Medicare is a federal program to provide health insurance for people 65 and over.  When you become eligible for Medicare, you can choose how to get coverage: either through Original Medicare or a Medicare Advantage Plan.

Medicare Advantage Plans, also referred to as Medicare Part C, are bundled plans that provide the same coverage as Original Medicare Parts A and B through private, Medicare-approved insurance companies. Since Medicare Advantage Plans are offered by private insurers, the scope of coverage and cost of plans varies. Most of these plans also include prescription drug coverage and some may offer even more benefits such as vision, dental and hearing coverage.

Read this article to learn everything you need to know about Medicare Advantage Plans in Pennsylvania.

Medicare Advantage Plans in Pennsylvania

Compare ratings of insurance companies offering Medicare Advantage Plans in Pennsylvania:

Insurance company Medicare rating A.M. Best rating BBB rating J.D. Power ranking
Aetna 4 stars A A+ 6th out of 9
Cigna 4 stars A- Not rated 8th out of 9
Humana 4 stars A- A+ 2nd out of 9

What You Should Know About Medicare Advantage Plans in Pennsylvania

  • In 2023, there are 262 Medicare Advantage plans available in Pennsylvania, compared to 240 plans in 2022.
  • 100% of Medicare beneficiaries have access to a zero premium Medicare Advantage plan in 2023.
  • The average Medicare Advantage monthly premium in 2022 is $30.05, a decrease from 2021.
  • Through the CMS Innovation Center’s Value-Based Insurance Design (VBID) Model, 50 plans will offer Medicare Advantage enrollees eliminated Part D cost-sharing; rewards and incentives programs related to healthy behaviors; and customized, innovative benefits that address social determinants of health, such as food insecurity and social isolation, for certain underserved and/or chronically ill enrollees.

Is Medicare Advantage Right for You?

You have choices in Medicare coverage. While you can opt to stick with Original Medicare, a Medicare Advantage Plan – also known as Part C – may be a better alternative for you.

Original Medicare Medicare Advantage Plans
Original Medicare covers your Part A hospital insurance and Part B medical insurance. Medicare Advantage Plans combine Part A, Part B, and additional benefits.
You can add Part D prescription drug coverage. Prescription drug coverage is usually included.
You’re able to use any medical provider in the U.S. that accepts Medicare. You’ll usually need to use doctors in your plan’s network.
You can buy supplemental coverage to manage out-of-pocket costs, including your coinsurance. Your Medicare Advantage Plan may have lower out-of-pocket costs than Original Medicare.
Vision, hearing, dental, and other benefits aren’t covered. Your plan may offer additional benefits, including vision, hearing, and dental.
Note:

  • You can’t have both a Medicare Advantage Plan and a Medicare Supplement Plan.
  • You must be enrolled in Medicare Parts A and B to join a Medicare Advantage Plan.

What’s covered with a Medicare Advantage Plan?

Medicare Advantage Plans cover benefits from Original Medicare Part A (hospital insurance), Part B (medical insurance), usually Part D (prescription drug coverage), and sometimes additional benefits that Original Medicare doesn’t cover. Each Medicare Advantage Plan insurer sets the rules about how you receive and pay for these benefits.

Hospital and skilled nursing facility inpatient care Home health care Prescription drug coverage (if included in your plan)
Medically necessary outpatient services, such as:

  • Doctor’s visits
  • Ambulance services
  • Emergency and urgent care
  • Durable medical equipment (DME)
  • Mental health care
  • Prescription drugs that you cannot self-administer
  • X-rays
  • Laboratory tests
Preventive services, such as:

  • Vaccinations
  • Cancer screenings
  • Diabetes screenings
  • Depression screenings
Additional benefits (depending on your plan), such as:

  • Routine vision exams with allowance for glasses
  • Routine dental exams
  • Hearing exams with allowance for hearing aids
  • Fitness and wellness programs and discounts
  • Transportation to medically necessary care
  • Over-the-counter (OTC) drugs

How to Compare Medicare Advantage Plans in Pennsylvania

With 262 Medicare Advantage Plans available in Pennsylvania, you likely have several options in your area. To help you choose the best plan for you, consider what is most important to you before selecting a plan. There are several factors to keep in mind:

  • Monthly premium: This is how much you pay for coverage monthly, regardless of the care you receive. You may need to pay your plan’s premium in addition to the Medicare Part B premium, although some plans have $0 premiums or help pay for your Part B premium.
  • Plan network: You may need to use doctors and providers who are within a plan’s network. Before choosing a Medicare Advantage Plan, think about the doctors and facilities (including pharmacies) you prefer to use, then check if the plan offers coverage at those locations. Some plans may provide out-of-network coverage, but this usually comes at a higher cost.
  • Deductible: Your deductible is the amount you must pay before your insurance plan starts helping cover the costs. Medicare Advantage Plans set their deductibles, and these may change only once per year on January 1.
  • Copayments and coinsurance: Copayments or coinsurance are how much you pay for each service or doctor’s visit, such as $20 per doctor visit. Each Medicare Advantage Plan sets its copayment or coinsurance amount that can differ from what you would pay through Original Medicare.
  • Out-of-pocket maximum: Each Medicare Advantage Plan sets a yearly limit on the maximum amount you’d be responsible for paying for services covered by Medicare. Once you reach this limit, you won’t have to pay anything for the services you receive covered by Part A and Part B in that year.
  • Additional coverage: Most Medicare Advantage Plans also provide prescription drug coverage and often include additional benefits that Original Medicare won’t cover, such as vision, dental, and hearing. Plans may provide even more benefits, like discounted gym membership or transportation to doctor’s visits. Medicare Advantage Plans can also tailor their benefits to the specific needs of particular chronically ill beneficiaries.

About Medicare Advantage Plans in Pennsylvania

Pennsylvania has 262 Medicare Advantage Plans available, including:

  • Local HMOs
  • Local PPOs
  • MSA
  • PFFS
  • Regional PPO plans
Number of Medicare Advantage Plans available Medicare Advantage Plan types available Medicare Advantage Plans rated 3.5 or higher by NCQA
262
  • Local HMO
  • Local PPO
  • MSA
  • PFFS
  • Regional PPO
  • Aetna Health HMO
  • Aetna Health HMO
  • Aetna Life Insurance PPO
  • CIgna-Health HMO
  • Geisinger HMO
  • Geisinger PPO
  • HealthAssurance PPO
  • Highmark Choice HMO
  • Keystone HMO
  • Keystone PPO
  • Sierra HMO/POS
  • UnitedHealthcare HMO
  • UnitedHealthcare PPO
  • UPMC HMO
  • UPMC PPO

Types of Medicare Advantage Plans in Pennsylvania

In Pennsylvania, the most common Medicare Advantage plans available are HMOs or PPOs, although there are also a few SNPs and regional PFFS plans available. Seniors eligible for Medicare may choose from plans provided by multiple private insurers, although the choices available vary by county.

Types of Medicare Advantage Plans
HMOs HMOs typically require that you receive all services from in network providers:

  • You must have a primary care physician (PCP), referrals for specialists, and prior authorizations for treatments and some prescriptions.
  • Drug coverage usually is included. You aren’t able to purchase standalone drug coverage.
  • Lower costs if you stay in network.
PPOs PPOs include a preferred network of providers, but you have the option of choosing doctors or hospitals from outside of the network for a higher cost.

  • You don’t need to choose a primary care doctor or referrals for specialists.
  • Drug coverage is usually included.
  • You aren’t able to purchase stand-alone drug coverage.
  • Higher premium and out-of-network costs.
PFFS Plans PFFS plans don’t require a primary care physician or referrals for specialists:

  • You can go to any Medicare-approved health care provider or facility that accepts the plan’s payment terms and agrees to treat you.
  • May include drug coverage, or you can purchase a standalone drug plan.
  • Higher cost if you choose a provider that doesn’t agree to the plan’s terms.
SNPs SNPs are only for people with specific conditions and characteristics, and include care coordination and targeted benefits tailored to meet your specific needs:

  • You need a PCP and referrals to specialists.
  • Drug coverage is always included.
  • If you’re eligible, you can join an SNP at any time.

Enrollment and Eligibility for Medicare Advantage Plans in Pennsylvania

You’re eligible for Medicare when you turn 65 or if you’re younger and have a qualifying disability. A qualifying disability means at least one of the following applies:

  • You’ve received Social Security Disability Insurance or Railroad Board Disability Annuity for 24 months
  • You have Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease
  • You have End-Stage Renal Disease

When you become eligible for Medicare, you are also eligible for Medicare Advantage Plans. There are specific times of the year when you can enroll for the first time in a Medicare Advantage Plan: during your Initial Enrollment Period and the Open Enrollment Period.

  • Your IEP begins three months before the month you turn 65 and extends for three months after the month you turn 65. During this period, you can enroll in a Medicare Advantage Plan. If you join before the month you turn 65, your coverage will begin the first day of the month you turn 65. If you enroll in the three months after turning 65, your coverage will begin the first day of the month after you enroll.
  • If you miss your IEP, you can sign up for Medicare during the General Enrollment Period from January 1 to March 31.
  • After you enroll in Medicare, you can enroll in or make changes to your Medicare Advantage Plan coverage during the Medicare OEP from October 15 and December 7 of each year. During this time, you can change from Original Medicare to Medicare Advantage, switch to a different Medicare Advantage Plan, or change from Medicare Advantage back to Original Medicare.

Medicare Advantage Open Enrollment occurs between January 1 and March 31 of each year. This period is only for beneficiaries already in a Medicare Advantage Plan, and you can change plans or switch to Original Medicare. You cannot switch from Original Medicare to Medicare Advantage during Medicare Advantage Open Enrollment.

There are exceptions to these enrollment periods called Special Enrollment Periods. Certain events or circumstances may make you eligible to change your Medicare Advantage Plan outside of the open enrollment periods, such as if you move outside of your existing plan’s service area or to a location with new plan options you didn’t have before. If you think you may qualify for a Special Enrollment Period, call 1-800-MEDICARE and explain your situation.

Medicare Enrollment Periods
Enrollment period When it happens Medicare plans you can choose What you can do
Initial Enrollment Period Three months before you turn 65, the month you turn 65, and three months after Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Sign up for Medicare Part A and Part B. Complete your Part B enrollment to avoid a late enrollment penalty.
General Enrollment Period January 1 – March 31 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan. If you enroll in Medicare during this period, your MAP enrollment is April through June. Sign up for Medicare if you missed your IEP
Open Enrollment Period October 15 – December 7 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Join, switch, or drop a plan
Medicare Advantage Open Enrollment Period January 1 – March 31 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan If you’re enrolled in a Medicare Advantage Plan, you can change your plan or switch to Original Medicare
Special Enrollment Period When you have a qualifying event Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Make changes to your plan

Pennsylvania Medicare Advantage Plans With Prescription Drug Coverage

Most Medicare Advantage HMO and PPO plans and all SNP plans provide prescription drug coverage like you would get from Medicare Part D. Some PFFS plans may provide prescription drug coverage, but not all do. Evaluate a plan’s prescription drug coverage when deciding which Pennsylvania Medicare Advantage Plan to use.

Prescription drug coverage may vary by cost, coverage, and convenience among Medicare Advantage Plans. Your monthly premium may include a premium for the drug coverage in the plan. There is usually a copayment or coinsurance amount that you have to pay for each prescription after you reach your annual deductible.

Some plans use different cost tiers with different costs for different drugs. For instance, you may pay less for generic drugs than brand-name drugs or less for brand-name drugs within different tiers. If your plan uses tiers, the formulary will list all covered drugs and their tiers. Verify your preferred or local pharmacies are included in the plan’s network.

Getting Help with Medicare Advantage Plans

Pennsylvania-wide Medicare Advantage Resources
Resource Contact How they help
Pennsylvania Department of Aging (717) 783-1550
[email protected]
The Pennsylvania Department of Aging works to ensure that older adults across Pennsylvania have access to quality services and supports that help them age and live well
Pennsylvania Medicaid Department (866) 550-4355 Medical Assistance (MA), also known as Medicaid, pays for health care services for eligible individuals
Pennsylvania Insurance Department (877) 881-6388 This site is designed to be your resource to find out more information and help you make informed decisions about your insurance coverage
Pennsylvania Consumer Assistance (877) 881-6388 The Pennsylvania Consumer Assistance Department provides assistance to consumers with health insurance questions or problems
Pennsylvania Medicare Savings Programs (800) 783-7067 The Medicare Savings Programs help lower-income older adults and persons with disabilities pay
their Medicare Part B premium
Pennsylvania Medicare Legal Help (800) 274-3258 The PA Health Law Project provides free legal services and advocacy to Pennsylvanians having trouble accessing publicly funded health care coverage or services
PA Health & Wellness (844) 626-6813 PA Health & Wellness provides quality Medicaid & health insurance plans in Pennsylvania
Local Medicare Advantage Resources
Resource Contact How they help
Adams County Office for Aging (800) 548-3240 The Adams County Office for Aging helps people maintain independence and dignity within their own homes and communities for as long as possible
Allegheny County Health Insurance Counseling P(412) 661-1438
[email protected]
Allegheny County Area Agency on Aging partners with other agencies to offer you FREE, completely confidential, expert health insurance counseling to answer your questions and address your concerns
Berks County Area on Aging (610) 478-6500 The mission of the Berks County Area Agency on Aging is to provide services, based on need, to all older Berks County residents and those with disabilities
Bucks County Area Agency on Aging (267) 880-5700
[email protected]
The Mission of the Bucks County Area Agency on Aging (BCAAA) is to develop, coordinate and promote a continuum of quality services that supports, respects and advocates for older adults and their families
Butler County Agency on Aging (888) 367-2434 Butler County Agency on Aging’s goal is to assist our county seniors to be safe and healthy and to age successfully in their communities with the supports they need
Cumberland County Aging & Community Services (717) 240-6110
[email protected]
The core focus of the Cumberland County Aging & Community Services is to support older adults, adults with disabilities and others who are at risk of losing their independence, to continue living in the community as long as possible
Dauphin County Area Agency on Aging (717) 780-6130 The Dauphin County Area Agency on Aging provides essential services to residents of Dauphin County who are 60 years of age or older
Lehigh County Medicare Education and Decision Insight (610) 782-3000 This site is an information guide on the Medicare program for those who live in Lehigh county
York County County of Human Services Medicare Savings Program (800) 632-9073
[email protected]
The primary focus of the York County Area Agency on Aging is to provide education, advocacy and coordination of community-based services to empower older adults to maximize their independence and quality of life
Federal Medicare Advantage Resources
Resource Contact How they help
CMS Medicare Managed Care Appeals & Grievances N/A Provided by the CMS, this page provides information related to dealing with Medicare managed care plan grievances and appeals
CMS Medicare Managed Care Eligibility and Enrollment N/A Provided by the Centers for Medicare & Medicaid Services (CMS), this page offers information for contacting MAP organizations plus other health plans and related aspects to Medicare health plan enrollment
CMS Medicare Prescription Drug Eligibility and Enrollment N/A Provided by the CMS, this page details prescription drug eligibility and enrollment as it relates to MAP
Medicare.gov (800) 633-4227 The homepage for the main Medicare website for the U.S
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Insurance and healthcare consultant

Tammy Burns is an experienced health insurance advisor. She earned her nursing degree in 1990 from Jacksonville State University, obtained her insurance billing and coding certification in 1995, and holds a health and life insurance license in Alabama, Georgia, Iowa, Mississippi, and Tennessee. Burns is Affordable Care Act (ACA)-certified for health insurance and other ancillary, life, and annuity products. She maintains an active nursing license and practices private-duty nursing.

Burns’ background as a nurse, insurance biller and coder, and insurance consultant includes infectious disease, oncology, gynecology, phlebotomy, post operative, family medicine, geriatrics, home health, hospice, human resources, management, billing, coding, claims, fixed annuities, group and individual health and life products, and Medicare. She’s always been driven by a desire to help people, spending more than 25 years as a practicing nurse in hospitals, private doctors’ offices, home health, and hospice. As a nurse, Burns supported patients filing insurance claims with Medicare, Medicaid, and private insurance companies as well as responding to billing questions from confused patients.

Seeing firsthand how unsuspecting patients are frequently confused by an overly complex system they don’t understand led Burns to become an insurance agent and health care consultant, now helping people understand the medical system. Since becoming an insurance agent in 2013, she has worked with some of the largest and most reputable insurance carriers and agencies in the nation, and she has built a large and loyal clientele by way of her commitment to transparency and personalized service.

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