AHIP Medicare - Module 2 - Medicare Advantage Eligibility

To be eligible to enroll in a Medicare Advantage plan?
A beneficiary must be entitled to Part A and enrolled in Part B.

• The beneficiary must permanently live in the MA plan’s service area. (If a beneficiary spends six months or more outside of the plan’s service area, they should only enroll in MA-PD plans with a visitor/traveler benefit.)

• Be a U.S. citizen or lawfully present in the United State on or before the enrollment effective date. (CMS makes this determination.)

MA plans must enroll any eligible beneficiary who applies regardless of health status.
- Certain special needs plans (SNPs) can limit enrollment to beneficiaries with certain chronic conditions, such as diabetes, chronic heart failure, end-stage renal disease, cancer, HIV, or other specified conditions.

• MA MSA plans, Special Needs Plans, and Employer Group Waiver Plans have additional eligibility requirements.

– An individual who receives health benefits that cover all or part of the annual deductible under the MA MSA plan. Examples include but are not limited to, primary health care coverage other than Medicare, Medicare hospice, certain supplemental insurance policies, and retirement health benefits.

– An individual who is enrolled in a Federal Employee Health Benefits plan or is eligible for health care benefits through the Veteran’s Administration.

– Dual eligible entitled to coverage of Medicare cost-sharing under Medicaid.

– An individual who cannot provide assurances that they will reside in the United States for at least 183 days during the year for which the election is effective.

– An individual who has already elected hospice.

Yes. Medicare Advantage Plans may charge a premium. If the plan charges a premium, beneficiaries must generally continue paying their Part B premium in addition to paying the monthly plan premium to remain enrolled.

Employer group waiver plans (EGWPs) or direct contract plans may only enroll Medicare beneficiaries who are active employees or retirees of the employer or union offering the plan.

A beneficiary’s enrollment in an EGWP must be based on receiving “employment-based” health coverage from an employer/union group health plan sponsor.

Coverage obtained through a professional or another type of group association would not make a beneficiary eligible for an EGWP, except to the extent that the coverage obtained through the association can properly be characterized as “employment-based group health plan coverage.

Medicare Advantage plans may also require their members to pay for a portion of the covered services they receive. This is known as member cost-sharing. There are several potential types of cost-sharing:

• Deductible: A set amount the member must pay for covered services before the health plan begins paying for those services.

• Copayment: A fixed dollar amount per service the member must pay. For example, $20 for each visit to a primary care provider, or $30 for each visit to a specialist.

• Coinsurance: A percentage of the cost of the service the member must pay. For example, 20% of the cost of durable medical equipment.

All Medicare Advantage plans must have a “maximum out-of-pocket” limit (known as the “MOOP”) for Part A and Part B benefits. That is, once the member pays a specified amount of cost-sharing, the health plan covers 100% of covered medical services. Each year CMS specifies a mandatory MOOP, which health plans cannot exceed, although they may have a lower MOOP.

• Each plan’s MOOP will be specified in its summary of benefits and its evidence of coverage.

For 2024, the maximum MOOP limit for Medicare Advantage coordinated care plans and private fee-for-service plans is $8,850, although most plans will have lower limits. PPOs must also have an aggregate MOOP for network and non-network providers of $13,000 in 2024. Again, it is likely that many will have lower limits.