Core requirements for Medicare Advantage eligibility
Enrolling in a Medicare Advantage (MA), or Part C, plan allows people with Medicare to get their Part A (hospital) and Part B (medical) benefits through a private insurance company approved by Medicare. To qualify, you must meet three primary criteria:
Enrollment in Original Medicare (Parts A and B)
The most important requirement is that you must first be enrolled in both Original Medicare, which includes Part A and Part B. A Medicare Advantage plan is an alternative way to receive these benefits, not a replacement.
- Medicare Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing facility care, hospice care, and home health services. Eligibility is often premium-free if you or your spouse paid Medicare taxes through work for a sufficient period.
- Medicare Part B (Medical Insurance): Covers medically necessary services, outpatient care, and some preventive services. A monthly premium is required.
It is essential to continue paying your Part B premium even if you enroll in a $0 premium Medicare Advantage plan, as the MA plan premium is in addition to the Part B premium.
Living within the plan's service area
Medicare Advantage plans are offered by private insurers and have defined service areas, usually by county. You must reside within a plan's specific geographic service area to be eligible. Plan availability depends on your location, and moving out of a service area generally requires enrolling in a new plan during a Special Enrollment Period (SEP).
U.S. citizenship or lawful presence
To enroll in any Medicare plan, you must be a U.S. citizen or lawfully present in the United States.
Important enrollment periods
You can only join, switch, or drop a Medicare Advantage plan during specific times of the year. These include an Initial Enrollment Period around your 65th birthday, the Annual Enrollment Period (October 15 to December 7), the Medicare Advantage Open Enrollment Period (January 1 to March 31), and Special Enrollment Periods for qualifying events.
Understanding different plan types and specific requirements
Medicare Advantage offers various plan types with different structures and requirements, such as HMOs, PPOs, and Special Needs Plans (SNPs). Each plan type has differing rules regarding networks, referrals, and cost-sharing.
Dual-Eligible Special Needs Plans (D-SNPs) in 2026
For individuals with both Medicare and Medicaid, eligibility rules for D-SNPs are being updated for 2026, impacting assessment timeframes and care plans. Changes also affect those with partial Medicaid or Qualified Medicare Beneficiary (QMB) status.
Potential hurdles to enrollment
Potential challenges include having End-Stage Renal Disease (ESRD) (though enrollment is possible since 2021), missing enrollment periods, or having existing coverage like a Medigap policy, as you cannot have both MA and Medigap simultaneously.
How to proceed with enrollment
Eligible individuals can enroll by contacting an insurance company, using the Medicare Plan Finder on Medicare.gov, or calling 1-800-MEDICARE. Comparing plans based on network, benefits, and costs in your area is recommended. For official details, visit the official Medicare website.
Conclusion
Understanding what are the requirements to qualify for Medicare Advantage is crucial for making an informed enrollment decision. Meeting criteria like having Original Medicare Parts A and B, living in the plan's service area, and enrolling during the correct period are key.
