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How Do Medicare Advantage Plans Work in Pennsylvania?

If you want to simplify your healthcare while limiting your out-of-pocket expenses, consider signing up for a Medicare Advantage plan in Pennsylvania for 2022. These comprehensive policies include all benefits guaranteed to those enrolled in Medicare Part A and Part B along with a variety of additional services.

For instance, your Medicare Advantage plan may include wellness programs, prescription drug coverage, hearing tests, or routine vision and dental services. You may even qualify for a policy with a $0 premium, but those policies aren’t necessarily the best deal.

When you sign up for a Medicare Advantage plan in Pennsylvania, you will use your Medicare Advantage card instead of the red, white and blue Original Medicare card. You should keep that card in a safe place in case you want to go back to standard Medicare Part A and Part B in the future.

What is Medicare Advantage in Pennsylvania?

Medicare Advantage plans in Pennsylvania are sold to Medicare beneficiaries by private insurance companies. Also known as Medicare Part C, these policies bundle Original Medicare (Medicare Part A and Part B) coverage into one policy. The insurance company offering the plan is responsible for claims, customer service, administration, and more.

U.S. federal law requires that every insurance company selling Medicare Advantage plans must provide at least the same benefits you would get through Original Medicare Part A and Part B. Most Part C plans also include extra benefits and prescription drug coverage.

If you have healthcare coverage with a Medicare Advantage plan in Pennsylvania, you are still responsible for paying your Part B premium in addition to your Medicare Part C premium.

Here are some reasons to consider a Medicare Advantage plan in Pennsylvania for your 2022 health insurance:

  • Medicare Advantage plans are becoming more and more popular every year
  • Benefits are provided by private insurance carriers
  • Most Medicare Advantage insurance plans and benefits involve specific network providers – like physicians, hospitals, pharmacies, and medical equipment suppliers.
  • MAPD or Medicare Advantage prescription drug plans include prescription drug coverage together in one plan.
  • Many plans also include extra coverage options like vision, dental, and hearing care; memberships for wellness and fitness clubs like SilverSneakers; over-the-counter prescription allowances; transportation to and from medical appointments, and meal delivery services.

What is the Best Medicare Advantage plan in Pennsylvania in 2022?

Here’s a look at the different types of Medicare Advantage health plans in Pennsylvania:

Best network freedom: Medicare Advantage PPO plans

  • PPO plans offer a larger network of medical providers and facilities with no referral requirements.
  • PPO premiums range between $0 and $100.00 per month.

Best for lowest out of pocket costs: Medicare Advantage HMO plans

  • HMO premiums are generally $0 per month.
  • These plans have lower out of pocket costs because they use the HMO referral network.

Best for low income or health conditions: Medicare Advantage D SNP

SNP, or Special Needs Plans, are best for beneficiaries who live on a limited income or have chronic health conditions. Eligibility for both Medicare and Medicaid coverage is possible for some beneficiaries. This dual coverage helps lower out of pocket expenses for copays, premiums, coinsurance, some deductibles, and other Medicare costs.

SNPs require that you use in-network providers unless:

  • You need emergency or urgent care while outside the network
  • You have end-stage renal disease and need out-of-network dialysis

What Medicare Advantage plans are available in Pennsylvania?

Although Medicare Advantage plans available in Pennsylvania for 2022 vary according to service areas, here is a list of the number of different types of Medicare Part C plans available in the state:

  1. Local HMOs: 96
  2. Local PPOs: 57
  3. Regional PPOs: 2

How much does Medicare Advantage cost in 2022?

In Pennsylvania, as in most states, there are HMO plans available with a monthly premium of $0.00. While there are states that offer PPOs with no monthly premium, it is becoming more common for PPOs to carry a premium.

Which plans are available in Pennsylvania and how much they cost vary from county to county. However, the average monthly premium for Medicare Advantage prescription drug plans (MAPDs) is $52.70.

Pennsylvania ranks in the top 10 of the 50 states for MAPD coverage. This is due to low drug coverage deductibles, which average at $34.01, and high plan quality. In fact, 73 percent of the 126 plans available in Pennsylvania have a star rating of four or above.

When can I make changes to my Medicare Advantage plan?

You can enroll in a Medicare Advantage plan during the following periods:

Open Enrollment Period (OEP) or Annual Election Period (AEP)

During AEP you can enroll in a Medicare Part C plan for the first time, switch to a different plan, or return to Medicare Part A and Medicare Part B coverage. You can also add Medicare Part D if you do not have prescription drug coverage. AEP runs from October 15th to December 7th and your changes take effect on January 1st.

Medicare Advantage Open Enrollment Period

During the Medicare Advantage Open Enrollment Period, you can switch your Medicare coverage by returning to Original Medicare or purchasing a new Part C plan. This period runs from January 1st to March 31st and changes take effect the first day of the month following the switch.

Special Enrollment Periods

In certain circumstances the Centers for Medicare and Medicaid Services (CMS) allow Medicare Advantage beneficiaries to make changes to their coverage or purchase a new MA or Part D plan. Medicare may offer you a special enrollment period for situations such as:

  • Moving out of your plan’s service area
  • Moving back to the United States
  • Moving in or out of a skilled nursing or long-term health care facility
  • Being released from jail
  • No longer eligible for Medicaid or you are dual eligible for Medicare and Medicaid
  • Medicare ends your plan or the insurance agent does not renew it
  • Dropping a Medigap policy to join Part C coverage

5-star Special Enrollment Period

If Medicare gives a 5-star rating to a plan within your service area, you can use a special enrollment period to switch over to that plan.

Special Enrollment Period if you get “Extra Help”

If you have Medicaid or “Extra Help”, you can switch, join, or drop a Medicare Advantage or Part D plan once during the following periods:

  • January – March
  • April – June
  • July – September

When can you enroll in a Pennsylvania Medicare Advantage plan for 2022?

You can enroll in a Medicare Advantage plan during the following periods:

Initial Enrollment Period (IEP)

When you enroll in Medicare Part B, your IEP begins, and you can enroll in Medicare Advantage.

If you qualify for Medicare because you are 65, your IEP begins three months before your 65th birthday includes the entire month of your birth date, and extends for three months beyond your birth month. This is a total of seven months.

If you qualify for Medicare due to disability, end-stage renal disease, or ALS, your IEP begins three months before the 25th month of receiving disability benefits. It includes the 25th month and ends three months later.

Open Enrollment Period (OEP) or Annual Election Period (AEP)

During AEP you can enroll in a Medicare Part C plan for the first time, switch to a different plan, or return to Medicare Part A and Medicare Part B coverage. You can also add Medicare Part D if you do not have prescription drug coverage. AEP runs from October 15th to December 7th and your changes take effect on January 1st.

Medicare Advantage Open Enrollment Period

During the Medicare Advantage Open Enrollment Period, you can switch your Medicare coverage by returning to Original Medicare or purchasing a new Part C plan. This period runs from January 1st to March 31st and changes take effect the first day of the month following the switch.

Special Enrollment Periods

In certain circumstances the Centers for Medicare and Medicaid Services (CMS) allow Medicare Advantage beneficiaries to make changes to their coverage or purchase a new MA or Part D plan. Medicare may offer you a special enrollment period for situations such as:

  • Moving out of your plan’s service area
  • Moving back to the United States
  • Moving in or out of a skilled nursing or long-term health care facility
  • Being released from jail
  • No longer eligible for Medicaid or you are dual eligible for Medicare and Medicaid
  • Medicare ends your plan or the insurance agent does not renew it
  • Dropping a Medigap policy to join Part C coverage

5-star Special Enrollment Period

If Medicare gives a 5-star rating to a plan within your service area, you can use a special enrollment period to switch over to that plan.

Special Enrollment Period if you get “Extra Help”

If you have Medicaid or “Extra Help”, you can switch, join, or drop a Medicare Advantage or Part D plan once during the following periods:

  • January – March
  • April – June
  • July – September

Are Medicare Advantage plans in Pennsylvania “bad”?

Medicare Advantage coverage is not bad, it is quite the opposite in fact. Medicare Advantage plans all across the U.S. provide high quality, comprehensive coverage and they are steadily gaining in popularity every year.

Here are some statistics highlighting the growth of Medicare Part C plans:

  1. Number of lives enrolled in Medicare Advantage in PennsylvaniaStatistics for 2021 show that there are just under 1.3 million Medicare Advantage beneficiaries in the state.
  2. Number of lives enrolled by plan type: (Based on 2018 statistics)*Local HMOs: 648,820
    *Local PPOs: 385,517
    *Regional PPOs: 4,798
  3. Percentage of Medicare beneficiaries enrolled in Medicare Advantage in Pennsylvania:In Pennsylvania, there are 2.8 million people who have Medicare. Out of this total number, 46 percent of these beneficiaries are enrolled in a Medicare Advantage plan in 2021 in the state.
  4. Number of lives enrolled in Medicare Advantage nationwide:
    In 2021, more than 26 million people have Medicare Advantage coverage in the United States.
  5. Percentage of Medicare beneficiaries enrolled in Medicare Advantage nationwide:In the U.S. in 2021, 42 percent of the Medicare population was coverage through Medicare Advantage.

Frequently Asked Questions about Medicare Advantage in Pennsylvania

What's the downside to Medicare Advantage plans?

  • Network restrictions on some plan types. Your Part C plan may require that you use a network of healthcare providers, medical facilities, and suppliers. You may also require referrals from your primary care physician before seeing specialists.
  • Financially less predictable due to more out of pocket costs every time you use the plan. Even though premiums are lower than Medicare Supplement (Medigap) plans, costs may add up over time.
  • More member involvement is required – you must confirm that you are staying in the network, pay copayments and Medicare bills, and research your plan every year to make changes if applicable.
  • Less long-term stability if you have changes to benefits, networks, drug coverage, premiums, additional coverage, etc. Medicare Advantage plans differ from Medicare Supplement plans that are standardized and don’t have these changes.

What are 4 types of Medicare Advantage plans in Pennsylvania?

  • Health Maintenance Organization Plans (HMOs)
  • Preferred Provider Organization Plans (PPOs)
  • Private Fee-for-Service Plans (PFFS)
  • Special Needs Plans (SNPs)

What are the top 3 Medicare Advantage plans?

The three top insurance providers based on nationwide enrollment are:

  • United Healthcare
  • Humana
  • Blue Cross Blue Shield

What Are Medicare Special Needs Plans?

Medicare Special Needs Plans (SNPs) are Medicare Advantage plans specifically for those who have certain diseases or characteristics. SNPs meet the needs of beneficiaries by customizing benefits, provider options, and drug formularies.

Does Medicare Advantage cover drugs?

Most Medicare Advantage plans include prescription drug coverage. These plans are called MAPD plans and have drug coverage built into the benefits.

Do Medicare Advantage plans use the SilverSneakers program in Pennsylvania?

Because this extra benefit is so popular, many Part C plans include it in their coverage. Ask your insurance provider if membership in SilverSneakers or a similar program is included in your plan before signing up.

Related Topics

Pennsylvania Medicare Resources

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