Medicare in Pennsylvania

U.S. seniors can turn to the federal Medicare program as the first stop for their health insurance and health care needs. As of 2020, this program insures more than 2.7 million seniors and disabled adults in Pennsylvania and helps seniors manage the cost of inpatient, outpatient and prescription drug services. In 2020 alone, the federal government spent $829.5 billion on Medicare benefits, which the Centers for Medicare & Medicaid Services (CMS) expects to increase every year until 2030 as the U.S. senior population grows.

Seniors can access Medicare benefits along two main pathways: Original Medicare and Part C. Under Original Medicare, Part A provides inpatient hospital coverage for eligible seniors, generally without a monthly premium. This coverage is automatically issued to seniors when they become eligible for it. Part B is Original Medicare’s outpatient support. This optional plan pays most of the cost for office visits, medical appliances and some transportation. In 2022, the monthly premium for Part B is $170.10.

Medicare Advantage is a popular alternative approach to Medicare benefits. Sometimes called Part C, Medicare Advantage plans are available throughout Pennsylvania through private insurance providers. These plans combine the benefits of Parts A and B, and often offer extra benefits, such as prescription drug assistance, dental and vision care. Especially attractive, many Part C plans come with an annual out-of-pocket cap on costs, which is helpful for many seniors on fixed incomes.

This guide goes over Medicare options in Pennsylvania. It gives an overview of the benefits available, and it lists helpful resources seniors in the Keystone State can access to get help making informed decisions regarding their health insurance.

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 is administered by the Centers for Medicare & Medicaid Services and is open to seniors aged 65 and over, along with those under 65 years old, but with certain disabilities or end-stage kidney disease. It includes two parts. Part A covers inpatient hospital care, nursing home and skilled nursing care, hospice and home health care. Part B, or medical coverage, pays for medically necessary goods and services such as durable medical equipment, mental health services and emergency medical transportation. 

Unlike most private Medicare plans, Original Medicare’s provider network isn’t limited to the beneficiary’s geographic region, making it easier to obtain services while traveling within the country. In most cases, Medicare doesn’t pay for health services the individual receives outside the United States. 

Under this program, seniors pay for services as they receive them. They must pay an annual deductible, which is $1,556 for Part A and $233 for Part B in 2022. After they’ve paid this amount, Medicare covers all eligible services at 80%. Beneficiaries pay the remaining 20% out of pocket.

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)

Medicare Advantage, sometimes called Part C, is an alternate path to accessing Medicare benefits for many seniors. Insurance companies licensed to operate in Pennsylvania issue Medicare Advantage plans, and the state Department of Insurance regulates the plans they offer. Authorized plans combine nearly all of the benefits of Original Medicare Parts A and B, except for hospice care, into a single plan with one monthly premium. This is the required minimum coverage offered, but issuers are allowed to add additional services with their plans. Common Part C benefits include prescription drug assistance, dental and vision care and even wellness programs to help keep seniors healthy.

The program organizes Medicare Advantage plans into four plan types: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee-for-Service (PFFS) plans and Special Needs Plans (SNPs). These plans vary in their coverage limits, rules for seeing specialists and requirements for primary care.

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 April 2022. 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 2022 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.