If you are a Medicare beneficiary in Pennsylvania, you may be able to modify your coverage to meet your need better. Find out about the state-run assistance programs available to anyone in Pennsylvania without the means to pay for Medicare or who has additional inquiries about the program. Which Medicare choice, or combination of options, is best for you will depend on your information. Let’s examine in full depth the types of healthcare services Medicare plans in Pennsylvania provide and the enrollment requirements for each.

Overview of Pennsylvania’s Medicare program

Before explaining anything, let’s take a look at the various components that come together to provide Medicare coverage. There are four different parts to Medicare: Part A, Part B, Part C, and Part D.

Original Medicare consists of Part A, which is commonly referred to as coverage for medical treatment received in a hospital, and Part B. (sometimes known as physician care coverage). The government is in charge of administering the original version of Medicare. Suppose you start receiving retirement benefits before you turn 65. In that case, you will typically be automatically enrolled in both Part A and Part B of Medicare when you sign up for the program. You are required to withdraw from Part B to avoid paying the associated premium if you do not wish to participate in Part B.

Medicare Advantage plans include Part C, which is not included in Original Medicare, as one of their benefits. Private insurance companies that have been granted approval by the Centers for Medicare & Medicaid Services are the only ones that may sell you Part C coverage. It covers at a bare minimum the same things that Original Medicare (Parts A and B) does, and it might cover considerably more than that.

Point to ponder:

You will have to spend less out of pocket for prescriptions thanks to the prescription drug benefit included in Medicare Part D. This benefit helps pay for some of the medications you use. Private insurance companies that CMS has sanctioned are the ones who provide coverage for Part D. These insurance companies may provide Medicare Prescription Drug Plans that operate independently or Medicare Prescription Drug Plans that are packaged together with Medicare Advantage (PDP).

Private insurance firms also offer coverage known as Medigap, which stands for Medicare Supplement Insurance. These additional insurance policies could be able to help you pay for some of the expenditures that Original Medicare does not cover. This is because Original Medicare only covers a portion of medical expenses.

Medicare Part A in Pennsylvania

If you are at least 65 years old, a US citizen or a legally permanent resident who has lived in the country for at least 5 years in a row, you may qualify for a pension. If you are permanently disabled, have been getting disability payments from Social Security or the Railroad Retirement Board for at least 24 months, and are younger than 65, you may be eligible for Medicare. Also, you may be able to get Medicare at a younger age if you have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS), ESRD, or both. Dialysis or a kidney transplant are needed to treat these conditions.

Medicare Part A covers inpatient hospital care, some home health care, hospice care, and skilled nursing care for inpatients who need it (like when they are moving from inpatient hospital care to care at home). Part B of Medicare, which works with Part A, pays for services like lab tests, doctor visits, and preventive care that don’t happen in a hospital. Part B of Medicare also pays for durable medical equipment and some home health care.

If a Medicare recipient has worked for at least ten years (40 quarters) and paid Medicare taxes, they do not have to pay a premium for Medicare Part A coverage. They may have to pay a premium if they have not worked for at least ten years (40 quarters). Most Medicare recipients pay a monthly fee for Part B insurance on top of any Part A and Part B deductibles, copayments, and coinsurance fees.

Services that are not covered:

However, not all healthcare services and products are covered under Original Medicare, Parts A and B. You might be required to pay for the following:

  • Most prescription medications
  • Long-term custody services (nursing home care)
  • Typical dental procedures and dentures
  • Regular eye exams, eyeglasses, and contact lenses
  • Health care services obtained abroad.

Prescription drug coverage in Pennsylvania (under Medicare Part D)

To get Medicare coverage for prescription drugs, you must have Medicare Part A or Part B and living in an area where a Medicare plan with prescription drug benefits is available (Medicare Part D).

Some of the cost of prescription drugs may be covered by Medicare Part D or Medicare prescription drug coverage. Separate Medicare Prescription Drug Plans fill in the gaps between Original Medicare and your needs for prescription drugs. As was already said, a Medicare Advantage plan that covers prescription drugs is another way to get this coverage.

A lot of the prescription drugs that Medicare recipients often take are covered by Medicare Prescription Drug Plans & Medicare Advantage Prescription Drug Plans. If you want Medicare prescription drug coverage, you should look at the plan’s list or formulary of covered prescriptions to see if the drugs you take are on it. Remember that the formulary is always subject to change. Your Medicare plan will tell you what you need to know.

The cost of the Medicare Part D premium is the same every month. In exchange for your monthly premium, your insurance company will pay some of the costs of your covered prescription drugs. Depending on how much money you make, you may be able to get “Extra Help” to cover all or part of your premium costs. The Extra Help program helps low-income beneficiaries pay for some of their prescription drug costs. If you don’t qualify for cost help, the Medicare plan you’re enrolled in will decide how much you have to pay for Part D.

How can I find affordable Medicare Advantage Plans in Pennsylvania?

We compared the plans in Pennsylvania based on their five-star quality ratings from the Centers for Medicare & Medicaid Services to help you select the right Medicare Advantage plan.

We also dissected the various plans to see which ones provide solid choices if you require prescription coverage and want to lower out-of-pocket costs.

However, these are merely basic advice. We suggest you do your homework and confirm that the medical facilities and specialists you intend to utilize are included in the network of the insurance plan you decide to purchase.

Pennsylvania’s top Medicare Advantage plan overall.

Knowing your precise demands is crucial because the finest Medicare Advantage Plans in Pennsylvania for you could not be the greatest for someone else.

For instance, Aetna Medicare’s Choice Plan might be the best choice for you if you desire a PPO plan with prescription coverage, the six essential benefits, and a high star rating from CMS.

A health plan with flexibility and extensive coverage is known as a Preferred Provider Organization. Compared to a Health Maintenance Organization plan, it is more expensive.

On the other hand, PPOs provide bigger networks and permit you to visit experts without a referral, providing you with more access to medical professionals and facilities. PPOs are fantastic if you want a lot of freedom and can afford it.

Pennsylvania’s top HMO Medicare Advantage Plan

Your specific demands will determine which HMO Medicare Advantage Plan is ideal for you in Pennsylvania. According to our analysis, the Community Blue Medicare HMO Signature plan provided by Highmark comes out on top for our typical Pennsylvanian consumer who wants an HMO plan with drug coverage, the six essential benefits, and a high CMS star rating.

A health maintenance organization is the most prevalent and least expensive kind of health plan. An HMO is most likely the best choice for you if you have easy access to in-network providers and want to spend less each month.

However, keep in mind that unless there is an emergency, you must remain within your network provider to receive coverage. To see a specialist, you will also require a recommendation.

Pennsylvania’s top Medicare Advantage Plan without Drug Coverage

There are other options in Pennsylvania if you don’t require Part D prescription medication coverage. We discovered that Community Blue Medicare HMO Signature from Highmark is the best overall plan for our sample consumer in the state who needs a Medicare Advantage plan with or without medication coverage, including the six basic benefits and a high star rating from CMS.

Pennsylvania’s top Medicare Advantage plan for minimal out-of-pocket expenses

You may still have to spend thousands of dollars in out-of-pocket expenses for your Medicare Advantage plan, even if you pay low or no premiums. You can think about selecting a plan with a low in-network maximum out-of-pocket limit if you want to lessen your financial load.

Your right option in Pennsylvania for a Medicare Advantage plan with a low in-network MOOP limit, medication coverage, the six essential benefits, and a good CMS star rating is probably Aetna Medicare’s Advantra Silver (PPO) plan.

Pennsylvania’s Medicare Advantage Plans: Statistics

In Pennsylvania, there are 15 organizations from which you can choose a Medicare Advantage Plan. In order to aid you in identifying both uncommon and standard plan components provided by your potential provider, the following section offers facts concerning Medicare Advantage in Pennsylvania.

  • A mixture of HMO and PMO plans make up Pennsylvania’s Medicare Advantage Plans, with 80.7% of them including prescription coverage.

Preferred Provider Organization plans are slightly more prevalent in Pennsylvania than Health Maintenance Organization plans. About 80.7% of these plans cover prescription drugs. Both HMO and PPO plans are options to consider if you require a drug coverage plan.

  • In Pennsylvania, 51% of Medicare Advantage Plans have a $0 premium.

There are roughly 72 different premium-free plans in Pennsylvania, accounting for 51% of the market’s options. The average monthly premium for the remaining 49% of the plans is $83.90.

  • In Pennsylvania, hearing, telemedicine, and vision benefits are typical, with the majority of plans including them.

Hearing, telemedicine, and vision are the most frequent perks that come with a Medicare Advantage Plan in Pennsylvania. In-home assistance, emergency response equipment, and home safety devices & adaptations are among the state’s least common perks.

Questions and Answers (FAQs)

What must each Medicare Advantage plan contain?

Part A and Part B of Original Medicare are included in every Medicare Advantage plan. Eighty percent of the cost of hospital stays, skilled nursing care, home health care, and care received in a hospice is covered by Original Medicare Part A. 80 percent of the cost of doctor visits, preventative care, mental health therapy, physical therapy, occupational therapy, lab services, and other outpatient services are covered by the original Medicare Part B program.

What distinguishes Original Medicare from Medicare Advantage?

Some Medicare Advantage plans also include dental and vision insurance, hearing aid coverage, and fitness benefits. The majority of Medicare Advantage plans include coverage for prescription drugs under Part D, and some also include dental and vision insurance, hearing aid coverage, and fitness benefits. Original Medicare covers the same benefits as Medicare Advantage. Plans vary in their supplementary perks and coverages. Participants participating in a Medicare Advantage plan are responsible for paying both the monthly premium for Original Medicare Part B ($164.90 for the majority of individuals in 2023) and the monthly premium for their Medicare Advantage (Part C) plan, as outlined above.

Where can I get Medicare plans in Pennsylvania?

Medicare health insurance plans offered by various health insurance companies are well-reputed in the state. With the right qualifications, if you meet the requirements and eligibility criteria, which are not a big deal, you can get the best Medicare plans in Pennsylvania for you.

Some top-rated health insurance companies include Humana, Aetna, Blue Shield, and Anthem Cross.

Is there free health insurance in Pennsylvania?

Typical health insurance policies don’t come free. And same goes for Medicare insurance plans. To procure a Medicare plan in Pennsylvania, you must pay a few costs, like the premium and other expenses.

However, free Medicare plans may be available in the state for individuals who can only afford a free health insurance plan or cannot foot the bills due to unemployment or other reasons.

Ensure you check with the health insurance board, find out the requirements and eligibility criteria for a free Medicare plan, and see if you meet up. You can surely apply for and get a free plan if you do.

Who stands to gain the most from Medicare Advantage?

A Medicare Advantage plan offers easy coverage alternatives that a single insurer mostly provides to any eligible adult in the United States. Individuals with chronic medical problems and specific coverage needs may find Medicare Advantage plans with bundled coverage more affordable than Original Medicare and Medigap plans.


Other varieties and types of Medicare plans are offered by the top-rated health insurance companies in Pennsylvania that have Medicare coverage plans for American citizens and residents in the state.

Even better, you must procure a Medicare health coverage plan or one for your family. Of course, it’s a financially wide action to take and you don’t want the unbearable expenses that things would amount to if medical services are needed in case of any eventuality.

It’s equally important that you weigh things out and determine the best plan for you. If it would be either a typical Original Medicare plan or if it’s a Medicare Advantage or Medicare Supplement plan.

Make sure to get the right Medicare Advantage plan in this case, or compare Medicare Supplement plans to know what suits your financial budget. It yet offers the medical services you need in a healthcare insurance policy.

Visit our website medicareleads.com to learn more.