Medicare Advantage Plans in Pennsylvania

Medicare Advantage in Pennsylvania, also known as Medicare Part C, is an alternative way for beneficiaries to get their Original Medicare health care benefits.

Medicare Advantage plans are sold by private insurance companies but are regulated by the federal government and the Centers for Medicare and Medicaid Services. In place of the government, the insurance company takes responsibility for claims, customer service, and administration of health plans.

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Top-rated Medicare Advantage Plan Providers in Pennsylvania

  • Aetna
  • Cigna
  • Highmark
  • Humana
  • Kaiser
  • UnitedHealthcare

Popular Medicare Advantage Plan Types in Pennsylvania

Best for network freedom: Medicare Advantage PPO plans

  • PPO plans have a more extensive network of providers and do not require referrals from their primary care physician
  • Monthly premiums for PPOs range between $0 and $100.00.

Best for low out-of-pocket costs: Medicare Advantage HMO plans

  • Monthly premiums for HMOs are typically $0.
  • HMOs use a referral network resulting in lower out-of-pocket costs

Best for low income or health conditions: Medicare Advantage D-SNP

  • Special needs plans are the best for people living on limited incomes or who have chronic health conditions like end-stage renal disease
  • Beneficiaries can have Medicare and Medicaid coverage for lower costs on copays, coinsurance, premiums, and deductibles.

Pennsylvania Enrollment Facts:

  • The number of people with Medicare Advantage coverage in Pennsylvania: 1.2 million
  • Number enrolled by type of plan:
  • Local HMO: 648,820
  • Local PPO: 385,517
  • PFFS: 8,891
  • Regional PPO: 4,798
  • Percentage of Medicare beneficiaries enrolled in Medicare Advantage in Pennsylvania: 43 percent.
  • Number of people enrolled in Medicare Advantage nationwide: 29.5 million
  • The percentage of Medicare beneficiaries enrolled in Medicare Advantage nationwide: 42 percent

How much does Medicare Advantage in Pennsylvania cost?

In Pennsylvania, those eligible for Medicare Part A and B coverage can find HMO plans with $0 premiums. Some areas also have PPOs with zero premiums, but it is becoming less common.

The plans available in Pennsylvania vary by service area. Still, the average monthly premium for Medicare Advantage prescription drug plans (MAPDs) is $50, with an average prescription drug deductible of only $32, one of the lowest among the states.

How much do Advantage Plans cost in Pennsylvania?

PPO Plan $0.00 to $50.00

HMO Plan $0.00

When can you enroll in a Pennsylvania Medicare Advantage plan?

1. The Initial Enrollment Period

At age 65:

For those receiving Social Security retirement benefits at age 65, eligibility for Original Medicare or Medicare Advantage goes hand-in-hand. The best time to enroll is when you are first eligible – during the Initial Enrollment Period (IEP).

Your IEP is seven months beginning three months before the month of your 65th birth date. It includes that entire month and continues for three months after that.

Younger than 65:

Those receiving Social Security or RRB benefits because of a qualifying disability like end-stage renal disease or ALS can also enroll in a Medicare Advantage plan in Pennsylvania during the IEP. In these instances, IEP begins three months before the 25th month of receiving disability benefits, includes the 25th month, and ends three months after.

2. The Open Enrollment Period (OEP) or Annual Election Period (AEP)

In Pennsylvania, during this enrollment period, you can sign up for Medicare Advantage, switch to a different Part C plan, return to Original Medicare Part A and Part B, and add a stand-alone Medicare Part D plan.

AEP runs from October 15 to December 7, and changes take effect on January 1.

3. The Medicare Advantage Open Enrollment Period

Every year from January 1 to March 31, during the Medicare Advantage Open Enrollment Period, you can switch from Medicare Advantage to Original Medicare or enroll in a different Medicare Advantage plan. Any changes you make during this period start on the first day of the month following the change.

4. Special Enrollment Periods

Those who qualify for a special enrollment period can sign up for Medicare Part C, Part D or change their health care plans.

These are the circumstances when Medicare allows special enrollment:

  • Moving from one service area to another
  • Moving back to the United States from abroad
  • Moving into or out of a skilled nursing or long-term care facility
  • Release from prison
  • Losing eligibility for Medicaid or becoming dually eligible for Medicare and Medicaid
  • Termination or non-renewal of a current plan
  • Changing from Medigap to Medicare Advantage coverage

5. The five-star Special Enrollment Period

You can upgrade your Medicare Advantage coverage to a plan with a five-star rating any time one becomes available at your location.

6. The Special Enrollment Period for “Extra Help” programs

A special enrollment period is available for the Extra Help program or Medicaid beneficiaries. During the following periods, they can change their Medicare Advantage or Part D coverage one time:

  • January – March
  • April – June
  • July – September

Medicare Advantage Highlights:

Here are some more features of Medicare Advantage in Pennsylvania:

  • Medicare Advantage plans must at least provide the same benefits as Medicare Part A and Medicare Part B.
  • Members must continue paying their Part B premiums to remain eligible for Medicare Advantage coverage.
  • The standard monthly Medicare Part B premium for 2023 is $164.90. The annual Part B deducible for 2023 is $226.
  • In Pennsylvania, Medicare Advantage plans are becoming increasingly popular every year.
  • Most Part C health plans and benefits are tied to network providers, i.e., physicians, hospitals, medical facilities, suppliers, and pharmacies.
  • Medicare Advantage Prescription Drug plans (MAPDs) combine prescription drug plans and Part C benefits into one plan.
  • Most Medicare Advantage plans in Pennsylvania offer extra benefits like vision, dental, hearing, wellness club memberships, over-the-counter medication allowances, transport services, and meal delivery.
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