The eligibility requirements for Medicare Advantage are tied to the same requirements as Original Medicare since it is inherently another way to receive Medicare benefits but through a Medicare-approved private insurance company instead of the federal government. The advantage over Original Medicare is that enrollees have the option to include plan coverage for dental, vision, hearing, and fitness programs. Advantage plans can also cover prescription drugs.
What Are the Eligibility Requirements for Medicare Advantage?
The basic eligibility requirements for Medicare Advantage and Original Medicare are the same, which include the following:
- Based on age most individuals will become eligible at 65.
- Qualified people must also be a U.S. citizen or be a resident of the U.S. for a minimum of 5 years.
- Younger people that have disabilities and people with diseases such as ESRD (End Stage Renal Disease requiring dialysis/kidney transplant) or ALS (amyotrophic lateral sclerosis – Lou Gehrig’s disease).
- Most people qualify for Medicare and are automatically enrolled in Original Medicare if the individual or their spouse has paid Medicare taxes for the last 10 years (40 quarters).
Unlike Original Medicare, Medicare Advantage’s enrollment coverage options are determined by private insurance companies by region. Enrollees must live within the service area of the plan and expect price and coverage variability by location. Some areas may not offer any Advantage plans.
Most will qualify for premium-free Medicare Part A if you or your spouse have paid Medicare taxes while working for 10 years (40 quarters). Those that have not reached that threshold should expect to pay some sort of monthly premium for coverage based on how many quarters you have worked.
For more information on Original Medicare eligibility visit Original Medicare Parts A and B Eligibility.
Who is Not Eligible for Medicare Advantage?
You must be enrolled in Original Medicare to be eligible for Medicare Advantage. If you have Medicare Supplement Insurance (Medigap) you are not eligible to also enroll in a Medicare Advantage plan. However, you can switch from Medigap to Medicare Advantage during the Open Enrollment Annual Election Period which is from Oct 15th to December 7th. If you switched during this time your enrollment in Medicare Advantage would begin January 1st of the following year. Most Advantage enrollees (90%) select plans that have prescription drug coverage. However, in some scenarios individuals can have a Medicare Part D drug plan if their Medicare Advantage plan does not have prescription drug coverage included.
- Medicare Advantage 2022: Premiums and Costs, Kaiser Family Foundation.