Medicare Advantage Plans in Pennsylvania
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: Jun 25, 2021
Original Medicare consists of Part A for hospital coverage and Part B, which is major medical. For those seeking an alternative to Original Medicare, Medicare Advantage plans are an option. Medicare Advantage plans (Part C) offered to Pennsylvania seniors includes both hospital and major medical coverage, but often also have ancillary services that may not be covered under Original Medicare. Pennsylvania Advantage plans may include hearing services, vision coverage, and dental, in addition to a prescription drug plan. These plans are offered by private insurance companies that meet Medicare standards.
- 1 In 2019, there were 160 Medicare Advantage plans available in Pennsylvania.
- 2 40% of the total Medicare population in Pennsylvania is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $10,149 per beneficiary in Pennsylvania, which is 1% higher than the national average.
- 4 Available Medicare Advantage plans range from 33 to 81 across Pennsylvania’s 67 counties.
When choosing healthcare coverage, Pennsylvania seniors can select from a range of Medicare Advantage plans with differing out-of-pocket costs and coverage levels. All plans offered to Pennsylvania residents must meet the minimum standards outline by Medicare and provide the same protections available through Medicare Parts A and B. Not all plans are available in all regions, but seniors can often choose from among four options — Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-For-Service plans, and Special Needs Plans.
Medicare Advantage Plans in Pennsylvania
Types of Medicare Advantage Plans
Pennsylvania’s Medicare Advantage Program consists mainly of HMOs and PPOs. There are a few PFFS plans offered in some counties and a limited number of SNPs available in certain areas. Many private companies offer these plans, each with different coverage and expected out-of-pocket costs. All Medicare-approved plans must include Part A and B coverage. Special rules may limit enrollment in some of these plans, SNPs in particular.
Health Maintenance Organizations (HMO)
When enrolled in an HMO plan, seniors access care through an approved network of hospitals, doctors, and other health care professionals. In most cases, all services must be provided through in-network health professionals in order for insurance to pay for care. However, there are exceptions for emergency care, urgent care while traveling, and out-of-area dialysis. Seniors enrolled in a Medicare HMO must select a primary care physician to act as the care coordinator. The PCP must provide referrals to all specialists and make final care decisions. While restrictive in how enrollees can access care, HMOs are often affordable with low or no deductibles.
Preferred Provider Organizations (PPO)
Like HMOs, PPO plans also have a network of providers, but these plans offer more flexibility and control over care providers. Members of a PPO can often select out-of-network providers at a lower reimbursement rate. To minimize out-of-pocket expenses, members should stay in-network when looking for doctors. There is often no need to select a specific primary care doctor, and seniors may not need referrals to access specialist services. PPOs tend to cost more than HMOs and always come with a deductible, but the tradeoff is greater flexibility in seeking out care.
Private Fee-For-Service Plans (PFFS)
A PFFS plan is distinctly different from HMOs and PPOs since it may or may not have a network of care providers. If it does have a network, that network is not a limitation but rather a group of providers guaranteed to accept the PFFS terms. PFFS plans offer a set payment amount for covered services and dictate reimbursement levels. Seniors on a PFFS plan can seek out treatment at any location that accepts the payment terms. With this type of insurance, there are no surprises in billing since cost-sharing amounts are listed before the service is provided. These plans offer the greatest flexibility when selecting doctors, but may also have the highest premiums.
Special Needs Plans (SNP)
Seniors with certain preexisting conditions may opt for SNP plans. Medicare Advantage plans are typically not available to those with End Stage Renal Disease unless an SNP is offered in their area. SNPs tailor their benefits to meet the needs of those with specific illnesses. The pharmacy formulary might cover drugs often prescribed to those with one of the covered conditions, and the plan might have a network of specialists available for treatment. Like an HMO, members must receive their care in-network, and there may be strict geographic limits on service areas.
Enrollment & Eligibility for Medicare Advantage Plans in Pennsylvania
When seniors become eligible for Medicare, they also become eligible to enroll in one of Pennsylvania’s Medicare Advantage plans. Enrollment typically starts at age 65, though those younger may qualify with a disability. To opt for a Medicare Advantage plan, seniors must:
- Live in a covered region for the desired Medicare Advantage plan
- Opt-out of Medigap insurance
- Have U.S. citizenship or permanent resident status
- Not be diagnosed with end-stage renal disease (SNPs are an exception)
In Pennsylvania, seniors who start receiving Social Security benefits or Railroad Retirement Board benefits are automatically enrolled in Original Medicare when they reach age 65. To select a Medicare Advantage plan, seniors can choose before their automatic enrollment or switch during an approved enrollment period.
There are several annual enrollment periods after the initial enrollment, and the option to select a Medicare Advantage plan may only be open to first-time members or existing members who would like to change their plan. Here’s a quick overview of the four enrollment periods that may affect Medicare Advantage plans.
- Initial Enrollment Period. For three months prior to a senior’s 65th birthday, during their birthday month, and for up to three months after, seniors can enroll in Medicare. Those who would otherwise be automatically enrolled in Original Medicare should select an advantage plan before their birthday month.
- Annual Election Period. Current Medicare members can switch to an Advantage plan from Original Medicare or change their Advantage plan during the annual election period that runs from October 15th to December 7th.
- Open Enrollment. Starting on January 1st, current Medicare Advantage members can change their plan or switch back to Original Medicare. This period ends on March 31st.
- General Enrollment. The general enrollment period runs from April 1st until June 30th. It allows those enrolled in Part B for the first time during the previous open enrollment period to select an Advantage plan.
Prescription Drug Coverage
In Pennsylvania, many Medicare Advantage plans include prescription drug coverage and are listed as MA-PD plans. In some cases, the premium may include drug coverage, or there may be a separate premium for prescriptions. Any senior enrolled in a Medicare Advantage HMO or PPO is prohibited from enrolling in Medicare Part D, the standalone Medicare prescription plan. If a senior does enroll in Part D while on a Medicare Advantage HMO or PPO, they are automatically switched to Original Medicare. SNPs all include prescription drug coverage as a legal requirement, while PFFS plans do not affect a senior’s ability to enroll in Part D.
Medicare Advantage Resources in Pennsylvania
For seniors, access to affordable health care is critically important. Medicare Advantage plans offer comprehensive coverage but can be confusing to those unfamiliar with comparing insurance plans. Pennsylvania’s Medicare Advantage program includes 160 different options, all with a separate set of out-of-pocket expenses, deductibles, co-pays, and other policy limits that may impact decision-making. To help seniors make the best decision regarding their health care insurance, Pennsylvania has state and local resources available to provide Medicare counseling.
APPRISE is a program managed by the Pennsylvania Department of Aging and is offered through a network of Area Agencies on Aging locations as Pennsylvania’s State Health Insurance Assistance Program (SHIP). Trained volunteers offer seniors free counseling concerning Medicare and benefits available. Volunteers are unbiased and have no financial motive involved in the decision-making process. Counselors can help with the application process and enrollment in Original Medicare or an Advantage Plan. They may also offer assistance when filing claims or appeals through a Medicare Advantage plan.
Contact Information: Website | 800-783-7067
Medicare Cost-Savings Programs
The Pennsylvania Department of Aging offers counseling and assistance to seniors that may have financial difficulties when faced with the cost of health care. It administers the Extra Help program, also known as the Part D Low-Income Subsidy, the Medicare Savings Program, and the Medicare Preventive Services program. For more information about these programs or help with the application process, contact a local Area Agency on Aging.
Contact Information: Website | 717-783-1550
Berks Encore is a nonprofit that offers Pennsylvania residents counseling and help accessing a variety of assistance programs. In addition to Medicare counseling, its staff members also provide information about several programs, such as LIHEAP, medical assistance, PACEplus, food stamps, and long-term care insurance, among others. Free appointments are available at multiple centers throughout the state. For seniors that would prefer to receive information over the phone or by email, that is also an option.
Contact Information: Website | 610-374-3195 ext. 208
- Sources [-]
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp | Last accessed June 2021
https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b | Last accessed June 2021
https://www.medicare.gov/blog/medicare-enrollment-period-2020 | Last accessed June 2021
https://www.medicare.gov/Pubs/pdf/11135-prescription-drug-coverage-with-ma-mcp.pdf | Last accessed June 2021
https://www.aging.pa.gov/aging-services/medicare-counseling/Pages/default.aspx | Last accessed June 2021
https://www.aging.pa.gov/local-resources/Pages/AAA.aspx | Last accessed June 2021
https://www.aging.pa.gov/aging-services/medicare-counseling/Pages/medicare-cost-savings.aspx | Last accessed June 2021
https://berksencore.org/services/referrals/medicare-counseling-services/ | Last accessed June 2021
Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.