If you’re thinking about getting private Medicare cover in Pennsylvania, finding an affordable plan with the right cover for you or your family can be hard.
This article will help you navigate your private health care options, show you how to choose the best private health plan, and guide you through Medicare Advantage in Pennsylvania.
The federal government's Medicare program provides health coverage to people over 65, people with disabilities, and those suffering from ESRD (End-Stage Renal Disease) and ALS (Lou Gehrig's disease).
Medicare is divided into "parts" that separate medical expenses and coverage for services, tests, and items.
Medicare Part A insurance covers hospital expenses and is for treatment you receive as an inpatient.
Medicare Part B insurance pays for outpatient or general medical expenses as well as preventative services.
Medicare Advantage (Medicare Part C), is private health insurance that offers the same coverage as Original Medicare along with added coverage and benefits.
These plans often have prescription drug benefits and hearing, dental, and vision coverage.
Medicare Part D covers self-administered prescription drugs. For example, medication for blood pressure or chronic conditions such as diabetes.
Original Medicare is government-run medical insurance that assists with Medicare Part A and Part B medical costs. When you sign up for Medicare, you’ll automatically join Original Medicare.
Medicare Supplement Insurance provides members additional coverage for out-of-pocket costs that Original Medicare doesn’t cover.
Part D Plans, also known as Prescription Drug Plans (PDPs), are stand-alone drug plans that cover prescription drug costs.
Monthly Premium is a fee you pay to be a member of Part D drug plans, Medicare Advantage, or Medicare Supplement Plans.
Deductibles are amounts that beneficiaries have to pay before their Medicare insurance starts to cover medical expenses.
Coinsurance amounts are portions of medical costs that beneficiaries have to pay for treatments, services, and tests.
Copayments are set amounts that beneficiaries pay for medical services, tests, and items.
Out-of-pocket costs are expenses that Medicare or a private health insurance company won’t cover.
Medicare Advantage is private Medicare coverage with the same benefits as Original Medicare. Most Medicare Advantage plans also include prescription drug costs and dental, hearing, and vision expenses.
In Pennsylvania, there are two main types of Medicare Advantage plans:
MA plans (without prescription drug coverage) do not include prescription drug coverage and only cover Medicare Part A and Part B expenses.
MA-PD plans (with prescription drug coverage) policies cover Part A and B expenses and prescription medication (Part D) costs.
Medicare Advantage plans also have unique structures which can influence costs, benefits, and coverage. Here are some of the different private health plan options:
Health Maintenance Organizations (HMO plans) offers health insurance through a specific health care provider network. People on HMOs usually are assigned a primary care doctor and are only covered for service in-network.
Health Maintenance Organization Point-Of-Service (HMO-POS plans) cover some health care services outside your network, but monthly premiums and copayments are usually higher than HMO plans.
Preferred Provider Organizations (PPO plans) allow you to see any provider that accepts insurance. You don’t need a referral from your primary care doctor to see a specialist.
Private Fee-for-Service (PFFS plan) allows members to see any health care provider enrolled in Medicare who accepts your plan.
Special Needs Plans (SNPs) are for people with specific needs or diseases. For example, these can be people who live with chronic conditions or live in assisted living facilities.
In Pennsylvania, Medicare Advantage plans have grown steadily over the last decade. Just under half of all Medicare beneficiaries in the state are members of a private Medicare health plan.
This can be seen in the state penetration rate, which is the number of Medicare enrollees who have joined a Medicare Advantage plan in the state.
For example, if ten people are eligible for Medicare and nine have a MA or MA-PD plan, the penetration rate is 90% (9 out of 10 people).
MA and MA-PD plans in Pennsylvania had a 46.3% penetration rate in 2021. This means that for every 100 Medicare-eligible people, around 46 have a Medicare Advantage plan.
To get a better idea of how MA and MA-PD plans have grown in Pennsylvania, look at the graph below.
Total Number of Medicare Beneficiaries in Pennsylvania Medicare Advantage, 2014 - 2020
According to the Kaiser Family Foundation, the number of people on a Medicare Advantage plan in Pennsylvania has increased from 971,144 to 1,215,262 between 2014 and 2020.
The number of Medicare Advantage plans offered by health care companies has decreased slightly.
In 2021, there were 244 MA and MA-PD plans available in the state.
In 2022, there are 240 Medicare Advantage plans to choose from in Pennsylvania.
Want to find out which MA and MA-PD plans are available in your county? Enter your zip code and find out today. If you need any assistance, feel free to give our team of Medicare consultants a call to discuss your options.
Learning about Medicare in your state can help you better understand what you can expect when joining a private health plan.
Here are some key takeaways you should consider about Medicare Advantage in Pennsylvania:
According to the Centers for Medicare and Medicaid Services (CMS), as of November 2021 there are 2,815,303 Medicare beneficiaries in Pennsylvania and 1,315,107 people enrolled in a Medicare Advantage plan.
Monthly premiums in Pennsylvania are going down. In 2021, the average monthly premium for a Medicare Advantage plan in Pennsylvania was $38.72. In 2022, the average Medicare Advantage premium was $32.79.
All Medicare-eligible people in Pennsylvania can buy a $0-premium Medicare Advantage plan. These are plans that don’t charge members a monthly premium to join.
- Just remember, when you join a $0 monthly premium plan, you will still have to pay your Medicare Part A and Part B monthly premiums.
The majority of doctors in Pennsylvania accept Medicare, which means you should be able to find health care providers that will treat you at Medicare rates. Of the 48,986 registered physicians, only 292 opted out of Medicare (less than 0.6% of doctors).
In Pennsylvania, Medicare Advantage plans can be purchased from a number of health insurance providers. Some well-known names include:
Health Partners Medicare
Independence Blue Cross
Wellcare by Allwell
UPMC for Life
Vibra Health Plan
Monthly Premium is the fee you pay to get coverage on Medicare Part A and B, Prescription Drug Plans, Medicare Advantage, or Medicare Supplement Insurance Plans.
Deductibles are amounts that beneficiaries have to pay before their Medicare insurance starts.
Coinsurance is the portion of medical costs that you will have to pay for medical treatment, services, and tests.
Copayments are set amounts that insurance companies charge for services, tests, and items.
Out-of-pocket costs are expenses that aren’t covered by Medicare or private insurance companies. Deductibles, coinsurance, copayments, and excess charges are all out-of-pocket costs.
If you’re looking at Medicare Advantage plans in Pennsylvania, follow these tips to find the best policy:
1. Check to see if your service provider has plans available in your area. Many people are unaware that Medicare Advantage plans differ by county.
For example, there are over 56 Medicare Advantage plans to choose from in Philadelphia County, Pennsylvania. However, there are only 48 Medicare Advantage plans available in Lackawanna County.
2. Decide if you want to buy an MA-PD (Medicare Advantage Prescription Drug) and an MA (Medicare Advantage only) plan.
3. Look at the costs associated with the plan you want to join and determine whether you can afford it when the price increases due to inflation.
4. Make sure you can afford the monthly premiums and out-of-pocket costs (costs that your plan does not cover), such as deductibles, coinsurance, and copayments.
5. Look at the Medicare Star Rating of the plan and health insurance company. Check out what other third-party reviews, such as ConsumerAffairs and JD Power, say about the health insurance company and plans.
The Centers for Medicare and Medicaid Services publishes an annual report on the quality and performance of Medicare and Medicaid plans and providers. This is done through a scoring system known as the Medicare Star Ratings System.
Each plan and provider is assigned a score of one to five, which indicates how well the plan performed during the previous year.
Here’s what the different star ratings mean:
⭐⭐: Below average
If you want to learn more, read our guide to Medicare Star Ratings. You can check out your plan’s current star rating by visiting the Medicare.gov website. Simply search for your county, find your plan, and check the number of stars it received
6. Ask friends and family members who have Medicare about their experiences with a specific provider or plan.
7. Speak with a licensed Medicare insurance agent about the plan's costs, benefits, and coverage. You'll be able to know whether the plan is right for you.
8. Before making a final decision, consider your options. Look around to see if any other providers offer similar coverage and plans.
Once you've found the right Medicare plan, it's important to know when you should apply. Here are the Medicare Advantage enrollment dates you should keep in mind:
This is your first chance to sign up for Medicare once you are eligible and begins three months before your 65th birthday. During the Initial Enrollment Period, you can sign up for Medicare Part A and B or join a Medicare Advantage plan or a Prescription Drug Plan.
The General Enrollment Period is from January 1st to March 31st. You can sign up for Medicare Parts A and B, as well as Medicare Advantage if you missed your Initial Enrollment Period.
These are periods when you can enroll outside the regular enrollment periods. There are specific circumstances when someone qualifies for a special enrollment period. For example, if you move to another state or if your employer health care coverage ends.
For more information, feel free to read our guide to Medicare Open Enrollment Period 2022.
Our Medicare Hub is a great place to start if you want to learn more about Medicare plans, costs, enrollment, coverage, and benefits.
If you require one-on-one support, we can also offer expert advice and assistance on any Medicare-related matters. Our team of knowledgeable Medicare consultants is on hand to answer any questions you have.