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If you’re a Medicare beneficiary in Pennsylvania looking for coverage beyond Original Medicare, you may want to consider enrolling in a Medicare Advantage plan, available through the Medicare Part C program. Medicare Advantage in Pennsylvania allows you to receive your Medicare benefits through a Medicare-contracted private insurance companies, rather than through the federally administered program. Medicare Advantage plans must offer at least the same level of coverage as Original Medicare, Part A and Part B (with the exception of hospice), but may also additional benefits. The specific plan details may vary depending on the zip code you live in and on the specific health plan you select.
Here’s an overview of how Medicare Advantage plans work in Pennsylvania.
As mentioned, Medicare Advantage plans in Pennsylvania, as in the rest of the United States, are required by the US government to offer at least the same medical and hospitalization benefits as Original Medicare, Part A and Part B (please note that the hospice benefit is still covered by Part A of Original Medicare). However, many Medicare Advantage plans also have additional benefits, like routine vision, hearing, routine dental, and prescription drug coverage.
Eligibility for Medicare Part C is the same for every state, regardless of where you live. If you want to enroll in Medicare Advantage in Pennsylvania, you must first be enrolled in or eligible to enroll in Original Medicare, Part A and Part B. In addition, you must live in the service area of a Medicare Advantage plan and, with some exceptions, you cannot have end-stage renal disease, or ESRD.
As mentioned, you must be enrolled in Original Medicare to be eligible for Medicare Part C. A good time to sign up for Original Medicare in Pennsylvania is during your seven-month Initial Enrollment Period, which begins three months before you turn 65, includes your birthday month, and ends three months after that month. Individuals who receive Social Security or Railroad Retirement Board disability benefits will be automatically enrolled in the 25th month of disability benefits. People with certain conditions, such as Lou Gehrig’s disease (also known as amyotrophic lateral sclerosis) or end-stage renal disease, may also be eligible for Medicare before turning 65.
Failure to sign up for Medicare during your Initial Enrollment Period may result in a late-enrollment penalty, which means you could have to pay higher Medicare premiums for Part A and/or Part B if you enroll later on. You may sign up for Original Medicare at a later date, during the annual General Enrollment Period, which runs from January 1 to March 31, but you may have to pay the late-enrollment penalty for not signing up when you were first eligible.
You may not have to pay a late-enrollment penalty if you’re eligible for a Special Enrollment Period (SEP). Some examples of situations that may qualify you for an SEP include if you were working and covered under employer-sponsored group coverage; in this case, you may be able to delay enrollment in Medicare and sign up later with a Special Enrollment Period when you stop working or that health coverage ends – whichever happens first.
Once you’re enrolled in Part A and Part B, you may be eligible for Medicare Part C if you meet the other criteria (living in the service area of a plan and not having ESRD, with some exceptions). You’re first eligible during your Initial Coverage Election Period (ICEP), which typically takes place during the same seven-month period as your Initial Enrollment Period for Part B (taking place three months before you turn 65, including your birthday month, and ending three months later). If you delay Part B enrollment, your ICEP starts three months before your Part B coverage begins and lasts three months.
Once you’re enrolled in Medicare Part C, you may switch Medicare Advantage plans in Pennsylvania (as in the rest of the country) during the Annual Election Period, which runs from October 15 to December 7. Also known as the Fall Open Enrollment, this is your yearly opportunity to make changes to your coverage, such as changing to a Medicare Advantage plan that includes prescription drug coverage (or, alternatively, a plan that doesn’t). You can also use this period to enroll in a Medicare Advantage plan for the first time, and your new coverage will then go into effect on January 1 of the following year. Or, if you like, you can also use the Annual Election Period to disenroll from your Medicare Advantage plan and return to Original Medicare.
You may also be allowed to switch Medicare Advantage plans in Pennsylvania during Special Election Periods, which take place in certain situations, like moving to a new address where your old plan may not be available or losing your current coverage (for example, losing your Medicaid eligibility), to name a few. Special Election Periods in Pennsylvania vary depending on the reason you’re eligible to make changes.
If you decide to switch back from a Medicare Advantage plan to Original Medicare, Part A and Part B, you’re allowed to do so during the annual Medicare Advantage Disenrollment Period, which runs from January 1 to February 14, in Pennsylvania and the rest of the United States. You can also use this period to enroll in a stand-alone Medicare Prescription Drug Plan, which provides prescription drug benefits if you have Original Medicare. These are the only changes you can make.
There are many types of Medicare Advantage plans in Pennsylvania, so it may be helpful for you to understand what each plan covers in order to find the Medicare Advantage plan that may best suit your personal health needs.
Under a Health Maintenance Organization (HMO) plan, you are required to visit doctors, health-care providers, and hospitals included in your plan’s network. The exception is emergency or urgent care, which the HMO plan will cover even if you use a non-network provider. HMOs typically require you to get a referral from your primary care doctor to receive coverage for certain health services (for example, if you need to see a specialist). An HMO Point-of-Service (HMO-POS) plan is a similar but more flexible type of Medicare Advantage plan, allowing you to go out of network for certain health services, generally at a higher cost.
A Preferred Provider Organization (PPO*) plan is a type of Medicare Advantage plan offering greater flexibility than either HMO or HMO-POS plans. Under a PPO plan, you’re allowed to choose doctors, health-care providers, and hospitals outside of your plan’s network, but at a higher cost. If you use providers in the plan’s preferred provider network, your copayments and coinsurance costs will generally be lower.
Another option is a Medical Savings Account (MSA) plan, which combines a high deductible plan with a medical savings account, allowing you to use the savings account to pay for your health-care expenses before reaching the deductible. Money withdrawn from the account for eligible medical expenses is tax free.
Another option is a Private Fee-for-Service (PFFS) plan, which is type of Medicare Advantage plan that may offer a partial or full network of providers and sometimes no network at all. If your PFFS plan doesn’t have a network, you’re allowed to see any doctor or provider that will accept the plan’s payment terms and conditions and agree to treat you on a case-by-case basis. Not every provider will, and you’ll need to have your doctor contract with the plan each time you get treated. Some PFFS plans have provider networks of doctors and hospitals that have contracted with the plan to always accept the plan and treat you.
If you have specific health conditions, you may want to choose a Medicare Special Needs Plan (SNP). There are Medicare SNPs for people with certain chronic diseases, those living in institutions (like nursing homes), and people who qualify for both Medicare and Medicaid. A Medicare SNP can offer coverage tailored to suit these situations.
If you’re seeking both health and prescription drug coverage, you may want to choose a Medicare Advantage Prescription Drug (MAPD) plan, which combines health and prescription drug coverage (also available as a stand-alone Medicare Part D Prescription Drug Plan if you have Original Medicare) into a single insurance plan. Most of the above plan types can be MAPD plans, with the exception of Medicare Savings Account plans and some PFFS plans. In these instances, you may be able to enroll in a stand-alone Medicare Prescription Drug Plan for your prescription coverage. However, in most cases, you should get your prescription drug coverage through a Medicare Advantage plan that includes this benefit, if available.
And don’t forget that even if you decide to enroll in a Medicare Advantage plan in Pennsylvania, you must remain enrolled in Original Medicare and continue paying your Medicare Part B premium in order to keep your health insurance coverage.
As a Medicare beneficiary in Pennsylvania, you may find it useful to compare the various Medicare Advantage plan options available in your area.
The availability and cost of Medicare Advantage plans generally varies depending on your state and service area you reside in. It’s common for premiums of a Medicare Advantage plan with the same coverage and benefits to vary between different service areas within the state of Pennsylvania. You may find that some Medicare Advantage plans in Pennsylvania offer premiums as low as $0; but always remember that have to keep paying your Medicare Part B premium, regardless which Medicare Advantage plan you choose, in order to keep your Medicare health insurance coverage. In addition, it’s important to consider all of your plan costs, not just the premium; Medicare Advantage plans with $0 premiums may have higher copayments, coinsurance, or deductible costs.
Some Medicare Advantage plans may offer additional benefits beyond what is included in Original Medicare, Part A and Part B, so you will need to determine exactly what kind of coverage you may require, plus whether or not you want prescription drug coverage through a Medicare Advantage Prescription Drug plan. Considering the various health insurance options available, you can see why it may be smart to compare each Medicare Advantage plan option in Pennsylvania offering benefits and costs that fit your individual health and budget needs.
To start comparing Medicare Advantage plans in Pennsylvania today, enter your zip code above for a customized list of plan options available in your area. You can also enter your prescription drug needs to further customize your search and cost estimates.
View the following page for more information on other types of Medicare coverage in Pennsylvania:
With the various Medicare Advantage plans available in Pennsylvania, it may be smart to get help choosing a plan option that works for your individual health needs. If you’d like one-on-one assistance, simply call the phone number on this page to reach a licensed insurance agent.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.