Fueled by increased plan options and expanding benefits, the popularity of Medicare Advantage (MA) just keeps growing. There were over 31 million people enrolled in an Advantage plan in 2023, accounting for over half of all eligible Medicare beneficiaries. This page looks at Medicare Advantage plans in Pennsylvania and explains how the program works.
What is Medicare Advantage in Pennsylvania?
Original Medicare includes Part A, hospital insurance and Part B, medical insurance. Prescription drug coverage is not part of Original Medicare. Those benefits are part of Medicare Part D.
Medicare Part C plans (more commonly known as Medicare Advantage) must provide the same coverage you'd get with Original Medicare. They are not limited to those services, though. For example, around 90 percent of Medicare Advantage plans cover prescriptions. Other common extras include fitness programs, hearing aids, and routine vision and dental care.
Pennsylvania Medicare Advantage plans with prescription drug coverage
Medicare Advantage Prescription Drug plans (MA-PD) combine your Parts A, B, and D benefits. If you want one of these all-in-one plans, look for the MA-PD designation when comparing your options.
If you choose an Advantage plan that does not include prescription drug coverage AND you don't have creditable coverage elsewhere, you need to join a standalone Medicare Part D plan. Creditable means that the plan provides the same level of coverage as Medicare at a comparable price.
If you don't have creditable prescription drug coverage, you'll owe the Medicare Part D late enrollment penalty once you join a Part D plan.
Who is eligible for Medicare Advantage in Pennsylvania?
You are eligible for Medicare Part C in Pennsylvania once you have Medicare Parts A and B.
American citizens and permanent legal residents age 65 and older qualify for Medicare. Enrollment in Parts A and B is only automatic if you begin collecting Social Security benefits at least 4 months before your 65th birthday.
You're eligible for Medicare before age 65 if you collect Railroad Retirement Board (RRB) or Social Security disability benefits for 24 months. Enrollment occurs automatically during month 25.
When can you sign up for a Medicare Advantage plan in Pennsylvania?
You may first join an Advantage plan during your Initial Enrollment Period (IEP), which lasts for 7 months and begins 3 months before your Medicare eligibility month. For example, if your birthday or 25th month of disability is in June, your IEP starts on March 1 and ends on September 30.
If you did not sign up for Medicare Part A and/or Part B during your IEP, you may do so during the General Enrollment Period, which starts January 1 and ends March 31. After General Enrollment ends, you may join a Part C plan between April 1 and June 30.
Current beneficiaries can sign up for an Advantage plan during the Medicare Annual Enrollment Period. AEP lasts from October 15 through December 7.
If you currently have a Part C plan, you may change to a different one during the Medicare Advantage Open Enrollment Period from January 1 through March 31. You may also choose to return to Original Medicare during this time. If the changes you make during Open Enrollment cause you to lose your prescription drug coverage, you may join a standalone Medicare Part D plan.
Finally, Special Enrollment Periods let you join an MA plan if you experience certain life changes. Find the full list of qualifying special circumstances on Medicare.gov.
Types of Medicare Advantage plans in Pennsylvania
There are four common types of Medicare Advantage plans in Pennsylvania:
- Health maintenance organizations: HMO plans require members to use a provider network, choose a primary care doctor, and get a referral to see a specialist. Non-emergency care received from an out-of-network provider is rarely covered by an HMO plan.
- Preferred provider organizations: PPO plans also have a network but they allow members to see an out-of-network provider for a higher copay. PPO plan members do not need a referral to see a specialist. They also don't have to choose a primary doctor.
- Private fee-for-service: PFFS plans determine how much they and their members will pay for services. They may also have a provider network, but plan members may go out-of-network for a higher copay. PFFS plans do not require members to choose a primary care provider or get a referral to see a specialist.
- Special needs plans: SNPs serve specific populations. To join an SNP, one of the following must be true for you: being dual eligible (i.e. qualifying for both Medicare and Medicaid), having a chronic condition, or requiring nursing home or in-home healthcare.
Choosing a Medicare Advantage plan in Pennsylvania
Private insurance companies provide Medicare Advantage plans, so costs and coverage can vary widely. Consider the following when comparing your options:
- Costs: May include a yearly deductible, monthly premium, and copays or coinsurance.
- Coverage: The plan's benefits help put the costs in perspective. If it's an MA-PD plan, don't forget to review the drug formulary.
- Network: If you have preexisting conditions or complicated medical issues, you may want an MA plan that includes your providers in its network.
- Ratings: Medicare rates all plans on a 5-point scale and releases their findings each fall, before Annual Enrollment.
Our Find a Plan tool makes comparing Medicare Advantage plans in Pennsylvania easy. Just enter your location information to review Medicare plans in your area.
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