Medicare Plan Options
Pennsylvania offers plenty of choices for Medicare coverage, with numerous plans you can enroll in, and in some cases, combine, to fit your health care needs. You can choose basic coverage through Original Medicare and add on optional Medigap or prescription drug plans. You can also get all-in-one, comprehensive benefits through Pennsylvania’s Medicare Advantage program. Here’s a look at how the programs differ.
Original Medicare is the federal government’s basic health insurance plan for seniors. It’s made up of two parts. Part A helps cover stays in hospitals, skilled nursing facilities, and hospices. Part B covers outpatient services, physician visits, diagnostic tests, and preventive health screenings. Original Medicare only covers services that are medically necessary and doesn’t include prescription drugs, eyeglasses, hearing aids, and other supplemental benefits. Your costs typically include monthly premiums, deductibles, and coinsurance each time you receive services. There’s no limit on out-of-pocket expenses.
Medicare Advantage Plans
Medicare Advantage Plans are available through private insurance companies and offer coverage beyond Medicare Parts A and B. The plans cover the same services as Original Medicare and an array of other benefits, including prescription drugs, vision, and fitness memberships. The benefits vary, enabling you to find the right mix for your needs. For example, some Medicare Advantage Plans include basic dental cleanings and X-rays, while others may cover other dental expenses, such as dentures, crowns, and bridges. Insurance companies are given leeway in setting their premiums, deductibles, and coinsurance, but must cap yearly out-of-pocket expenses.
Medicare Prescription Drug Coverage Plans
Part D prescription drug plans help pay for medicine your doctor prescribes for an illness or chronic condition. You can add a standalone Part D plan to your Original Medicare coverage or get a Medicare Advantage Plan that has a prescription drug component. All Medicare Part D plans must cover the same categories of drugs but may stipulate different drugs within each category. Drugs are usually placed into tiers, with lower-tier drugs, such as generic ones, costing the least. You can compare prescription drug plans based on the plan’s drug list, network of pharmacies, and costs.
Medicare Supplement Insurance Plans
Although Original Medicare helps pay for some of your health expenses, you still incur costs, such as Part B premiums, deductibles, and coinsurance. Some Pennsylvanians purchase Medicare Supplement Insurance Plans, also called Medigap, to cover some of these out-of-pocket costs. Health insurance companies can offer 10 different categories of Medigap plans (A, B, C, D, F, G, K, L, M, and N) in Pennsylvania. All plans within the same letter category have similar benefits but different coverage levels. You can only enroll in a Medigap plan if you’re getting your Part A and Part B coverage through Original Medicare.
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 $471 per month*
Plan B: $148.50 per month**
Medicare Resources in Pennsylvania
With so many Medicare options in Pennsylvania, it’s important to take time to make a well-informed decision and get the benefits you need. Here are some state resources for further Medicare information.
APPRISE provides free one-on-one counseling to help Pennsylvanians understand how Medicare works. The statewide phone line provides access to knowledgeable counselors who can answer questions about eligibility, enrollment, and covered services. APPRISE can also assist with comparing plans, filing claims, reviewing your Medicare Summary Notice, submitting appeals, and applying for financial assistance. The helpline is open from 9 a.m. to 4 p.m., Monday to Friday.
Contact Information: Website | 800-783-7067
Philadelphia Corporation for Aging (PCA)
The PCA is Pennsylvania’s largest Area Agency on Aging and provides a broad range of services for seniors. It administers the APPRISE program in Philadelphia, which is staffed with trained counselors who can help you compare Medicare, Medicare Advantage, Medigap, and prescription drug plans. They can also assist with Medicaid enrollment. These free, private counseling services are available through two centers based on where you live in Philadelphia. Visit the PCA website to look up the APPRISE center nearest you based on your zip code or contact the APPRISE statewide helpline.
Contact Information: Website | 800-783-7067
Pennsylvania Insurance Department
The Pennsylvania Insurance Department has online information about a variety of general insurance needs for seniors, including home, travel, health, and life insurance. The website includes an overview of Medicare Advantage, Medicare Supplement Insurance, and Part D prescription drug plans. While the department can’t recommend specific plans, its Consumer Service Bureau can assist with insurance-related questions and help resolve issues or complaints you have with an insurance provider in the state.
Contact Information: Website | 877-881-6388
Pennsylvania Department of Human Services (DHS)
The state’s Medicaid program, called Medical Assistance, is administered through the DHS. Through this program, seniors with limited resources and income may qualify for health care coverage to ensure they get the care they need. Some individuals may qualify for both Medicare and Medicaid. Contact your local County Assistance Office if you have questions about Medical Assistance eligibility or need help completing forms.
Contact Information: Website | 866-550-4355
Pennsylvania Health Law Project (PHLP)
PHLP is a nonprofit law firm that helps Pennsylvanians having difficulty getting or keeping Medical Assistance health care coverage. PHLP’s legal assistance is free and available throughout the state by contacting their helpline. When you call, you’re asked to provide information about your problem, household income, family members, and health issues. You should also be prepared to send copies of documents, such as denial letters and other paperwork.
Contact Information: Website | 800-274-3258