Pennsylvania is the fifth-most populous State in the United States, with over 13 million residents. Surprisingly, 2,875,916 Pennsylvania residents are enrolled in Medicare plans.
Medicare is a health insurance program based in the United States. This comprehensive health coverage plan is administered by the federal government and funded by the General Revenue and Federal Insurance Contributions Act.
Medicare plans in Pennsylvania aim to meet the increasing healthcare complexities and needs of senior adults aged 65 and above, those with certain disabilities, and people with last-stage renal disease (ESRD).
The US federal government directly administers Original Medicare, the standard fee-for-service plan. However, Pennsylvania residents can also enroll in Medicare Advantage plans provided by private health insurance companies.
These healthcare plans lower the expenses associated with hospital bills and medical care by providing comprehensive coverage for both inpatient and outpatient care. Let us learn more about Medicare Advantage plans in Pennsylvania and how they benefit residents.
Medicare Advantage Plans in Pennsylvania
Over 2.5 million Pennsylvania residents are 65 and above, making up about 19.23% of the State’s population. Since Pennsylvania’s life expectancy is just under 77, medical insurance plans are essential to lowering healthcare bills for older adults.
The increase in medical needs with growing age is inevitable. In 2024, hospital bills are soaring due to high inflation. In these times, it is challenging to manage healthcare costs.
Health insurance plans in Pennsylvania, such as Medicare Advantage plans, mitigate the high costs associated with medical and hospital bills. Consequently, a whopping 2.8 million Pennsylvanian residents use Medicare plans to lower healthcare bills.
Beneficiaries enrolled in Original Medicare have the choice to join a Medicare Advantage plan. A Medicare Advantage plan works as an alternative to the standard Medicare plan. It consolidates the benefits of Medicare Parts A and B but offers additional benefits such as coverage for vision, hearing, and dental care.
As of 2024, nearly 49% (1.3 million) of all Pennsylvania residents with Medicare are enrolled in private Medicare Advantage plans. The State is served by 281 Medicare Advantage plans.
Medicare Advantage Networks
Medicare Advantage plans in Pennsylvania feature networks available in different areas of the State. Hence, each plan option is based on a ZIP code. These plans have varying copayments, premiums, and deductibles due to varying providers and coverage options.
The standard plans start at a $0 premium across the State. Every Medicare-eligible person in Pennsylvania has access to this $0 premium Medicare plan. Notably, Pennsylvania’s average monthly premium for a Medicare Advantage plan is $27.94.
These private Medicare Advantage plans consist of specific networks they collaborate with. Consequently, they come with one limitation—a restricted choice of healthcare providers.
This means that Medicare beneficiaries cannot seek treatment outside of their network. To consult a specialist outside your network of choice, you require pre-authorization or a referral from your primary healthcare provider.
General Analysis | Ratings of Medicare Plan Providers in Pennsylvania
| Insurance Company | Medicare Rating | A.M. Best rating | Better Business Bureau (BBB) rating | J.D. Power ranking |
| Aetna | 4 stars | A+ | A+ | 6th out of 9 |
| Cigna | 4 stars | A- | Not rated | 8th out of 9 |
| Highmark | 4.5 stars | A | A- | 3rd out of 9 |
| Humana | 4 stars | A- | A+ | 2nd out of 9 |
| UnitedHealthcare | 3.5 stars | A- | A | 4th out of 9 |
Types of Medicare Advantage Plans
The State of Pennsylvania has four types of Medicare Advantage plans. Depending on your healthcare needs, you can enroll in any of the following plans.
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Special Needs Plans (SNPs)
- Private Fee-For-Service Plans (PFFS)
Let us look into the details of these Medicare Advantage plans to help you make an informed decision.
Health Maintenance Organizations (HMOs)
An in-network provider, typically called an HMO provider, is an approved healthcare expert within the plan’s network.
In an HMO plan, beneficiaries receive care from a doctor, healthcare physician, or a hospital within their network of choice.
In emergencies, beneficiaries require pre-authorization or referral from their primary healthcare provider to consult another specialist outside their network. HMO plans mostly include prescription drug coverage.
Preferred Provider Organizations (PPOs)
PPO, another type of Medicare Advantage plan, allows you to receive medical care from both in-network and out-of-network providers. But seeking out-of-network care typically costs more than your standard plan. But this plan doesn’t restrict you to your primary care doctor.
You also don’t require a referral from your primary care physician to consult physicians outside your network. However, you incur relatively lower costs for medical experts and hospitals within the plan’s network.
Special Needs Plans (SNPs)
SNPs are ideal for beneficiaries with specific diseases who require specialized healthcare. Individuals with chronic conditions, living in nursing homes, or those who have both Medicaid and Medicare receive tailored benefits.
Generally, beneficiaries are limited to the plan’s network of providers. Pre-authorization is required to consult physicians outside the network. SNPs also include prescription drug coverage.
Private Fee-For-Service Plans (PFFS)
PFFS allows you to consult any Medicare-approved provider within your State. Hence, you’re not obligated to see a specific healthcare expert. Thus, PFFS plans work the same as Original Medicare, but you can visit any doctor at any hospital if they agree with the plan’s payment terms and conditions. These plans have fewer restrictions.
However, this plan establishes the pay rate for the doctor, the hospital, and the healthcare provider, as well as your out-of-pocket expense for the care you receive.
In some PFFS, you have a network of providers where you incur lower costs. However, your plan may not always have prescription drug coverage.
Comparison of the Top-Rated Medicare Advantage Plans in Pennsylvania
As of 2024, the following are Pennsylvania’s best Medicare Advantage plans. Here’s a comparison.
| Insurance company | CMS Star Rating | States available | Members in high-rated plans | Member experience |
| Humana | 4.3 | 49 states | High (90% or more) | Above average |
| UnitedHealthcare | 3.8 | 49 states | Medium (50% to 89%) | Average |
| Blue Cross Blue Shield | 3.8 | 48 states | Medium (50% to 89%) | Above average |
| Aetna | 3.9 | 46 states | Medium (50% to 89%) | Above average |
| WellCare | 3.0 | 37 states | Low (49% or less) | Below average |
| Cigna | 3.7 | 29 states | Medium (50% to 89%) | Above average |
Benefits of Medicare Advantage Plans in Pennsylvania
Medicare Advantage plans provide a range of additional benefits with your standard coverage options.
These benefits include coverage for wellness programs, hearing services, dental care, vision care, transportation services, meal accommodation, telehealth services, OTC benefits, chronic condition management, etc.
Hence, Medicare Advantage plans work as a bundled coverage option for beneficiaries seeking an all-in-one solution.
Since Pennsylvania has about 281 Medicare Advantage plans, it’s crucial to look into the supplemental benefits your plan of choice offers before enrolling yourself to choose the best available health coverage.
Here are the common benefits offered with Medicare Advantage plans in Pennsylvania.
Hospital and Medical Insurance
Medicare Advantage plans in Pennsylvania combine hospital and medical insurance, providing the same coverage as Original Medicare Parts A and B. This ensures that you receive primary coverage with your healthcare services.
Prescription Drug Coverage (Part D)
Most Medicare Advantage plans include prescription drug coverage to lower the out-of-pocket costs associated with prescription medications. Therefore, in most cases, you don’t require additional prescription drug coverage with a Medicare Advantage plan in Pennsylvania.
Dental Care
Medicare Advantage plans also offer preventive dental services, including routine checkups, scaling, and medically deemed necessary dental procedures.
Vision Care
Comprehensive Medicare Advantage plans also provide coverage for routine eye examinations, eyeglasses, and contact lenses, promoting better eye health.
Hearing Services
Some Medicare Advantage plans offer coverage for hearing exams. These plans typically cover hearing aids and other necessary equipment.
Wellness Programs
Many Medicare Advantage plans include wellness programs, such as gym memberships, fitness classes, and yoga classes, with the primary aim of bettering beneficiaries. Such plans help older adults achieve a healthy lifestyle and combat healthcare problems that arise from a lack of fitness.
Transportation Services
Various Medicare Advantage plans offer assistance with transportation services. These plans ensure you access medical care at facilities more conveniently since you don’t have to worry about transportation to and from a hospital.
Over-the-Counter Benefits
OTC benefits allow beneficiaries to purchase over-the-counter items, non-prescription medications, drugs, and health-related products.
Chronic Condition Management
Chronic condition management includes specialized care for individuals with long-term health problems. Medicare Advantage plans with this benefit are ideal for individuals who require comprehensive healthcare. However, such plans may have a higher premium.
Cost of Medicare Advantage Plan in Pennsylvania
The average monthly premium in 2024 for a Medicare Advantage plan in Pennsylvania is $27.94.
Certain Medicare Advantage plans also require you to pay out-of-pocket premiums, deductibles, copayments, and coinsurance.
These additional costs are associated with supplemental benefits and may vary from provider to provider. Therefore, you must familiarize yourself with deductibles, copayments, and coinsurance to avoid higher out-of-pocket premiums.
- Deductibles are expenses that you cover before Medicare provides coverage for health services. Thus, deductibles apply to all Medicare plans, including the standard Original Medicare.
- A copayment is a fixed payment for a doctor’s visit or a prescription drug. This amount is paid after you pay your deductibles, thus covering certain supplemental benefits.
- Coinsurance is a cost-sharing method in which you pay a percentage of the total amount for specific services after paying your deductibles. Your insurance plan covers the rest of the cost.
Medicare Advantage plans usually charge a copayment instead of the 20% coinsurance you pay under Original Medicare. Also, Medicare Advantage plans significantly vary from provider to provider and plan to plan. Therefore, looking into your plan’s requirements before signing up is best.
Medicare Eligibility and Enrollment in Pennsylvania
What makes you eligible for Medicare in Pennsylvania, and how can you enroll? Medicare has the same eligibility criteria across all the States. You qualify for Medicare if:
- You are 65 years old or above
- You have a medical disability
- You have end-stage renal disease (ESRD)
- You have amyotrophic lateral sclerosis (ALS)
To qualify for Medicare services, the Social Security Administration must also approve your age or disability.
You can enroll yourself in a Medicare plan during the initial enrollment period or wait for the general enrollment period.
However, if you have been receiving your Social Security benefits four months before your 65th birthday, you will automatically get enrolled into Medicare. Otherwise, you must apply through mail or by contacting a local Social Security office.
Enrolment Period in Pennsylvania
Medicare has an initial enrolment period (IEP) and a general enrolment period (GEP). The initial enrollment period is 7 months, starting 3 months before your 65th birthday.
However, if you miss your IEP, you can access Medicare by applying for it during the general enrollment period (GEP) between January 1st and March 31st every year.
Why Is Medicare Vital for Pennsylvania Residents?
Pennsylvania is the 5th most populous State. According to the US Census Bureau, 27.5% of Pennsylvania’s population will be 60 and older by the year 2030, an increase of almost 28% from 2012.
With these demographics, programs such as Medicare are vital in the region to assist seniors in lowering expenses associated with medical and hospital bills.
Moreover, Pennsylvania has unique health implications due to its varying climatic conditions, such as humid summers and extremely cold winters, which aggravate respiratory diseases.
Besides this, urban areas with high air pollution also contribute to respiratory conditions such as asthma, bronchitis, and COPD. The changing weather conditions also extend the season for ticks, resulting in a higher risk for Lyme disease, which is prevalent in Pennsylvania.
Due to this, senior adults are prone to health-associated risks and require routine checkups. With Medicare Advantage plans, older adults can leverage healthcare insurance programs with supplemental benefits to enhance their quality of life and lower healthcare bills.
Medicare Pennsylvania Resources
Certain organizations in Pennsylvania offer guidance and counseling to senior adults. These organizations provide channels through which Pennsylvania residents can gather information about Medicare plans. Here are some of the most important resources for Medicare in Pennsylvania.
| Organization | How you can get help | Website & Contact Info |
| Pennsylvania Department of Aging (PDA) | The Pennsylvania Department of Aging (PDA) supports senior citizens by providing them with care facilities, protective measures, and channels for reporting elder abuse. | Website | (717) 783-1550 |
| Pennsylvania Department of Human Services (DHS) | The Pennsylvania Department of Human Services (DHS) runs a Medicaid program, known as Medical Assistance, offering health coverage to qualifying low-income seniors or those with limited resources. | Website | (866) 550-4355 |
| Pennsylvania Insurance Department | The Pennsylvania Insurance Department provides senior citizens with online insurance information. | Website | (877) 881-6388 |
| Pennsylvania Area Agencies on Aging | The Pennsylvania Area Agencies on Aging supports local seniors by helping them develop community-based long-term care. | Website | (717) 783-1550 |
Select the Right Medicare Advantage Plan With Silveredge in Pennsylvania
In the State of Pennsylvania, the major public health risks due to the warming climate affect the overall health quality of residents.
Considering 2.5 million Pennsylvania residents are aged 65 and above, inevitable health problems arise. Due to this, services such as Medicare are deemed necessary in the region to cut down expenses associated with healthcare.
With more than 280 Medicare Advantage plans in the region, it may seem challenging to pick a plan that best suits your needs. With Silveredge, you can compare various Medicare Advantage plans in your State to select a coverage option that’s ideal for your health status.
Licensed advisors at Silveredge also provide guidance regarding Medicare plans, enrollment, and more. Contact Silveredge today for a streamlined Medicare experience!
