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

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Medicare Part C, or Medicare Advantage, provides an alternative way for individuals with Medicare Parts A and B to receive their benefits.

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

The plans feature either the same or, in many cases, a superior level of coverage as Medicare Parts A and B. Medicare Advantage plans often have additional benefits, such as routine vision care, hearing aids, dental care, or gym membership.

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

In general, a person must meet two eligibility requirements to qualify for Medicare Part C:

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

People can enroll in Original Medicare if they are 65 years of age or older and are a citizen of the United States or have been a legal permanent resident for at least 5 years.

Specific rules apply to those younger than 65 who have certain illnesses or disabilities. Read more about eligibility under the age of 65 here.

People with certain illnesses may be entitled to Medicare Parts A and B but not be eligible for Part C.

These illnesses include:

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

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

They must also be a U.S. citizen or have been a legal permanent resident for at least 5 years.

These are the most common types of Medicare Advantage plans:

Health Maintenance Organization

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 in emergencies.

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

Many people find that an HMO plan is less expensive than other Medicare Advantage plans.

Preferred Provider Organization

As with HMO plans, Preferred Provider (PPO) plans use a network of healthcare providers. However, an individual does not need to select a PCP to coordinate their care. They are free to see specialists without referrals.

Generally, a PPO offers coverage even if the insured person uses a healthcare 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 who have particular health needs. The eligibility criteria for an SNP depends 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 Private Fee-for-Service (PFFS) plans use a network of contracted healthcare providers 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 out.

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

Medical Savings Accounts

A Medical Savings Account (MSA) plan allows the insured person to choose their healthcare services and providers.

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 from 3 months before a person turns 65 and lasts for 7 months. During this enrollment period, a person can enroll in:

• Medicare Parts A and B
• Medicare Part C (Medicare Advantage)
• Medicare Part D

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

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

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 or special enrollment period (SEP) is when someone can change their Medicare Advantage coverage outside of the official AEP or IEP.

When certain qualifying events happen, such as moving to a new area or losing existing insurance coverage, this triggers an SEP.

There are various rules and approved reasons that affect what changes an individual can make to their Medicare coverage.

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, or Medicare Advantage, provides equivalent coverage to Original Medicare with some additional benefits.

Some people find that a Medicare Advantage plan works out cheaper 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.