Medicare Advantage Plans for People Under 65

Who can get Medicare Advantage before turning 65

You can enroll in a Medicare Advantage plan before 65 if you have End-Stage Renal Disease (ESRD), ALS (amyotrophic lateral sclerosis), or have been receiving Social Security Disability Insurance (SSDI) for at least 24 months. These are the only three paths to Medicare before 65, and each has different timing rules for when you become may be able to access.

If you have ESRD, you become may be able to access for Medicare the first day of the month you start dialysis or get a kidney transplant, regardless of age. If you have ALS, you skip the usual 24-month waiting period and become may be able to access immediately. If you receive SSDI, you become may be able to access after 24 months of receiving benefits — the clock starts from the month your benefits began, not from when you applied.

Medicare Advantage is one of two ways to receive Medicare benefits (the other is Original Medicare with a Medigap supplement). Unlike Original Medicare, Advantage plans are run by private insurance companies and bundle hospital, medical, and usually prescription drug coverage into one plan.

Key Takeaways

• You can join Medicare Advantage before 65 only if you have ESRD, ALS, or have been on SSDI for 24 months.
• Medicare Advantage plans are run by private insurers and include hospital, doctor, and usually drug coverage in one plan, with a network of providers you must use.
• Plans vary by region and change every year, so you will need to check what is offered in your area and compare costs and networks annually.
• You can switch plans once a year during the Annual Enrollment Period (October 15 to December 7), or immediately if you have a may have access to life event.
• Costs include a monthly premium, copays for visits and services, and an annual out-of-pocket maximum that caps what you pay in a year.

How Medicare Advantage differs from Original Medicare

Original Medicare is run by the federal government and covers hospital stays (Part A) and doctor visits (Part B) with no network restrictions — you can see any provider who accepts Medicare. Medicare Advantage is run by private insurance companies and requires you to use doctors and hospitals in their network, with some exceptions for emergencies.

Original Medicare does not include prescription drug coverage or dental, vision, or hearing benefits. Most Medicare Advantage plans include all of these, though the coverage and copays vary by plan. If you choose Original Medicare, you would need to buy a separate Medigap policy to cover costs Medicare does not pay, and a separate Part D plan for prescriptions.

Medicare Advantage plans have an annual out-of-pocket maximum — once you reach it, the plan pays 100% of covered services for the rest of the year. Original Medicare has no out-of-pocket maximum, which means costs can be unpredictable if you need a lot of care. For people with chronic conditions or high medication costs, an Advantage plan's maximum can provide more financial protection.

What costs you will pay with Medicare Advantage

Every Medicare Advantage plan has a monthly premium, which is the cost to enroll. This premium varies by plan and by region. Some plans have a $0 premium, but you still pay the standard Medicare Part B premium to Medicare itself (this amount changes yearly and is deducted from your Social Security check if you receive benefits).

Beyond the premium, you pay copays when you use services — typically $10 to $50 for a doctor visit, more for specialists or hospital stays. You also pay a portion of prescription drug costs, which may be a copay or a percentage of the drug's cost depending on the plan and the drug's tier. Preventive services like annual checkups and screenings are usually covered at no cost.

Each plan has an annual out-of-pocket maximum, which is the most you will pay in copays and coinsurance in a year. Once you reach it, the plan covers 100% of covered services for the rest of that year. Out-of-pocket maximums vary by plan but are capped by Medicare at a certain amount each year.

How to find and compare plans in your area

Medicare Advantage plans are only available in certain geographic areas, and the plans offered change every year. To see what plans are available where you live, visit Medicare.gov and use the plan finder tool, or call 1-800-MEDICARE. You will need to enter your zip code to see local options.

When comparing plans, look at the monthly premium, the copays for the services you use most often, whether your doctors are in the network, and the prescription drugs covered. Many plans have a formulary (a list of covered drugs) that you can view online or request by phone. If a drug you take is not on the formulary, ask the plan if they will cover it or if there is a similar drug they do cover.

You can also contact plans directly to ask questions about their network, coverage, or costs. Most plans have customer service phone numbers on their websites. Some people find it helpful to call 2-3 plans to compare before deciding.

When you can enroll and switch plans

If you are newly may be able to access for Medicare (because you just started dialysis, were diagnosed with ALS, or reached 24 months on SSDI), you have a 3-month window to enroll in a plan. This window starts the month you become may be able to access. If you miss this window, you may have to wait until the next Annual Enrollment Period, which runs from October 15 to December 7 each year.

Once you are enrolled in a Medicare Advantage plan, you can switch to a different plan or to Original Medicare during the Annual Enrollment Period. Changes take effect January 1 of the following year. If you have a may have access to life event — such as moving out of your plan's service area, losing employer coverage, or experiencing a major change in income — you may be able to switch plans outside the enrollment period.

To enroll or switch plans, you can go online at Medicare.gov, call 1-800-MEDICARE, or contact the plan directly. Some plans also have local enrollment events or agents who can help you in person.

What happens if you move or your plan changes

Medicare Advantage plans have service areas, usually defined by county or region. If you move outside your plan's service area, your coverage ends and you have 60 days to enroll in a new plan where you live. This counts as a may have access to life event, so you can switch plans immediately rather than waiting for the Annual Enrollment Period.

Even if you stay in the same area, plans change every year. A plan you are in may change its premium, copays, network, or covered drugs. Medicare sends you a notice in the fall listing any changes to your current plan. If the changes are significant, you may want to compare other plans during the Annual Enrollment Period and switch if a different plan better fits your needs.

Some plans are discontinued entirely. If your plan ends, Medicare will notify you and you will need to choose a new plan. You have until December 7 to enroll in a new plan for coverage starting January 1.

Frequently Asked Questions

Can I switch back to Original Medicare after I choose Medicare Advantage?

Yes, you can switch to Original Medicare during the Annual Enrollment Period (October 15 to December 7) or if you have a may have access to life event. If you switch to Original Medicare, you will need to buy a Medigap policy and a Part D prescription drug plan separately. Some Medigap policies have waiting periods for pre-existing conditions, so ask about this before you switch.

What if my doctor is not in my plan's network?

You can usually see an out-of-network doctor, but you will pay more — either a higher copay or a percentage of the cost. Emergency care is covered in-network rates even if you go to an out-of-network hospital. If your main doctor is not in any local plan's network, that is a good reason to compare plans or consider Original Medicare instead.

Do Medicare Advantage plans cover mental health services?

Yes, Medicare Advantage plans must cover mental health services, including therapy and psychiatric care. However, copays and the number of covered visits vary by plan. Check your plan's coverage details or call the plan to ask about mental health benefits before you enroll.

What if I cannot afford the monthly premium?

If your income is low, you may be able to get help paying your Medicare premiums through the Medicare Savings Program, which is run by your state. You can also ask the plan if they have financial assistance programs. Contact your local Medicaid office or call 1-800-MEDICARE to learn about programs in your state.

Can I have both Medicare Advantage and Medigap coverage?

No, you cannot enroll in both at the same time. If you have Medigap and want to switch to Medicare Advantage, you will need to drop the Medigap policy first. If you later switch back to Original Medicare, you may be able to re-enroll in Medigap, though some policies have waiting periods for pre-existing conditions.