Medicare in Pennsylvania
Find affordable Medicare plans in Pennsylvania
Overview of Medicare in Pennsylvania
Did you know that in 2015, more than 2.5 million Pennsylvanians were enrolled in Medicare? As a Medicare beneficiary, you can choose from a variety of Medicare coverage options in your state.
Let’s start by looking at the components that comprise Medicare coverage. Medicare includes Part A, Part B, Part C, and Part D.
Medicare Part A (sometimes referred to as hospital care coverage) and Part B (sometimes referred to as physician care coverage) are considered Original Medicare. The federal government administers the Original Medicare program. Typically when you sign up for Medicare, you are automatically enrolled in Part A and Part B if you’re already receiving retirement benefits before you turn 65; in this case, you must disenroll in Part B to avoid paying the Part B premium if you don’t want it. If you don’t get Medicare automatically, you can manually sign up for it during your Initial Enrollment Period, the seven-month period that starts three months before you turn 65, includes your birthday month, and ends three months later.
Part C is available through Medicare Advantage plans, which are an alternative to Original Medicare. Private insurance companies approved by the Centers for Medicare & Medicaid Services (CMS) offer Part C, which includes at least the same level of benefits as Original Medicare (Part A and Part B) and may include more coverage as well.
Part D is the Medicare prescription drug benefit that helps cover certain medication costs and lower your out-of-pocket expenses for prescriptions. Private insurance companies approved by CMS offer Part D coverage. These insurers may offer either Medicare Advantage Prescription Drug plans or stand-alone Medicare Prescription Drug Plans (PDP).
Medigap (Medicare Supplement) insurance is also offered by private insurance companies. These plans can help you pay for certain out-of-pocket costs not covered under Original Medicare.
So how do you get the coverage you need? You can pair some of these types of Medicare coverage to fit your particular health-care coverage needs.
1. Original Medicare can be paired with Medigap policies, which work alongside Part A and Part B coverage.
2. Original Medicare and Medigap can also be paired with a Medicare Prescription Drug Plan. You must be enrolled in Part A and/or Part B if you want to enroll in a Medicare Prescription Drug Plan.
Please note that you cannot pair a Prescription Drug Plan with a Medicare Advantage plan that offers Part D prescription drug coverage, also known as a Medicare Advantage Prescription Drug plan.
You can, however, enroll in a Medicare Advantage plan that offers Medicare Part D prescription drug coverage as part of its benefit package to have your medical and medication coverage covered under a single plan.
You’ll want to make an informed decision about which Medicare option, or combination of options, is suitable for you. Let’s look in more detail at what kind of health-care services each option covers and what makes an individual eligible to enroll in each option.
Original Medicare in Pennsylvania
You are eligible for Original Medicare if you are 65 years old or older and either an American citizen or a permanent legal resident who has lived in the United States at least five continuous years. You may be eligible for Medicare when you are younger than 65 if you are permanently disabled and have received disability benefits from Social Security or the Railroad Retirement Board for at least 24 months. Also, you may be eligible for Medicare at a younger age if you have been diagnosed with Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS), or you have permanent kidney failure (end-stage renal disease, or ESRD) that requires dialysis treatment or a kidney transplant.
Medicare Part A covers inpatient hospital care, inpatient skilled nursing care (for circumstances such as nursing care in transition from inpatient hospital care to home), some home health care, and hospice care. Complementing Part A, Medicare Part B covers outpatient services, including lab tests, doctor visits for diagnosis and treatment of illnesses, injuries, and preventive care. Medicare Part B also covers durable medical equipment and some home health care.
Medicare beneficiaries get Medicare Part A without a premium if they’ve worked at least 10 years (40 quarters) and paid Medicare taxes; otherwise, they may owe a premium for their Part A coverage. Most Medicare beneficiaries pay a premium for Part B coverage, along with any deductibles, copayments, and coinsurance costs that apply to Medicare Part A and Part B coverage.
Original Medicare, Part A and Part B, does not cover all health-care services and items, however. You may be responsible for paying:
- Most prescription drugs (except for medications you receive while in the hospital or certain medications you receive in an outpatient treatment center)
- Custodial long-term services (nursing home care)
- Routine dental care and dentures
- Routine vision care and eyeglasses or contact lenses
- Health services received outside of the country
Medicare Part D prescription drug coverage in Pennsylvania
To be eligible for Medicare prescription drug coverage (Medicare Part D), you must have Medicare Part A and/or Part B and live in the service area of a Medicare plan with prescription drug benefits.
Medicare Part D, or Medicare prescription drug coverage, can help pay for certain prescription drug costs. Stand-alone Medicare Prescription Drug Plans cover the gap between your prescription drug needs and Original Medicare. As mentioned, another option is to get this coverage through a Medicare Advantage plan that includes prescription drug benefits. Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans cover many of the prescription drugs frequently used by Medicare beneficiaries. However, there can be differences in prescription drug coverage between plans. Medicare plans with prescription drug coverage publish a list of prescription drugs they cover, often referred to as a formulary. Therefore, it’s wise to see if the medications you take are on the plan’s list or formulary of covered drugs if you want Medicare prescription drug coverage. Please keep in mind that the formulary may change at any time. You’ll be notified by your Medicare plan when necessary.
Medicare Part D has a fixed monthly cost, the premium. In exchange for the premium you pay each month, your insurer will cover a certain share of your covered prescription drug costs. Depending upon your income, you may qualify for “Extra Help” to offset some or all of your premium cost; the Extra Help program pays for certain prescription drug costs for low-income beneficiaries. If you don’t qualify for cost assistance, your Part D costs are based on the Medicare plan you’re enrolled in. Different Medicare plans with prescription drug benefits will cover different pharmacy networks, drugs, and benefits and will have different premiums, deductibles, copayments, and coinsurance.
Medicare Advantage plans in Pennsylvania
You are eligible to sign up for a Medicare Advantage plan in Pennsylvania if you have Original Medicare, Part A and Part B; do not have end-stage renal disease (ESRD, or permanent kidney failure) with some exceptions; and you live in the Medicare Advantage plan’s service area.
Medicare Advantage plans (Part C) may provide you more coverage than Original Medicare offers. In addition to covering at least the same level of benefits as Original Medicare (except for hospice care), many Medicare Advantage plans include additional benefits, including routine dental and vision care, hearing, wellness programs, and prescription drugs. Medicare Advantage plans that include prescription drug coverage are known as Medicare Advantage Prescription Drug (MA-PD) plans; these plans give you the convenience of having all of your Medicare medical and prescription drug benefits through one plan, instead of having to enroll in a separate plan for your Medicare Part D coverage.
Also, Medicare Advantage plans must limit beneficiaries’ out-of-pocket spending for services covered under Medicare Part A and Part B. All Medicare Advantage plans must include an annual out-of-pocket spending limit; once your out-of-pocket costs reach this limit (including the deductible), your Medicare Advantage plan pays 100% of covered health-care costs for the remainder of the year. This yearly maximum spending limit varies by plan. In contrast, Original Medicare doesn’t have a maximum spending limit to cap your annual out-of-pocket costs.
Unlike Original Medicare, Medicare Advantage plans come in various types. The most common types are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). HMOs and PPOs have networks of participating hospitals, doctors, and other health-care professionals. If you select a Medicare Advantage HMO, you will choose a primary care physician who provides or coordinates your care and may refer you to other participating providers. Except for emergencies, out-of-network providers’ services are not covered unless approved in advance by the Medicare Advantage HMO plan. If you select a Medicare PPO, your out-of-pocket costs are lower when you use hospitals, doctors, and other health-care professionals who participate in the PPO’s preferred provider network than if you use non-participating health-care providers. You don’t need referrals for specialist care if you’re enrolled in a PPO.
Medicare Advantage plan members must continue to pay their Medicare Part B premium and may also pay an additional premium directly to their Medicare Advantage plan, along with any deductible, copayment, or coinsurance amounts that may be applicable to the benefit plan.
Medicare resources in Pennsylvania
Pennsylvania Department of Aging – This state office offers a wide range of information and services designed to improve the quality of life and independence for seniors living in the state. Assistance with Medicare plans in Pennsylvania is available through the following programs:
- Apprise Health Insurance Counseling Program – This program offers free counseling to Pennsylvania Medicare beneficiaries to help them make the right choices in finding Medicare benefits for their needs.
- PACE, PACENET, and PACE Plus – These programs offer assistance to Pennsylvania Medicare beneficiaries who need help affording the costs of their prescription drugs. Applicants qualify for the program by their income level.
- Medical Assistance – This is a statewide program available to Medicare beneficiaries who cannot afford their Medicare premiums or deductibles. Eligibility for this program is also dependent on income level.
Pennsylvania Health Law Project – The Pennsylvania Health Law Project offers free legal assistance to seniors and low-income residents of the state. In addition, the website for the organization offers a wealth of information about Pennsylvania Medicare plans, including information for low-income Medicare beneficiaries and those interested in enrolling in a Medicare insurance plan for additional health or prescription drug coverage. Seniors who are denied health care coverage can contact this organization for assistance and possible representation.
Center for Advocacy for the Rights and Interests of the Elderly (CARIE) – This organization, also referred to as CARIE, oversees the Senior Medicare Patrol (SMP) of Pennsylvania. SMP is a federal program overseen at the state level to educate seniors about the potential of Medicare fraud, waste, and abuse. Through education and awareness, the hope is that beneficiaries can help prevent Medicare fraud or report it as soon as it occurs. The program is staffed through senior volunteers who are thoroughly trained on the subject of Medicare fraud, waste, and abuse. The program provides information online and through one-on-one counseling over the phone and in person.
Medicare statistical trends in Pennsylvania
As you consider Medicare coverage in your home state, you are likely to be impressed with the options available to you. For 2016, some points of interest regarding Medicare coverage in Pennsylvania appear below.
- 100% of people with Medicare have access to a Medicare Advantage plan in Pennsylvania. And if you decide Medicare Part C is an attractive coverage option for you, you likely enjoy choice in your selection of Medicare Advantage plans. There are 168 Medicare Advantage plans available statewide. In addition, 29 Medicare Prescription Drug Plans are available in Pennsylvania.
- 86% of people with Part D have access to a plan with a lower premium than what they paid in 2015.
- 27% of people with Medicare Part D get Extra Help (also called the Low-Income Subsidy, or LIS).
- The lowest monthly premium for a Prescription Drug Plan is $18.40. Please note, however, your premium cost for a Prescription Drug Plan may differ because of various factors:1. The plan you select (for example, the premiums of plans with lower cost sharing generally cost more than comparable plans with higher cost sharing)2. If you receive Extra Help with your Medicare Part D coverage, you may get your prescription drug coverage at no additional premium cost, or at a reduced premium.3. If you did not have Medicare Part D coverage or creditable prescription drug coverage for 63 days in a row after you were first eligible to receive it, you may pay a late-enrollment penalty, which is added to the cost of your Medicare Part D prescription drug coverage.
Whether you choose a Medicare Advantage plan, Original Medicare (Part A and Part B), or a Part D Prescription Drug Plan, you have access to important benefits brought to you by the Affordable Care Act. For example, some preventive care services, including an annual wellness exam and certain cancer screenings, cost you nothing as long as you receive the services from qualified, participating health professionals. Also, if you reach the coverage gap (also known as the “donut hole”) in Medicare’s Part D prescription drug benefit, you will get certain savings on covered brand name drugs and increased savings on generic drugs.
To explore your options in more detail, you may want to use the eHealth plan finder located on this page to compare Medicare plan options available where you live. Simply type your zip code into the tool on this page to get started. If you want, you can provide your current list of prescription drugs to find Medicare plan options that cover those medications.
This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.
Call to speak with a licensed
insurance agent now.
1- TTY users 711