Optima Medicare (PPO)
Eligibility Requirements
Original Medicare Eligibility Requirements
To be entitled to original Medicare, you must be a U.S. citizen or have been a permanent legal resident for five continuous years, and also must answer yes to at least one of the following questions:
- Are you age 65 years or older and eligible to receive Social Security benefits?
- Are you under 65, permanently disabled and have been receiving Social Security disability insurance payments for at least two years?
- Do you receive continuing dialysis for permanent kidney failure or need a kidney transplant?
- Do you have Amyotrophic Lateral Sclerosis (ALS — Lou Gehrig’s Disease)?
Medicare Advantage Eligibility Requirements
You can generally join a Medicare Advantage Plan if you meet these conditions:
- You have Part A and Part B
- You live in the service area of the plan
- You don’t have End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
If you have ESRD (permanent kidney failure requiring dialysis or a kidney transplant) and you have Original Medicare, you may join a Medicare Prescription Drug Plan. However you usually cannot join a Medicare Advantage Plan:
- If you are already in a Medicare Advantage Plan when you develop ESRD, you can stay in it or join another plan offered by the same company under certain circumstances;
- If you have an employer or union health plan or other coverage offered by a company that offers Medicare Advantage Plans, you may be able to join one of the plans; or
- If you have had a successful kidney transplant, you may be able to join a Medicare Advantage Plan.
For more information about ESRD, download the booklet “Medicare Coverage of Kidney Dialysis and Kidney Transplant Services.”
Important Note: Federal Government rules require that if you join a Medicare Advantage Plan like Optima Health, and you want Medicare prescription drug coverage, you must get that drug coverage from your Medicare Advantage Plan. Government rules do not allow you to join Optima Medicare Preferred or Optima Medicare Value and get your Medicare drug coverage from a stand-alone prescription drug plan.
In addition, Medicare has special rules that dictate when you can join, change or leave a Medicare Advantage Plan.
For more information, see our enrollment information.
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