Maintenance Organization (HMO)
• Preferred Provider Organization (PPO)
• Special Needs Plan (SNP)
• Private Fee-for-Service (PFFS)
• Medicare savings account (MSA)

Health Maintenance Organization

HMO plans use a network of physicians, clinics, hospitals, and other healthcare professionals who deliver services at a discounted rate.

HMOs generally do not cover out-of-network care, except for emergencies.

Individuals must select a primary care physician (PCP) to coordinate their care and any necessary specialist referrals.

People may find that an HMO plan is less expensive than other Medicare Part C plans.

Preferred Provider Organization

As with HMO plans, PPO plans use a network of providers.

However, an individual does not need to select a PCP to coordinate their care. They are able to see specialists without referrals.

Generally, a PPO plan offers coverage even if the insured person uses a provider outside the network. However, there could be higher coinsurance or copayments.

PPO plans feature greater flexibility than HMO plans. Due to this, they tend to be more expensive.

Special Needs Plans

Medicare has designed SNPs specifically for people with particular health needs. The eligibility criteria for an SNP depend on the health conditions that the plan covers.

SNP membership is available to individuals who:

• live in certain institutions, such as a nursing home
• live in their own home but require nursing care
• are eligible for both Medicare and Medicaid
• have specific chronic or disabling conditions, including diabetes, ESRD, HIV, chronic heart failure, or dementia

Typically, the person must receive their care from healthcare professionals within the SNP network.

Exceptions to this rule include emergencies and a person with ESRD requiring out-of-area dialysis.

Private Fee-for-Service

Some PFFS plans use a network of contracted healthcare professionals who supply services at a lower cost.

Generally, with a PFFS plan, the insured person can see any healthcare professional who accepts the payment terms and conditions that the insurance company has set.

If the healthcare professional does not accept the terms and conditions, an individual might have to pay the entire cost out of pocket.

Medicare savings account

An MSA plan allows the insured person to choose their healthcare services and doctors.

An MSA has two parts. The first part is a health plan that covers costs once the insured person has met a high yearly deductible.

The second part is a medical savings account. The MSA plan deposits money into the account, which the insured person can use to pay healthcare costs before they meet the deductible.

Typically, MSA plans do not include prescription drug coverage.

The Medicare initial enrollment period (IEP) begins 3 months before the month in which a person turns 65 and lasts for 3 months after that. This period is a total of 7 months.

During the IEP, a person can enroll in:

• Medicare Part A and Part B
• Medicare Part C (Medicare Advantage)
• Medicare Part D (prescription drug coverage)

The annual election period is the interval in which Medicare beneficiaries can make changes to their coverage. It is also called the annual enrollment period (AEP) or Medicare open enrollment.

The AEP dates run from October 15 through December 7. During this time, people can switch between Original Medicare and Medicare Advantage plans or between the various Medicare Advantage plans available.

Individuals may also change from one Medicare Part D plan to another or enroll in a Part D plan if they did not do so when they were first eligible.

What is a special election period?

A special election period, also called a special enrollment period (SEP), is when someone can change their Medicare Advantage coverage outside of the official AEP or IEP.

Certain qualifying events, such as moving to a new area or losing existing insurance coverage, trigger an SEP.

Various rules and approved reasons may affect what changes an individual can make to their Medicare coverage.

Medicare Part C (Medicare Advantage) provides equivalent coverage to Original Medicare (parts A and B), with some additional benefits.

Some people find that a Medicare Advantage plan is less expensive for them than Original Medicare.

To enroll in a Medicare Advantage Plan, people must live in the insurance company service area and already have Medicare parts A and B.