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Medicare in Pennsylvania

October 6, 2016

Original Medicare, the government-sponsored insurance program, offers health insurance coverage for people aged 65 or over and for some people under 65 with qualifying disabilities. For Pennsylvania Medicare beneficiaries, as for those living in other states, Original Medicare benefits include medical and hospital insurance. Medicare beneficiaries have the option of signing up with Medicare plans offered by private insurance companies under the Medicare Advantage (Medicare Part C) program and/or enrolling in a Medicare plan that provides prescription drug coverage.

Original Medicare for Pennsylvania beneficiaries

If you are approaching the age of 65, it’s a good time to become familiar with the benefits available under Original Medicare, which includes Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).

To be eligible for Original Medicare, you must be 65 or older and a U.S. citizen or legal permanent resident of five continuous years or more. People under the age of 65 may be eligible for Medicare if they have certain health conditions such as amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease) or if they’re collecting disability benefits for 24 continuous months or more from the Social Security Administration (SSA) or the Railroad Retirement Board.

The first time you can enroll in Original Medicare is three months before the month you turn 65, your birthday month and three months after your birthday month. This is the seven-month Medicare Initial Enrollment Period. If you fail to enroll in Original Medicare during that seven-month period you can still sign up for coverage during the General Enrollment Period, which runs from January 1 to March 31 each year. But be aware that if you miss your Initial Enrollment Period and enroll in Medicare at a later date, you may have to pay a late-enrollment penalty which could result in a higher monthly premium for as long as you remain enrolled in Medicare.

In Pennsylvania, enrollment in Medicare Part A is usually premium-free. However, even if you (or your spouse) did not pay Medicare taxes for at least 10 working years, you may still enroll in Original Medicare if you meet the eligibility requirements listed above. But you’ll have to pay a premium for your coverage. As a Pennsylvania Medicare beneficiary, Part A covers services including:

  • Hospital care
  • Skilled nursing facility care
  • Nursing home care (non-custodial)
  • Hospice care
  • Home health services

Medical insurance is available through Medicare Part B. In Pennsylvania and the rest of the United States, you pay a Medicare Part B monthly premium. Medicare Part B beneficiaries receive the following coverage:

  • Physicians’ services, including preventive care
  • Outpatient services
  • Laboratory and Radiology (X-ray) services
  • Medicare-approved clinical research
  • Ambulance services
  • Durable medical equipment
  • Mental health (inpatient, outpatient, or partial hospitalization)
  • Limited outpatient prescription drugs, such as those administered by a health-care provider

Medicare plan options in Pennsylvania

Pennsylvania Medicare beneficiaries can also receive their Medicare benefits by signing up for Medicare Advantage plans offered by private insurance companies contracted with Medicare. Medicare Advantage plans are required to cover at least the same hospitalization and medical benefits as Original Medicare, Part A and Part B (with the exception of hospice care, which remains a Part A benefit). As in the rest of the United States, in Pennsylvania Medicare Advantage plans may offer additional benefits such as dental, routine vision, hearing or health fitness programs.

Another option for Pennsylvania residents is a Medicare Advantage Prescription Drug Plan. This plan combines health and prescription drug coverage into one private insurance plan. Just remember that if you sign up for a Medicare Advantage plan or a Medicare Advantage Prescription Drug plan, you remain enrolled in Original Medicare and continue paying the Medicare Part B premium to keep your health insurance coverage.

For Pennsylvania Medicare beneficiaries who want to stay enrolled in Original Medicare, a stand-alone Medicare Part D Prescription Drug Plan can work alongside your Original Medicare (Part A and Part B) benefits. Medicare Part D Prescription Drug Plans are offered by Medicare-approved insurance companies, and they are designed to help Medicare beneficiaries cover costs for prescription drugs. Costs for each Pennsylvania Medicare Part D Prescription Drug Plan vary, but they generally require payment of a monthly premium, annual deductible, and copayment or coinsurance. If you decide on this option, instead of getting your Medicare benefits through a Medicare Advantage plan (described above), you may also be able to sign up for a Medicare Supplement (Medigap) plan to help pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.

Pennsylvania residents may have different Medicare plan offerings in different parts of the state. Residents of Philadelphia in Philadelphia County, for example, may have different Medicare plan offerings than residents of Pittsburgh in Allegheny County. With the great variety of Pennsylvania Medicare Advantage plans available, it may be a good idea to customize your search for plans based on your personal health and prescription needs. To start comparing plans available in your area, simply enter your zip code in the box on this page.

For more information about private Medicare insurance for Pennsylvania beneficiaries, please see:

Pennsylvania resources for Medicare beneficiaries

There are a number of resources designed to help Pennsylvania Medicare beneficiaries with Medicare-related issues and concerns. Here are some of the resources that may be helpful to you:

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