Understand Medicare in Pennsylvania

Medicare, the United States federal medical insurance program, provides coverage for more than 1.5 million people in Pennsylvania who qualify for Medicare.  You can get Medicare if you’re 65 or older or have a qualifying disability.

Your disability typically qualifies if you’ve received at least 24 Social Security or Railroad Retirement Board (RRB) disability insurance payments. You can also enroll in Medicare Advantage Plans if you have End-Stage Renal Disease (ESRD) or amyotrophic lateral sclerosis (ALS).

Most people have premium-free Part A but, if you have to buy it, the cost can reach up to $499 per month in 2022. Part B costs $170.10 per month but can be more if you have higher income.  There are 160 Medicare Advantage Plans in the state that are an alternative to Original Medicare.  Learn more about your Medicare options in Pennsylvania.

Medicare Plans in Pennsylvania

Compare ratings of Pennsylvania’s Medicare plan providers:
Insurance company Medicare rating A.M. Best rating BBB rating NCQA rating J.D. Power ranking
Aetna 4 stars A A+ 2.5 to 4.5 stars 5 out of 10
Cigna 4 stars A- Not rated 2.5 to 4.5 stars Seventh out of 10
Highmark 4.5 stars A A- 2.5 to 4.5 stars Second out of 10
Humana 4 stars A- A+ 1.5 to 4.5 stars Third out of ten
UnitedHealthcare 3.5 stars A- A- 4 stars Fourth out of 10

Medicare Plan Options in Pennsylvania

Residents of Pennsylvania have just two Medicare plans to choose from. Seniors and individuals with disabilities who don’t need much coverage can apply for Original Medicare. Pennsylvania’s Medicare Advantage program might be a better option if you need more comprehensive insurance. Some Medicare policies offer additional prescription drug add-ons or supplementary coverage.

Original Medicare (Parts A and B) Original Medicare is the basic Medicare plan, which is a fee-for-service form of insurance. It has two parts: Part A hospital insurance and Part B medical insurance. Part A covers hospital stays and periods spent at skilled nursing facilities, lab tests an individual has performed, and hospice care. Part B covers doctor’s office visits and home health care services. It may also cover some preventive care, such as screenings for cancers and mental illnesses, including depression. With Original Medicare, you’ll pay a deductible along with your share of the fees incurred during an inpatient or outpatient visit:

  • Original Medicare is a good choice if you want flexibility in choosing and accessing providers that accept Medicare anywhere in the U.S.
  • There is no cap on what you could spend for out-of-pocket expenses, and you must purchase drug coverage separately, so it’s a better choice for you if you don’t need much in the way of health care or prescription drugs.
  • If you don’t purchase a Medigap policy to supplement Original Medicare when you are first eligible, you may not be able to purchase one or may have to pay higher premiums, depending on your health status.
Medicare Advantage Plans (Part C) Medicare Advantage plans, also known as Part C, are an alternative to Original Medicare offered by private insurance companies. These plans include both Part A and Part B coverage, except for hospice care. Most services are provided by network providers, and you may need primary care physicians, referrals for specialists, and prior authorizations for treatment and medications. Medicare Advantage offers additional coverage for essential needs, such as prescription drugs, dental and vision care. Some Medicare Advantage Plans also cover gym memberships and transportation to and from medical appointments. Part C may also pay for adult day care services:

  • Medicare Advantage is a good choice if you want to have all of your health care and drug benefits bundled together in one plan and if you don’t mind being restricted in your choice of providers to save on costs.
  • There is a cap on what you can spend for out-of-pocket Medicare-covered expenses.
  • You also have access to services that Medicare doesn’t cover, like routine dental and vision exams.
Medicare Prescription Drug Coverage Plans (Part D) Many Medicare Advantage policies add Part D drug coverage automatically to their package, but you can also add Medicare prescription drug coverage to Original Medicare. Medicare prescription drug coverage is offered to all Medicare enrollees, but you may have to pay a penalty if you wait to enroll after being initially eligible. Medicare Part D plans may not all cover the same drugs or have the same costs as Medicare Advantage policies. Standalone Part D coverage is provided by Medicare-approved private insurers. Most plans require a deductible and a copay for each prescription drug:

  • Part D is a good choice if you have Original Medicare, or if you have a Medicare Advantage Plan ― not a health maintenance organization (HMO) or preferred provider organization (PPO) ― that doesn’t have prescription drug coverage.
  • You pay a penalty if you wait to enroll in a Part D plan, unless you have creditable coverage from an employer-sponsored group plan.
  • If you don’t require medications now, you can enroll in a low-premium Part D plan to avoid late enrollment penalties later.
Medicare Supplement Insurance Plans (Medigap) Some Pennsylvania seniors purchase a Medicare Supplement Insurance policy, also known as Medigap. These plans are intended to fill in the gaps Original Medicare doesn’t cover. Some of these gaps include medical coverage while overseas, Part A and Part B copays, and excess Part B charges. Medigap doesn’t pay for anything related to Medicare Advantage. You cannot have a Medigap plan and a Medicare Advantage Plan at the same time.

  • Medigap is a good choice if you have Original Medicare and want help paying for out-of-pocket expenses you incur when you access your Part A and Part B benefits.
  • You pay a monthly premium, and most copays and coinsurance costs are covered.
  • If you have significant health care needs, want the freedom to see any Medicare provider without network restrictions, a Medigap plan offers predictable coverage and costs for Medicare-covered care.
  • Medigap doesn’t cover prescription drugs or other benefits like dental and vision.

Medicare in Pennsylvania by the Numbers

People enrolled in Original Medicare  Average plan cost Annual state spending per beneficiary Spending per beneficiary compared to the national average
1,535,135 Plan A: $0 to $499 per month*

Plan B: $170.10 per month**

$10,149 -1.00%

*Most people pay no premium, but this can vary depending on how long they paid Medicare taxes.
**This is the average number, but it can vary based on income.

Medicare Resources in Pennsylvania

Getting support can help when you’re making Medicare decisions. Pennsylvania has numerous locations where enrollees can receive help through the Pennsylvania Department of Aging and other local resources.

Pennsylvania Department of Aging (PDA)

The Pennsylvania Department of Aging (PDA) provides numerous resources for state seniors, including senior community centers, adult day centers, caregiver support, protective services and resources for reporting elder abuse. It also sponsors the state’s Area Agencies on Aging, which can help you find more local programs and services in your area.

Contact information: Website | (717) 783-1550

Pennsylvania Department of Human Services (DHS)

The Pennsylvania Department of Human Services (DHS) administers the state’s Medicaid program, called Medical Assistance. The program provides qualifying seniors who have limited resources or low income with health coverage. If you qualify for both Medicaid and Medicare, the two programs can work together to provide you the optimum health coverage. Local county offices are available throughout the state to answer your questions about eligibility or completing the applications.

Contact information: Website | (866) 550-4355

Pennsylvania Health Law Project (PHLP)

The Pennsylvania Health Law Project (PHLP) is a nonprofit providing free legal assistance to Pennsylvanians who need help getting or keeping Medical Assistance health coverage. You can contact PHLP by calling their helpline. Be prepared to answer questions about your family size, income and health issues and to provide copies of your health coverage documents.

Contact information: Website | (800) 274-3258

Pennsylvania Insurance Department

The Pennsylvania Insurance Department provides online insurance information for seniors, including health insurance. You can see an overview of the available Medicare Supplement Insurance, Medicare Advantage and prescription drug plans available on their website. The Consumer Service Bureau can also answer your insurance-related questions and help you resolve complaints with state insurance providers, although they won’t comment on specific plans.

Contact information: Website | (877) 881-6388

Pennsylvania Area Agencies on Aging

Supported by the Pennsylvania Department of Aging, Pennsylvania Area Agencies on Aging advocates for local seniors and helps to develop community-based long-term care services for older adults in the area. They provide services to seniors living within the county and serve as resource connections to help you find the programs and services you need.

Contact information: Website | (717) 783-1550

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