Pennsylvania Medicare Advantage Plans | Your Essential Guide

What Are Medicare Advantage Plans in Pennsylvania? 

Medicare Advantage (MA) plans in Pennsylvania are an alternative to Original Medicare offered by Medicare-approved private insurers. These bundled plans provide Medicare Part A and B benefits, and many include Part D (prescription drug) benefits. MA plans may also offer additional services, such as hearing, vision and dental care.¹

What You Need to Know 

The average cost for a Medicare Advantage plan in Pennsylvania in 2021 is $38.97, which is significantly higher than the national average of $21.

Most Pennsylvania Medicare Advantage plans include Medicare Part D, which is prescription drug coverage.

You can enroll in a Pennsylvania Medicare Advantage plan by contacting the insurance company you’d like to sign up with or by using the Medicare Plan Finder. 

What Types of Medicare Advantage Plans Are Available?

You can choose among several types of Medicare Advantage plans in Pennsylvania, including:

• Health maintenance organizations (HMOs): With this plan type, you’re required to seek treatment from healthcare providers who belong to the plan’s network. A network is a group of doctors and healthcare facilities that have contracted with an insurance company. If you go to an out-of-network provider, you may be responsible for the costs. You also may need a referral from your primary care doctor to see a specialist. HMOs are the most common type of Medicare Advantage plan.² 
• Preferred provider organizations (PPOs): Like an HMO, a PPO has a network of providers. Although you can go to out-of-network providers, you may pay more if you do. You typically don’t need a referral to visit a specialist. 
• Special needs plans (SNPs): These plans are for Medicare members who have specific healthcare needs. There are three types of SNPs:
  • Chronic special needs plans (C-SNPs): This plan type is for those with chronic health conditions like diabetes, autoimmune disorders, cancer and end-stage renal disease (ESRD). 
  • Dual eligible special needs plans (D-SNPs): These plans serve those who qualify for both Medicare and Medicaid. 
  • Institutional special needs plans (I-SNPs): These plans are for those who live in an institution, such as a nursing home, or who need nursing care at home. 
• Private fee-for-service (PFFS) plans: With this type of plan, you can see any healthcare provider who accepts the plan’s terms. Some plans have a network, and you pay less if you seek care from in-network providers. 
• Medical savings accounts (MSAs): This plan type combines a high-deductible Medicare Advantage plan with a medical savings account. Your deductible is the amount you pay for Medicare-covered healthcare services and supplies before your plan starts to pay. Your plan contributes funds to your MSA, and you can use those funds to pay for your out-of-pocket medical costs. If you use all the money in your MSA before meeting your deductible, you’re responsible for all Medicare-covered costs until your deductible is reached.³ 

What Are Prescription Drug Options with Medicare Advantage?

Most Pennsylvania Medicare Advantage plans include Medicare Part D, which is prescription drug coverage. If you join an MSA or PFFS plan without drug coverage, you can purchase a separate, standalone Part D plan. If you join an HMO or PPO without drug coverage, you cannot buy a separate plan to cover prescriptions. 

If you don’t join a plan with Part D coverage, you may have to pay an ongoing late penalty once you do enroll.^{4 5}

How Do You Choose a Medicare Advantage Plan?

The right Medicare Advantage plan for you depends on several factors. One of the most important considerations for many people with Medicare is the plan’s premiums (monthly costs). Many options have a $0 premium, but some do have a cost. The national average premium for a Medicare Advantage plan in 2021 is $21 per month.⁶

Medicare Advantage plans have other costs as well. Your plan may have a deductible, which is the amount you pay for Medicare-covered services before your insurance starts to pay. You may have a $200 deductible for prescription drugs, for example. That means you pay the first $200 in prescription costs, and above that amount your insurance starts paying according to the terms of your plan. 

Your plan may also have coinsurance and copayments. Coinsurance is a percentage you pay for a covered service or item, typically after you’ve met your deductible. Copays are a set dollar amount that you pay for covered services. Copays may apply before and after you meet your deductible. A plan may charge 20% in coinsurance for an inpatient hospital stay, for instance, and a $20 copay for primary doctor visits.⁷

Plans also have an out-of-pocket maximum, which is the most you will pay for Medicare-covered services in a given year.⁸

Plan Benefits

You should also consider the additional benefits offered by Medicare Advantage plans. Plans may provide vision, dental and hearing benefits. Many also offer a fitness club membership, and almost all plans offer telehealth benefits. You may also find plans that help pay for over-the-counter medications, meal benefits and transportation to medical appointments.⁹

When and How to Enroll in Medicare Advantage?

You can enroll in a Pennsylvania Medicare Advantage plan by contacting the insurance company you’d like to sign up with or by using the Medicare Plan Finder. Enrollment is restricted to certain periods, including:

• Initial enrollment: This seven-month period starts three months before your 65th birthday month and ends three months after that month. You can enroll in a Medicare Advantage plan during this time.
• Open enrollment: Also known as the annual election period, this lasts from October 15 – December 7 each year. You can start, drop or switch plans, with changes taking effect on January 1.  
• Medicare Advantage open enrollment: This lasts from January 1 – March 31, with changes taking effect the first of the month after you make the change. You can switch Medicare Advantage plans or drop your Medicare Advantage plan during this time. 
• General enrollment: If you start Medicare Part B between January 1 and March 31, you can also join a Medicare Advantage plan.¹⁰
• Special enrollments: You’re also entitled to an enrollment period in certain circumstances that change your coverage or insurance needs, including: 
  • Moving to a new address that isn’t in your plan’s service area
  • Losing Medicaid or employer coverage
  • Gaining employer, union or Medicaid coverage
  • Losing your plan because Medicare terminated the plan’s contract
  • Being diagnosed with a chronic health condition that would be better served by a C-SNP¹¹

How Many People Have Enrolled in Medicare Advantage?

About four in ten (41%) Pennsylvanians who qualified for Medicare opted for a Medicare Advantage plan. That number, or penetration rate, has increased by nearly 50% with enrollment growing about 813,000 in 2008 to 1,236,000 in 2020.

How Much Do Medicare Advantage Plans Cost in Pennsylvania?

The average cost for a Medicare Advantage plan in Pennsylvania in 2021 is $38.97, which is significantly higher than the national average of $21.¹²

In Pittsburgh, for example, Medicare members have access to 45 plans from seven insurance providers. Nineteen plans have a $0 premium, 17 plans have a premium above $0 but less than $100 per month, and the most expensive plan is $199 per month. 

In Philadelphia, people with Medicare have access to 49 plans from nine insurance providers. Twenty-six plans have a $0 premium, 14 plans have a premium above $0 but less than $100 per month, and the priciest plan is $290 per month.

What If You Want to Change Your Medicare Advantage Plan?

You have two opportunities to change your Medicare Advantage plan each year. During open enrollment, between October 15 and December 7, you can switch or drop your Medicare Advantage plan. You can also enroll in a different plan or disenroll from your current one from January 1 – March 31.¹³

What Are Medicare Resources in Pennsylvania?

If you need assistance with choosing a Medicare Advantage plan or you have a question about Medicare, contact APPRISE. It offers free Medicare counseling from trained counselors. You can call APPRISE at 1-800-783-7067 from 9 a.m. to 4 p.m. Monday – Friday. You can also contact APPRISE through your local Area Agency on Aging office.

If you have a complaint about your insurance plan, contact the Pennsylvania Insurance Department. You can file a complaint online or by calling 1-877-881-6388.

If you have limited income and assets, consider applying for Medical Assistance, which is also known as Medicaid. You can apply online or by calling 1-866-550-4355.

State Medicare Advantage Data in Pennsylvania

Next Steps

To find the right Medicare Advantage plan for you, visit the Medicare Plan Finder or contact insurance providers. Compare the plan costs, including the premiums, deductibles, coinsurance and copays. Find out if your prescription medications are covered and whether your doctors are considered in-network. Choose a plan that’s affordable and offers the benefits you need.