Qualifying for a Medicare Advantage Plan

You can generally qualify for a Medicare Advantage plan if you meet these conditions:

  • You have Medicare Part A and Part B coverage.
  • You live in an area serviced by the plan you want to join.
  • You do not have End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

NOTE:  Many plans include medicare prescription drug coverage (Part D). If the plan provides this coverage, it is called a Medicare Advantage Prescription Drug (MAPD) plan.


Initial Enrollment Period (IEP)--available when you first become eligible for Medicare after reaching age 65, or qualifying because of a disability.  IEP is a seven (7) month period that begins three (3) months before, and ends three (3) months after your birth/eligibility month.

Annual Election Period (AEP)-- general time period each year when you can make changes to your coverage for the upcoming year. Again in 2014, this period will begin on October 15th and end of December 7th.

Annual Disenrollment Period (ADP)-This period begins on January 1st and ends on February 14th.  

Special Enrollment Period (SEP)-You may also make changes to your Medicare coverage options at any time when certain circumstances apply, such as:

  • Coming off an Employer Group Health plan
  • Moving out of a plan area

For more enrollment periods and situations, please go to:

Medicare Enrollment Periods


Premium.  If you join a Medicare Advantage plan, you will continue to pay your Part B premium and your Part A premium, if you have one. The plan may also charge its own premium, although some Medicare Advantage Plans do not.  Premiums for Medicare Advantage plans vary widely.

Deductible.  Some plans charge deductibles, and some do not. LOOK AT AND REVIEW THE PLAN FOR SPECIFIC DETAILS.


Coinsurance.  Medicare Advantage plans set their own terms about coinsurance.  LOOK AT AND REVIEW THE PLAN FOR SPECIFIC DETAILS.

Maximum out-of-pocket limits.  All Medicare Advantage plans protect you from high cost sharing by limiting the amount you will have to spend each year.  Original Medicare Parts A and B DON NOT have this feature.

Need Plan/Company Information?


Medicare Advantage plans are usually referred to as Medicare Part C. They are Medicare-approved private health insurance plans for individuals eligible for Medicare. When you join a Medicare Advantage plan, you are still in the Medicare program.  

What is a Medicare Advantage plan?

A Medicare Advantage plan, also referred to as a Medicare Part C or MA plan, is an additional health plan option offered to those eligible for Original Medicare (Part A and Part B). Unlike Medigap insurance, MA plans do not offer supplemental coverage. Instead, these plans are a private insurance alternative to Original Medicare. 

When you join a Medicare Advantage plan, you are still in the Medicare program, and you are still required to pay your monthly Part B premium; however, your Medicare services are covered through this one plan, and are not paid for under Original Medicare.

What does a Medicare 
Advantage plan cover? 

Medicare Advantage plans provide all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage and must cover medically necessary services, emergency and urgent care. 

They generally offer additional benefits, such as vision and dental, as well as membership to health and wellness programs.  

Most include Medicare Part D prescription drug coverage. These plans often have networks, which mean you may have to see certain doctors and go to certain hospitals in the plan’s network to get care.

What Providers Can You See?
The terms of these plans vary. In some plans, your health care is “coordinated.” That means the plan coordinates your coverage through a primary care physician who manages the care you receive from specialists and hospitals. You may have to choose specific doctors and hospitals. In other plans, you can get care from any Medicare eligible provider who accepts the terms, conditions and payment rates of the plan before providing coverage. 

Doctors and hospitals can decide whether or not to accept those terms, conditions and payment rates each time they furnish covered services. 

All Medicare Advantage plans have “service areas.” These are areas, typically a county, state or region, where they offer coverage. Generally, you must live in a plan’s service area in order to join it. However, all Medicare Advantage plans must offer nationwide coverage for emergency care, urgent care (care provided outside a doctor’s office or emergency room for conditions that require immediate attention) and renal dialysis. 

Services Not Covered

Medicare Advantage plans must cover the same services as Medicare Parts A and B, except they don’t provide hospice care, which is still covered by Original Medicare. You can keep your Medicare Advantage plan and receive hospice at the same time. Your Medicare Advantage plan covers your health benefits not related to your hospice care. Look at the plan details to see what other exclusions from coverage it might have. Plans that include drug coverage may have restrictions related to that coverage.


Medicare Advantage (MA) plans often offer more benefits than Original Medicare and may have lower out-of-pocket costs. Your health insurance rate and out-of-pocket costs will depend on the particular MA plan selected. Some plans charge monthly premiums, and many plans have an annual deductible. Other costs include copayments for each doctor or hospital visit, and premiums for optional benefits, such as vision, hearing, and/or dental coverage.


Even if you enroll in a Medicare Advantage plan, you are still required to pay monthly premiums for Medicare Part B coverage. Part B premiums must be paid directly to Medicare. The monthly cost may increase based on your annual household income from two years prior.

In addition to the Part B premium, Medicare Advantage plans often charge a monthly premium for coverage. Some plans may even offer a $0 premium Medicare Advantage plan; however, in these plans, you may be responsible for higher cost sharing. A detailed comparison of the plans available in your area will help you control your Medicare costs.

Annual deductibles

Some Medicare Advantage plans require you to meet an annual deductible before your coinsurance takes effect. These deductibles vary by plan, with higher annual deductibles often meaning lower monthly plan premiums.


Medicare Advantage copayments can vary drastically between plans. Some plans charge copayments for doctors’ visits, hospital stays, ambulance rides, and/or visits to the emergency room. Copayments are sometimes structured on a two- or three-tier system, in which visits to your primary care physician have lower copayments than a visit to a specialist. Emergency care copayments, if applicable, are often the most expensive. A detailed review of your particular Medicare Advantage plan will explain your plan’s particular copayments structure.

Prescription Costs

Medicare Advantage plans that include prescription drug coverage will have a formulary, which is a list of covered prescriptions. The formulary places prescriptions into tiers, with generic prescriptions generally located in the lowest one. The lowest-tiered prescriptions are typically cheaper than the drugs located in the higher tiers.  Extra Help is available and provides assistance with prescription drug-related costs for Medicare consumers who have limited income and resources.  Our LIS/EXTRA HELP page will show you the eligibility requirements and how to apply!

Spending limits

Maximum Out-Of-Pocket (MOOP)

Another aspect that affects your health insurance rates and how much you pay for services under a Medicare Advantage plan is each plan’s Maximum Out-Of-Pocket (MOOP) limit. The MOOP refers to the maximum amount of money you can pay out-of-pocket each year for health care services, and this amount can vary between plans.

It is important to note that most annual out-of-pocket spending limits apply only to in-network Medicare providers. If you choose to go out of network for services, you may either be subject to a higher out-of-network MOOP limit or your payments may not be figured into your annual expenditures at all.

Medicare Advantage plans can save you money, because out-of-pocket costs in these plans can be lower than with Original Medicare alone. However, your cost will vary by the services you use and the type of plan you purchase. Each Medicare Advantage plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or can use only doctors, facilities, or suppliers in the network).

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