Pennsylvania Medicare Guide

Schedule a free consultation with one of our licensed Pennsylvania Medicare Advisors or give us a call at (888) 604-0055 to get started.

In this guide, you’ll learn the basics about Medicare in Pennsylvania to help you make the right Medicare choices and get the most value from Medicare.

Use this table of contents to jump to specific sections:

A Snapshot of Medicare in Pennsylvania

There are 2.8 million Pennsylvania Medicare beneficiaries, making up 22% of the state’s total population. Most beneficiaries are on Medicare due to age, but about 13% are on Medicare due to disability. 22% of Medicare enrollees also receive full or partial Medicaid benefits.

Medicare beneficiaries have options. One decision you need to make is whether to stay on Original Medicare or enroll in a Medicare Advantage plan. In Pennsylvania, 53% stay on Original Medicare and 47% move to Medicare Advantage.

Pennsylvania Medicare Eligibility and Enrollment Steps

All US citizens over the age of 65 are eligible for Medicare. You also may be eligible if you’re under 65 and have certain disabilities like ALS or End-Stage Renal Disease.

Medicare Enrollment Steps

1. Enroll in Original Medicare (Part A & Part B)

If you’re eligible for Medicare by way of turning 65, you have a seven-month window to enroll. This is called your Initial Enrollment Period (IEP). Your IEP starts three months before the month you turn 65 and ends three months after it. Some people choose to delay enrollment in Part B because they’re still working and receiving employer-linked health insurance. If you choose to delay Part B enrollment, just be sure you qualify for a Special Enrollment Period once you stop working to avoid paying a late enrollment penalty!

2. Compare additional coverage options

We mentioned that Medicare beneficiaries have options, specifically one between Original Medicare and Medicare Advantage. Which type of Medicare coverage you choose is up to you, and the decision should be based on your unique health and financial situation. We’ll explain more about your options under both Original Medicare and Medicare Advantage in the next section. If you have questions about your options or need advice, we’re here to help! Just give us a call at (888) 604-0055 to get personalized advice from one of our Pennsylvania Medicare Advisors.

3. Get the most value from Medicare

There are two things you should do to ensure you’re always getting the most value from Medicare. First, use your plan! Even if you don’t need to visit the doctor, schedule preventive services and share your prescription plan information with your pharmacy to make sure you’re utilizing your coverage. Second, use the Medicare Open Enrollment Period, which lasts from October 15 - December 7 every year to review your coverage and compare options. Medicare Advantage and prescription plans change every year, and your healthcare needs may too! In some cases, shopping around helps Medicare beneficiaries save thousands of dollars!

Pennsylvania Medicare Advantage Plans

There are 205 Medicare Advantage plans available in Pennsylvania. The plans and pricing available to you is dependent on the county you live in. For example, in 2023, Philadelphia County has 65 Medicare Advantage plans from eleven different insurance companies. York County has 73 plans from nine insurance companies.

Medicare Advantage combines Part A and Part B and must legally provide at least the same level of coverage. They also and generally provide coverage for prescription drugs and some dental, vision, and hearing services. Most insurance companies also tack on healthcare-related benefits, like:

Flex cards
Fitness perks
Transportation to doctor appointments
Meal services

Medicare Advantage plans are popular because they provide extra coverage and benefits and tend to have low or no premiums (although you still need to pay your Part B premium). They also have their drawbacks, including:

Limited networks
Preauthorization requirements
Higher out-of-pocket costs ( compared to coverage through Original Medicare + Medigap)

Pennsylvania Medicare Supplement Plans

Unlike Medicare Advantage plans, which replace Original Medicare, Medicare Supplement plans stack on top of Original Medicare to help cover the 20% of costs Medicare doesn’t pay. Medicare Supplement plans are also commonly referred to as Medigap plans, and there are ten of them in Pennsylvania, labeled by letters A-N. All of these plans significantly reduce your out-of-pocket costs, but Plan G is generally considered the most comprehensive. If you’re enrolled in a Plan G, once you meet your Part B deductible, you don’t owe anything else for the year for covered services!

In addition to low out-of-pocket costs that provide better financial stability, Medigap plans have a couple benefits that improve your access to care. Like Original Medicare, Medigap plans don’t have limited provider networks. You can see any doctor who accepts Medicare, which is about 90% of doctors nationwide. You also won’t have to get prior authorization for covered services.

The best time to enroll in a Medigap plan is during the Medigap Open Enrollment Period, which lasts for six months after your Part B effective date. During this time, you are guaranteed acceptance to any Medigap plan offered by any insurance company. Outside of this and a few other special guaranteed issue periods, insurance carriers are allowed to ask you questions about your health history and may charge you more or deny your application.

Pennsylvania Part D Plans

Original Medicare doesn’t cover prescriptions. If you enroll in a Medicare Advantage plan, there’s a good chance it covers prescriptions (just be sure it covers the prescriptions you need). If you’re on a Medicare Advantage plan that doesn’t have prescription coverage or you’ve decided to stay on Original Medicare, you can enroll in a stand-alone Part D (prescription drug) plan. There are 26 Pennsylvania Part D plans, but plan pricing and availability varies by county.

If you don’t need prescription coverage when you first enroll in Medicare, we recommend enrolling in a low-cost plan to avoid a Part D penalty later on when you do need coverage!

If you have questions about your Medicare options or want to compare plan benefits and pricing, schedule a free consultation with one of our licensed Pennsylvania Medicare Advisors or give us a call at (888) 604-0055.

Get help paying for Medicare in Pennsylvania

Pennsylvania Medicare enrollees with low income and resources can apply for government programs that can help pay for medical expenses.

Pennsylvania Medicaid

Medicaid is a joint federal and state program that helps US citizens with low income and resources pay for medical expenses. Each state is responsible for the implementation of Medicaid, and Pennsylvania’s Medicaid program is commonly called Pennsylvania’s Medical Assistance program.

Pennsylvania has a special program for older residents: Medical Assistance for Older People and People with Disabilities. Pennsylvania also offers Medicare Savings Programs (MSPs), which operate under an umbrella program called Healthy Horizons. These programs include:

Qualified Medicare Beneficiary (QMB) - Categorically Needy Program

This program is also known as Healthy Horizons in Pennsylvania. It helps individuals by paying for Part A and Part B premiums as well as Medicare deductibles and coinsurance. Individuals who are eligible for this program are also eligible for medical coverage through Pennsylvania’s Medical Assistance program.

Qualified Medicare Beneficiary (QMB) - Medicare Cost-Sharing

This program is also referred to as Healthy Horizons-Medicare Cost-Sharing. It helps individuals by paying for Part A and Part B premiums as well as Medicare deductibles and coinsurance.

Specified Low-Income Medicare Beneficiary (SLMB) Program

Eligible individuals receive help paying for Part B premiums.

Qualifying Individuals Group 1 (QI-1)

Eligible individuals receive help paying for Part B premiums.

Medicare Extra Help

If you have limited income and resources, you may be eligible for Extra Help, a federal program that helps pay for costs associated with prescription drug coverage. Extra Help is also commonly referred to as the Part D Low Income Subsidy (or LIS).

You automatically qualify for Extra Help if you:

Receive full Medicaid coverage from Pennsylvania
Pennsylvania pays your Part B premium
Are eligible for Supplemental Security Income (SSI)

If you don’t automatically qualify for Extra Help, you may still be eligible. Reach out to one of our licensed Pennsylvania Medicare Advisors to get free support with your application.

Supplemental Security Income (SSI) Benefits

Eligible US citizens receive monthly payments from the SSI program. You’re considered eligible if you meet the following criteria:

You are 65 and older, blind, or have a disability
You have limited income and limited resources

You can apply for SSI Benefits online or by calling 1-800-772-1213 / TTY 1-800-325-0778.

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