Medicare Advantage Plans In Pennsylvania

Fact Checked
Published: 5/16/2021

Slightly different than Original Medicare, Medicare Advantage, or Medicare Part C, is a component of the federal health care program for seniors and disabled. Unlike Original Medicare, Medicare Advantage is managed by private health care insurance companies. While it must provide the same coverage as Original Medicare Parts A and B, Medicare Advantage usually offers additional coverage not included in Original Medicare, such as dental, vision, and prescription drugs.





  • In 2019, there were 160 Medicare Advantage Plans available in Pennsylvania.
  • 40% of the total Medicare population in Pennsylvania is enrolled in Medicare Advantage Plans as of 2018.
  • In 2018, Original Medicare spent an average of $10,149 per beneficiary in Pennsylvania, which is 1% higher than the national average.
  • Available Medicare Advantage Plans range from 33 to 81 across Pennsylvania’s 67 counties.

If you’re currently enrolled in Original Medicare, you can switch to Medicare Advantage during one of the designated enrollment periods. There are several types of Medicare Advantage Plans with different levels of copays, premiums, and deductibles. Your ability to select a particular program depends on where you live and the Medicare Advantage Plans offered.

Medicare Advantage Plans in Pennsylvania

Types of Medicare Advantage Plans

Pennsylvania’s Medicare Advantage program offers a broad range of options for seniors, including HMO, PPO, PFFS, and SNP plans. Keep in mind that you can only select a plan that’s available in the county where you live, regardless of how good a plan in the county next door sounds.

Health Maintenance Organizations (HMO)

The most popular Medicare Advantage Plans in Pennsylvania, HMO plans require you to obtain your care from the plan’s in-network providers, get referrals to see specialists, and choose a primary care physician. You’ll pay less for your health care than with other plans. In some cases, you’ll need to continue paying premiums for Medicare Part B and Part A if applicable. Some, but not all, HMO plans include prescription drug coverage.

Preferred Provider Organizations (PPO)

More flexible than HMO plans, PPOs offer you the option of using out-of-network health care providers. You won’t need referrals to see a specialist, nor do you need to choose a primary care physician. However, you’ll pay more for these services than when you use the plan’s in-network doctors and hospitals. Most PPO plans offer prescription drug coverage and cover the costs of vision, hearing and dental appointments.

Private Fee-For-Service Plans (PFFS)

Under a PFFS plan, the insurance company decides how much it, and you, pay for your coverage. You can use any health care provider who will accept your PFFS plan. Not every provider will accept your plan, although all are required to in emergencies. Most PFFS plans offer prescription drug coverage, but if yours doesn’t, you can purchase a separate Medicare Part D plan without a penalty.

Special Needs Plans (SNP)

SNPs are designed (including benefits, access to providers, and drug coverage) to best suit the needs of a specific group. These plans are limited to people who are eligible for both Medicare and Medicaid, have a specific illness or disease, or live in an institution, such as a nursing home. Most Special Needs Plans require you to select a primary care physician and get a referral to see a specialist. These plans are required by law to provide prescription drug coverage.

Enrollment and eligibility For Medicare Advantage Plans In Pennsylvania

Eligibility

To qualify for Medicare or Medicare Advantage in Pennsylvania, you must be aged 65 or older or have a qualifying disability, be a U.S. citizen or a permanent resident for the past five years, and be enrolled in Original Medicare’s Part A and Part B but not in Medigap. Starting in 2021, seniors with end-stage renal disease (ESRD) can select a Medicare Advantage Plan.

Enrollment periods

You can enroll in a Medicare Advantage Plan or switch between plans during certain enrollment periods throughout the year, including:

  • Initial enrollment period. This period starts three months before your 65th birthday, includes your birth month, and continues for three months after your birthday.
  • Open enrollment period. From October 15 to December 7, you can switch from Original Medicare to a Medicare Advantage Plan, or vice versa. You can also switch between different Medicare Advantage Plans.
  • Medicare Advantage open enrollment period. During this period, which runs from January 1 to March 31, you can switch between Medicare Advantage Plans or return to Original Medicare. However, you cannot move from Original Medicare to a Medicare Advantage plan. If you haven’t signed up for Medicare Part B in the past, you can do so during this period and then select a Medicare Advantage Plan between April 1 and June 30 with coverage starting on July 1.

You are eligible for a special enrollment period if you change jobs, lose your job or move to a new coverage area.

Prescription drug coverage

Many HMO and PPO plans already include prescription drug coverage, but you may be required to pay a separate premium. If the price is included, that plan may be more expensive than others.

HMO and PPO plans that don’t include prescription drug coverage forbid plan members from purchasing a separate Medicare Part D drug plan. HMOs and PPOs will expel members who do this and return them to Original Medicare. Most PFFS plans include prescription drug coverage, but if your plan doesn’t, you can purchase a separate Medicare drug plan. SNPs are legally required to provide prescription drug coverage.

Medicare Advantage Resources in Pennsylvania

Navigating your way through Medicare or Medicare Advantage can be confusing and frustrating. Fortunately for Pennsylvania seniors, several organizations provide free counseling, giving you an overview of your options and helping you find a Medicare Advantage Plan to suit your needs. For example, every county in Pennsylvania has a local Area Agency on Aging, a federally mandated organization in every state that provides seniors with a variety of programs, including counseling on health care issues.

APPRISE (SHIP) — Medicare Counseling

Senior Pennsylvanians in need of counseling about their Medicare or Medicare Advantage options can turn to the APPRISE program. You can discuss your options with specially trained counselors free-of-charge. These counselors can provide objective information about Medicare, Medicare Advantage, Medicare Supplemental Insurance, Medicaid and Long-Term Care Insurance.

Contact Information: Website | 800-783-7067

Area Agency on Aging – Pennsylvania Department on Aging

The Pennsylvania Department on Aging serves as the primary conduit for the state’s various Area Agencies on Aging (AAA). The AAA provides many services for senior Pennsylvanians, including consultation on Medicare and Medicare Advantage plans. The Department on Aging offers a locator, so you can find your local AAA.

Contact Information: Website | 717-783-1550

Pennsylvania Insurance Department

While Medicare and Medicare Advantage are federal programs, some of these programs are regulated by both federal and state agencies. In the case of the Pennsylvania Insurance Department, this includes overseeing brokers who sell Medicare coverage and the regulation of Medigap plans. If you’re interested in finding out who can sell Medicaid Advantage Plans in your county, check with the department.

Contact Information: Website | (717) 787-7000

Medicare Rights Center

The Medicare Rights Center is a source of independent information on Medicare and Medicaid Advantage for all Americans, including senior Pennsylvanians. The center offers counseling for seniors, their families, or their caregivers to help them navigate and understand the various Medicare and Medicare Advantage options available.

Contact Information: Website | 800-333-4114

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