Medicare Advantage, also called Medicare Plan C, is private health insurance offered through government-approved companies. Medicare Advantage plans are an alternative to Original Medicare and Medicare supplements. By law, all MA plans include the same hospital, doctor and medical provider benefits as Part A and Part B Medicare. Some MA plans also include Part D prescription drug benefits, plus additional coverage not paid by Medicare such as for vision, dental and hearing services. MA plans cannot be combined with Medicare Supplemental insurance or Medigap. As with Original Medicare, Medicare Advantage enrollment is available to those age 65 or older, and any adult who qualifies for Medicare and Medicaid.
Medicare Advantage adoption has expanded nationwide, rising from 11.1 million members in 2010 to 24.1 in 2020. According to a report from the Kaiser Family Foundation, Medicare Advantage enrollment in Pennsylvania is at 44%, which is 5% higher than the national Medicare Advantage enrollment rate. Pennsylvania’s Medicare Advantage adoption rates are similar to rates in Michigan (45%), Wisconsin (46%) and Alabama (45%). In neighboring New York, 43% of Medicare-eligible seniors have an MA plan, while to the south the MA adoption rate in Maryland is just 13%, and 18% in Delaware.
Seniors in Pennsylvania who are interested in joining Medicare Advantage have over 2,500 plans to choose from. Plan selection and service provider availability varies in each county, and some Medicare Advantage plans include prescription drug benefits. Pennsylvania Medicare Advantage plans include Preferred Provider Organizations (PPOs), Medicare-Medicaid Plans (MMPs) and Health Maintenance Organizations (HMOs). In this guide, we’ve provided details about each type of Medicare Advantage plan available in Pennsylvania and the enrollment process, along with local and state resources that can help seniors explore and understand their Medicaid options.
Pennsylvania seniors who want to purchase private insurance to replace Medicare Plan C can enroll in either a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO). Benefits, co-pays and premiums vary between plans, and plan availability is different in each county. Some Medicare Advantage plans also include prescription medication benefits that are comparable to, or better than, Medicare Part D plans. Dual-eligible seniors and adults with qualifying health conditions must enroll in a Dual-Eligible Special Needs Plan (D-SNP).
Dual-Eligible Special Needs Plans (D-SNPs)
Seniors who are eligible for both Medicare and Medicaid must enroll in a Medicare Advantage Dual-Eligible Special Needs Plan. These plans are designed to reduce service redundancies and costs, while improving overall care coordination and delivery for seniors who are institutionalized. Adults who have a qualifying permanent disability or chronic illness that meets government-regulated eligibility requirements can also enroll in a D-SNP. Prescription medication coverage is included with all D-SNPs.
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations consist of a network of doctors, hospitals, clinicians and medical services that provide contracted medical services to HMO members at a negotiated, reduced rate. HMO plans only cover care delivered through providers in the plan’s network, and members who seek out-of-network care cannot receive reimbursement or partial coverage from their HMO. HMO members must also get a referral from their primary care physician to see a specialist, have medical tests done or qualify for most HMO-covered services. In general, HMO plans are the lowest-priced option for seniors looking to enroll in a Medicare Advantage plan, but may also be the most restrictive.
Preferred Provider Organizations (PPOs)
Preferred Provider Organizations are managed care organizations that deliver medical services through a network of participating providers. In order to pay the lowest possible co-pays and coinsurance fees, PPO members need to seek care from in-network service providers. Unlike HMOs, PPOs do let beneficiaries see specialists directly, without first obtaining a referral from a primary care physician. PPOs also allow their members to access out-of-network care without forfeiting Medicare Advantage coverage altogether, although the PPO co-pays for out-of-network services are higher than for in-network services. When compared to HMO premiums, PPO plans tend to be higher.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
In Pennsylvania, seniors who need prescription drug coverage can either purchase a Medicare Advantage plan that includes drug coverage, or enroll in a separate prescription drug plan. Medicare Advantage plans that include prescription drug coverage may cost more than similar MA plans without drug benefits. As with health care services, HMO Medicare Advantage plans with drug benefits usually only cover prescriptions filled at an in-network pharmacy, while PPO MA plans often provide some coverage for purchases from an out-of-network pharmacy.
While Medicare beneficiaries are not required to enroll in Medicare Part D or an approved plan that offers comparable benefits, seniors who are eligible for drug coverage and decline this coverage then later seek drug benefits may be assessed a lifetime monthly late enrollment penalty. By law, all Medicare Advantage SNPs include Medicare Part D prescription drug coverage.
Navigating the complex and often confusing information about Medicare Advantage plans, premiums, options and exclusions can be overwhelming for seniors, family members and caregivers. To help make the process of picking a Medicare Advantage plan easier, a number of state and local programs are available that offer Medicare counseling, legal assistance and up-to-date, unbiased information about MA plans in each county. Below you’ll find a list of resources that assist seniors with Medicare plan selection, benefits and financing.
Pennsylvania’s APPRISE program is a free Medicare, Medicaid and long-term care insurance counseling program. The program is operated by the Department of Aging, and administered through the statewide Area Agency on Aging network. APPRISE counselors can help seniors understand Medicare eligibility and enrollment criteria, Medicare Part A and B benefits, Medicare Part D prescription drug and Medicare Advantage plans. Seniors can book a one-on-one counseling session with a local APPRISE counselor, or schedule a phone consultation to discuss their specific situation. APPRISE counselors are also available to make presentations to seniors groups and community organizations.
The Center for Advocacy for the Rights and Interests of the Elderly, CARIE, launched the Pennsylvania Senior Medicare Patrol (PA-SMP) in 1997 to combat Medicare abuse, errors and fraud. The PA-SMP works to educate seniors and caregivers about Medicare Advantage scams, overbilling and other issues that can decrease care quality and increase health care costs. The SMP also operates ScamWire, an alert service that notifies seniors, caregivers and support agencies about emerging scams targeting older adults. PA-SMP services are delivered through a network of trained volunteers who give informational presentations to community, faith and seniors groups throughout Pennsylvania. Volunteers also staff information booths at health fairs and public events.
Low-income and isolated seniors aged 60 and older who need legal assistance can contact the Older Pennsylvanians Legal Assistance Program, or OPLAP. This program provides elders with access to free legal services including one-on-one legal advice and representation with civil matters. Seniors who have concerns about Medicare Advantage, Social Security, guardianship, age discrimination or elder abuse can use this program.
Seniors can contact the OPLAP by calling the Pennsylvania Department of Aging at 717-783-1550.
The Pennsylvania Health Law Project, or PHLP, is a nonprofit organization that works to improve access to health care for the elderly, people with disabilities and low-income adults. The PHLP operates a free helpline that seniors can call to connect with a legal advocate who will review the caller’s concerns and provide legal advice. The organization also provides free legal representation to clients who are struggling to pay health care costs, need support obtaining health care services or who have been denied coverage.
Seniors can contact the Pennsylvania Health Law Project by calling the PHLP helpline at 1-800-274-3258.
The Pennsylvania Assistive Technology Foundation (PATF) is a nonprofit organization that works to connect older adults and people with disabilities with affordable assistive technology devices and services. Seniors who need mobility devices and other items that are not fully covered by their Medicare Advantage plan can contact the PATF to learn about low-cost loans for medical equipment, grants and other resources that can be used to supplement their MA plan benefits.
To contact the PATF, call 484-674-0506 or toll free at 1-888-774-1938.
The Vintage Center for Active Adults provides services to Pittsburgh seniors to help elders avoid institutionalization, maintain community connections and stay active. The Center offers a variety of free and low-cost programs that seniors who are considering enrolling in a Medicare Advantage plan can utilize, including preventative screening services, one-on-one health behavior counseling and chronic condition management clinics that can help seniors assess their current and future health insurance needs. The Center also holds regular information sessions to keep seniors up to date on Medicare Advantage plans, regulations and related issues.
To learn more about services available at the Vintage Center for Active Adults, call 412-361-5003.