Medicare Advantage Plans in Pennsylvania

Pennsylvania Medicare Advantage plans are managed by private insurance companies and provide additional benefits that make them stand out from Part A and B of the Original Medicare system. Part A covers inpatient hospital care, while Part B provides services such as doctor visits, preventive screenings, and durable medical equipment. However, with a Medicare Advantage plan, you may access additional benefits, including dental coverage, routine vision exams, and discounts on gym memberships.

Pro tip: It is essential to remember that not all plans include coverage for dental, vision, and hearing services.

Thoroughly considering the available plans from various companies will ensure you choose an option that both suits your medical needs and includes the use of all of your existing healthcare providers.  

What Do Medicare Advantage Plans Cover?

Medicare Advantage plans cover all the benefits of Original Medicare Part A (hospital insurance) and Part B (medical insurance), and Part D (prescription drug coverage). They often also have extra benefits that aren't included in Original Medicare.

Advantage plans cover:

Medically necessary outpatient services, such as:

• Doctor's visits
• Ambulance services
• Emergency and urgent care
• Durable medical equipment (DME)
• Mental health care      
• Laboratory tests

Preventive services, such as:

• Vaccinations
• Cancer screenings
• Diabetes screenings
• Depression screenings

Depending on the plan you choose, other benefits may include the following:

• Prescription drug coverage
• Regular eye exams with glasses coverage
• Routine dental check-ups
• OTC medication
• Yearly hearing tests with hearing aid discounts
• Fitness and wellness programs/discounts
• Transportation to the required medical care facility

Types of Medicare Advantage Plans in Pennsylvania

In Pennsylvania, four plans are available through the Medicare Advantage program: HMO, PPO, PFFS, and SNP.

Health Maintenance Organization (HMO) - You will need to receive all services from providers in the network.

This includes:

• Primary care physicians
• Referrals for specialists
• Prior authorizations for treatments and some prescriptions
• Drug coverage is usually included with this type of plan, so you do not need to purchase a standalone drug coverage.
• The upside to this policy is that costs tend to be lower if you stay within the network of approved providers.

Preferred Provider Organization (PPO) -You will have a network of preferred providers, but you can see doctors or hospitals outside the network for additional costs. You don't need to designate a primary care doctor or get specialist referrals.

• Drug coverage is usually included in these plans.
• You cannot purchase standalone drug coverage with PPOs.
• The drawback to this type of plan is higher premiums and out-of-network costs.

Private Fee-For-Service (PFFS) - PFFS plans don't require a primary care physician or referrals for specialists.

• Here's how it works: you can go to any Medicare-approved healthcare provider or facility that accepts the plan's payment terms and agrees to treat you. However, it's essential to know that some providers may not agree to the plan's terms, which could result in higher out-of-pocket costs.
• Another thing to remember is that these types of plans may include drug coverage, or you can purchase a standalone drug plan.

Special Needs Plan (SNP) - SNPs are for people with pre-existing conditions or other specific health needs.

They include care coordination and benefits that target your individualized needs, such as:

• You will be assigned a Primary Care Physician (PCP) and referrals to any specialists you need.
• All of your drugs will be covered under this insurance plan.
• If you believe you meet the criteria for an SNP, you can enroll any time throughout the year.

Your network's care providers' levels of flexibility differ between each type and the price. Although all Medicare Advantage plans cover the same services provided in Original Medicare, you may be required to pay a higher premium for extra benefits.

What Does It Cost?

On average, premiums for a standard Medicare Advantage plan range from $0.00 - $295.00 per month.

Here's how you can figure out your total cost.

There are four costs to consider:

• The Medicare Part B premium - you will still have to pay your Part B premium after buying an Advantage plan. The 2024 premium is $174.70 per month.
• Monthly premium - many Advantage plans have no monthly premium, but several of them do, so always make sure to check. Premiums vary by provider.
• Deductible - the amount you must pay out-of-pocket before your Advantage plan starts covering your care.
• Copays and coinsurance - what your Advantage plan charges you each time you see a medical provider.

When Am I Eligible?

To be eligible for a Pennsylvania Medicare Advantage plan, you must enroll in Parts A and B of Original Medicare. You also cannot have a Medigap policy. If you're 65 or older or receive disability benefits from Social Security or the Railroad Retirement Board (RRB), you qualify for enrollment. However, two groups can enroll at any age: those with End-Stage Renal Disease (ESRD) and those with amyotrophic lateral sclerosis (ALS).

When Can I Sign Up?

There are three periods when you can enroll:

• The Initial Coverage Election Period is when you first become eligible. This includes the three months before your 65th birthday, the month of your birthday, and the three months following. If you have a disability, this period will occur during your 25th month of receiving benefits.
• The Annual Election Period is the time of year when you can switch your Medicare coverage. If enrolled in Original Medicare, you can switch to a Medicare Advantage plan during this period. If you're already enrolled in a Medicare Advantage plan, you can shop around and switch to another plan that better meets your needs during this time. The Annual Election Period runs from October 15 to December 7 each year.
• The Open Enrollment Period is the time of year when you can change your Medicare Advantage plan or go back to Original Medicare. This period takes place between January 1 and March 31.

Medicare allows for a special enrollment period under extraordinary circumstances, such as job loss or moving to an area where your current carrier does not service.

How to Choose a Medicare Advantage Plan in Pennsylvania

When choosing a plan, you should consider the following before buying:

Provider Network: To keep costs down, ensure your doctors, hospitals, and pharmacies are all in-network.

Out-of-pocket max: Following the plan's rules for in and out-of-network coverage, this is the most you'll spend on Medicare-covered services, besides your premium, deductible, and drug costs.

Deductibles, coinsurance & copays: Cost-sharing expenses are charged when you use your benefits. Review your plan to see what doctor's visits, services, treatments, and prescription drugs cost.

Drug coverage/formulary: Use the plan's formulary to see if your drugs are covered and how much they cost per prescription. You might want to discuss generic or alternative options with your doctor.

Additional benefits: In addition to basic coverage, think about what other benefits are most important. For example, many plans require using network providers and may have additional charges for more comprehensive protection.

Ready to Learn More?

We help educate Medicare beneficiaries on their options and help them go through the process of reviewing and comparing plans. We work with most of the nation's top-rated insurance carriers, such as Aetna, Cigna, Mutual of Omaha, and Florida Blue. So, call us today, or request a quote online to learn more.