Medicare in Pennsylvania

Medicare is a federal health care program for adults aged 65 and older and younger people with qualifying disabilities. By 2022, 65 million citizens had enrolled in the program, with seniors making up 57.3 million of beneficiaries. Forward to 2023, Pennsylvanians comprise 2.8 million of the cohort, which, according to the latest financial data, costs the Commonwealth of Pennsylvania $15.8 billion annually. However, a growing number of Pennsylvanians are switching to Medicare Advantage. In 2022, 49% had signed up for a plan, rising to 51% the following year. The country’s average is 48%, suggesting Pennsylvanians are slightly keener to move away from Original Medicare.

Medicare’s foundation is Original Medicare, also called Part A and Part B. The former covers essential services, such as hospital stays, blood transfusions, skilled nursing care and limited home health care. The latter covers outpatient services, including primary care physicians, medical transportation, medical equipment and supplies. Most beneficiaries of Part A don’t pay a premium, but, as of 2023, Part B’s recipients must pay $164.90 per month. Medicare Part D provides coverage for prescription drugs. Premiums vary between beneficiaries because several factors influence costs, particularly the individual’s drug prescription and the tier their drugs have been assigned. 

Medicare Advantage, known as Part C, consolidates the coverage provided by Parts A and B into one plan, minus hospice care. As of 2023, Pennsylvanians can choose from 262 plans, 22 more than the previous year. While the Centers for Medicare and Medicaid Services (CMS) administer Original Medicare, approved private insurance companies are responsible for Part C plans. Premiums start at 0%, but they rise as beneficiaries add more coverage, such as hearing, vision and dental care. As a consequence, Pennsylvania’s median monthly premium is $30.05, an 11% reduction on 2022’s average. Seniors concerned about the expenses Medicare doesn’t cover, such as deductibles, co-pays and coinsurance, can enroll in a Medicare Supplement Insurance plan, commonly known as Medigap. 

This guide considers Medicare options in Pennsylvania, including how to tailor plans to suit specific needs. It also lists several resources that can help seniors get the most from Medicare.

Options for Medicare Coverage in Pennsylvania

Original Medicare can be a great choice for many seniors, but it isn’t right for everyone. Pennsylvania seniors have several other options for structuring their benefits in ways that better suit their particular needs. In addition to the basic Medicare program, seniors may be eligible to participate in Medicare Advantage, Medigap and private health insurance designed for seniors.

Original Medicare (Parts A & B)

Original Medicare enables access to the same care services nationwide, including when beneficiaries are vacationing or relocating to another state. However, Medicare rarely pays medical costs outside the United States. Consequently, it’s recommended that Americans traveling to other countries purchase appropriate health insurance before they leave.

Original Medicare beneficiaries must pay an annual deductible, which, as of 2023, is $1,600 for Part A and $226 for Part B. Furthermore, they must pay their medical costs when they receive the service. However, Original Medicare subsequently covers 80% of the fee for eligible services, with the beneficiary covering the remaining 20%. 

Who Should Consider Original Medicare

Original Medicare may be a good option for those who:

• Travel frequently within the United States
• Don’t need extra benefits such as home-delivered meals and coverage for over-the-counter medication
• Want to choose their own prescription drug coverage

Medicare Advantage (Part C)

Original Medicare’s coverage is uniform nationwide, but Medicare Advantage’s flexibility enables personalized coverage. There are five types of plans, each of which can be adapted by approved private insurance companies to ensure their clients get the care services they want at their preferred price point. For example, PFFS plans give beneficiaries wider networks of providers, allowing more choice over who delivers medical care. Conversely, HMO plans have restricted networks, but premiums are often lower. Every plan the insurance company develops must conform to CMS rules and regulations, which are intended to protect consumers and ensure standards are maintained.

Who Should Consider Medicare Advantage 

Medicare Advantage may be a good option for those who: 

• Want to limit out-of-pocket costs 
• Need extra benefits such as vision and dental care 
• Are generally healthy and may benefit from low premiums 
• Are comfortable with managed care 

The Top 10 Medicare Advantage Plans in Pennsylvania 

Pennsylvania seniors live in a state with several highly rated Medicare Advantage plans open to them. The table below lists the top Part C providers according to their enrollment figures. The list gives prices for each provider, which are current as of August 2023. Visit the Medicare Advantage Plans in Pennsylvania page for the most up-to-date information about these plans.

Medicare Prescription Drug Coverage (Part D)

Original Medicare doesn’t pay for most prescription drugs through Part A or B coverage. Instead, seniors purchase separate prescription drug policies, also called Part D coverage. Medicare contracts with private health insurance companies to provide this coverage. There are multiple plans to choose from with varying monthly premiums, which beneficiaries pay in addition to their Original Medicare premiums. While seniors don’t have to purchase prescription drug coverage when they’re first eligible for Medicare, not obtaining this coverage at this time may result in late enrollment penalties they pay for as long as they have Medicare if they enroll later.

Each prescription drug plan has its own formulary, or list of covered drugs. Formularies are typically split up into tiers. The tier a medication is in determines how much the insurance company pays and how much the beneficiary pays for it. Lower-level tiers are usually made up of generic and low-cost brand name drugs, while higher tiers are composed of more expensive brand name and specialty drugs. In most cases, the lower the tier, the lower the policyholder’s cost-sharing responsibility.

Who Should Consider Medicare Prescription Drug Coverage

Seniors who may benefit from prescription drug coverage include those who:

• Currently take prescription medication or expect to in the future
• Want to avoid late enrollment penalties
• Want to reduce out-of-pocket prescription drug expenses

Medicare Supplement Insurance (Medigap)

While Original Medicare provides coverage for many medical costs, seniors may still have significant out-of-pocket expenses. These may include copays, coinsurance and deductibles. Seniors may be able to reduce their cost-sharing obligations by purchasing a Medigap plan. These plans can only be used with Original Medicare. It’s illegal for private insurance companies to sell Medigap plans to those with Medicare Advantage plans.

For more information on Medigap plans, seniors can refer to the Best Medicare Supplement Companies of 2023 page.

Who Should Consider Medicare Supplement Insurance

Good candidates for Medigap may be those who:

• Have ongoing health issues and expenses
• Travel overseas often
• Want to access an expanded network of health care providers
• Expect to need health services not covered by Original Medicare

Medicare Resources in Pennsylvania

Pennsylvania seniors have a lot of options for how to structure their Medicare, Medigap and other health insurance plans. Finding the right programs and successfully applying for coverage can be challenging, especially for seniors navigating the system for the first time. Fortunately, Pennsylvania has several state and private nonprofit resources available to help out. These agencies have trained counselors who can answer questions about health insurance, Medicare in particular, and assist seniors with filing for and structuring their benefits.