Medicare Advantage Plans in Pennsylvania

There aren’t many things in life that are perfect and, like most things, Medicare has both its pros and cons.

With more than 200 Medicare Advantage plans available in Pennsylvania in 2023, pinpointing the right one for you isn’t a simple task. On this page we’ll help you understand how Medicare Advantage plans in Pennsylvania work, and explain when and how you can enroll.

While there are hundreds of Medicare Advantage plans in Pennsylvania,  you won’t have quite that many to choose from. The availability of Medicare Advantage plans varies based on geographic location. This is because many Medicare Advantage plans in Pennsylvania are either HMOs (Health Maintenance Organizations) or PPOs (Preferred Provider Organizations). These organizations create a network of local providers and facilities. The insurance companies negotiate with these providers to receive discounted rates. In return, their subscribers will utilize the in-network or chosen providers.

When you look for a Medicare Advantage plan in Pennsylvania, you may have a range of plans to choose from. Some will offer Part D (prescription drug) plans in combination, some may have a $0 premium, and others will provide extra benefits such as dental, vision or hearing coverage. The availability and choices allow you to prioritize what you’re willing to pay and what coverage types you most need.

Regardless of plan type, Medicare requires all Medicare Advantage plans to offer at least the same coverage as Parts A and B of Original Medicare. Many may offer expanded coverage.

The average Pennsylvania resident pays $30.05 for their monthly Medicare Advantage premium in 2023. However, there are several Medicare Advantage plans available in Pennsylvania that have a $0 premium, and 100% of Pennsylvanians have access to a Part C plan with a no-cost premium. However, a $0 premium plan may not be the right fit for you.

Medicare Advantage plans can offer $0 premiums because they will receive money from Medicare to provide your insurance coverage. Through negotiation with providers and facilities, they can ideally manage your care without charging you a premium. However, if you pay a premium, you may have a lower a deductible, copayment or coinsurance. These differences depend upon the plan.

Qualifying for a Medicare Advantage plan is not too different from qualifying for Original Medicare.

How do you qualify for Medicare Advantage? You must begin with Medicare Parts A and Part B of Original Medicare. If you are not eligible for Part A and Part B, you don’t qualify for Medicare Advantage. So, if you’re an American citizen (or have been a permanent resident for at least five years) who is 65 or older, you’re eligible for Part A and Part B. Also, you can qualify for Medicare due to disability, even if you’re under age 65.

In most cases, eligibility for Medicare Advantage is simple. First, you must be enrolled in Medicare Part A and Part B, or be eligible to enroll. Second, you must live in the area covered by the plan that you want. This is an essential detail because Medicare Advantage plans cover specific areas and are not portable. You may be able to see an out-of-network provider, but it will typically cost more.

You will have the opportunity to enroll in Medicare Advantage when you are initially enrolled in Medicare Parts A and B — called your Initial Coverage Election Period. Alternatively, if you’re already enrolled in Parts A and B, you can switch to a Medicare Advantage during the Medicare Open Enrollment Period, also called the Annual Enrollment Period, which runs from October 15 to December 7 each year. When you enroll in a new Medicare Advantage plan at this time, your coverage will begin January 1.

Medicare releases a rating system of Medicare plans no later than October 8. Their ratings system takes into account many factors, including customer reviews and complaints. If you’d like to see what plans are offered in your area, and what they cover, a GoHealth licensed insurance agent can assist you.

Most Medicare Advantage plans in Pennsylvania include drug coverage. But not all drug plans are equal. If you sign up for Part C with drug coverage, you’ll want to make sure your new plan covers the medications you need.

When you compare prescription drug plan coverage, it’s important to review a plan’s formulary. This is the listing of medications a prescription drug plan covers. The insurance company will usually split the formulary into five categories. Generic medications are often Tier 1 medications and cost you the least. Tier 5 medications are specialty drugs that will usually cost you more. Medicare requires that all formularies include at least two medications in every major drug category.

The key is finding the right combination of covered prescription drugs with a monthly premium that’s affordable.

If you try a Medicare Advantage plan and you aren’t happy with it, there are some protections that allow you to make a switch. Like almost everything with Medicare, this must be accomplished within a certain timeframe. From January 1 through March 31, you can modify your Medicare Advantage coverage by switching to another Medicare Advantage plan, or you can go back to Original Medicare.