Medicare in Pennsylvania

Pennsylvania's Medicare Advantage market is robust, with 30+ plans available in all but one county

Photo credit: Jason Lander | Flickr

At a glance: Medicare health insurance in Pennsylvania

Medicare enrollment in Pennsylvania

As of July 2020, there were 2,769,667 Pennsylvania residents enrolled in Medicare. That’s more than 21 percent of the state’s population, versus nationwide Medicare enrollment encompassing just under 19 percent of the United States population. Pennsylvania has the fifth-highest percentage of residents who are age 65 or older, so it makes sense that the state has a higher than average percentage of residents with Medicare coverage enrollment.

For most Americans, eligibility for Medicare benefits is tied to turning 65. But Medicare eligibility is also triggered when a person has been receiving disability benefits for at least two years (people with ALS or end-stage renal disease do not have to wait two years for their Medicare enrollment to begin).

As of 2018, 15 percent of Pennsylvania’s Medicare beneficiaries were under 65 and eligible for Medicare due to a disability (as opposed to being eligible due to their age), which was the same as the nationwide average.

Medicare coverage options

Residents can choose how to access their Medicare benefits. The first choice is between Medicare Advantage plans, where coverage is through private Medicare Advantage plans, or Original Medicare, where coverage is paid for directly by the federal government. Medicare beneficiaries also have options around Medigap policies and Medicare Part D (prescription drug) coverage.

Original Medicare includes Part A (also called hospital insurance, which helps pay for inpatient stays, like at a hospital, skilled nursing facility, or hospice center) and Part B (also called medical insurance, which helps pay for outpatient care like a doctor appointment or a preventive healthcare service, such as most vaccinations). Medicare Advantage plans bundle Parts A and B under a single monthly premium and often include other services like prescription drug and vision coverage. There are pros and cons to either option, and the “right” solution is different for each individual.

Medicare Advantage in Pennsylvania

In Pennsylvania in 2018, 40 percent of Medicare beneficiaries were enrolled in Medicare Advantage plans (at that point, nationwide Medicare Advantage enrollment covered 34 percent of Medicare beneficiaries). But by the middle of 2020, private Medicare coverage enrollment had grown to nearly 45 percent of Pennsylvania’s Medicare population. Enrollment in Medicare Advantage plans has been steadily increasing since the early 2000s, and Medicare Advantage enrollment in Pennsylvania is running a little higher than the national average.

Pennsylvania stands out as having among the most robust Medicare Advantage markets in the country. Plan availability varies by county, but every county in Pennsylvania has at least 24 plans available in 2020, and most have far more than that.

Medicare beneficiaries can switch between Medicare Advantage and Original Medicare during the annual election period in the fall, which runs from October 15 to December 7 each year, with coverage effective January 1. There is also a Medicare Advantage open enrollment period in the first quarter of the year (January 1 to March 31) during which people who are already enrolled in Medicare Advantage plans can change to a new Medicare Advantage plan or drop their Medicare Advantage plan and enroll in Original Medicare instead.

Medigap in Pennsylvania

Original Medicare has out-of-pocket costs that can be substantial and there is no out-of-pocket cap with Original Medicare. Many Original Medicare beneficiaries use Medigap plans to supplement their coverage, with the Medigap plan covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that they would otherwise have to pay themselves.

There are 66 insurers that offer Medicare plans in Pennsylvania as of 2020. According to data compiled by AHIP, 700,155 Pennsylvania residents had Medigap coverage as of 2018.

Medigap plans are standardized under federal rules, with ten different plan designs (differentiated by letters, A through N), but premiums vary significantly from one insurer to another. Federal rules provide a six-month guaranteed-issue window for Medigap plans, which begins when the person is at least 65 and enrolled in Medicare Part B.

There’s no federally-guaranteed access to Medigap plans for people under the age of 65 who are eligible for Medicare due to a disability, but Pennsylvania is among the majority of the states that have rules ensuring at least some access to Medigap plans for enrollees who are under the age of 65. In Pennsylvania, the six-month open enrollment window for Medigap plans starts when you’re enrolled in Part B, and it applies regardless of age. Pennsylvania state law regarding Medigap plans (Chapter 89, Subchapter K) is available here.

Pennsylvania statute (Title 31, § 89.778) prohibits Medigap insurers from charging higher premiums based on medical history when a person enrolls during their initial six-month enrollment window, so premiums cannot be higher for disabled enrollees (in many states, Medigap coverage is guaranteed-issue for beneficiaries under 65, but premium can be higher; Pennsylvania does not allow this). According to Medicare’s plan finder tool, average premiums for Medigap Plan A in Philadelphia (male, non-smoker) range from about $83/month to $340/month, depending on the insurer.

According to a Business Insider analysis, the average cost of a Medigap plan in Pennsylvania in 2018 was $140/month. Twenty states have higher average premiums, and 29 have lower average premiums, ranging from about $109/month in Hawaii, to about $162/month in Massachusetts.

Pennsylvania Medicare Part D

Original Medicare provides fairly comprehensive coverage, but it does not pay for outpatient prescription drugs. Some Medicare beneficiaries have supplemental prescription coverage as part of an employer-sponsored plan, including retiree plans. If that’s not an option, an individual can get needed coverage for medications by enrolling in a stand-alone Medicare Part D plan or a Medicare Advantage plan that includes Medicare Part D coverage for prescription drugs.

In 2020, there are 31 stand-alone Medicare Part D plans for sale in Pennsylvania, with monthly premiums that range from about $13 to $168.

As of mid-2020, there were 1,116,231 beneficiaries of Medicare in Pennsylvania with stand-alone Part D coverage, and another 1,077,018 had Part D coverage integrated with Medicare Advantage plans. Total Medicare enrollment and total Medicare Part D enrollment have been increasing in Pennsylvania and nationwide as the Baby Boomer population ages into Medicare. But enrollment in stand-alone Medicare Part D plans has been decreasing in Pennsylvania, while enrollment in Medicare Advantage plans (most of which include Part D coverage) has been increasing rapidly.

Medicare Part D enrollment (for stand-alone plans as well as Medicare Advantage plans with integrated Part D coverage) is available during the annual election period, from October 15 to December 7 each year. Plan changes made during this window will take effect the following January 1.

Medicare spending in Pennsylvania

In 2018, Original Medicare spent an average of $10,149 per beneficiary in Pennsylvania. Nationwide, the average per beneficiary Original Medicare spending was $10,096 per enrollee, so spending for Medicare in Pennsylvania was very similar to the national average. These data were standardized to account for regional differences in payment rates (the data did not include costs for Medicare Advantage enrollees).

On the ends of the spectrum, there were five states (Florida, Louisiana, Oklahoma, Mississippi, and Texas) where Original Medicare’s per-beneficiary spending was more than $11,000, while in Hawaii it was just $6,971.

How does Medicaid provide financial assistance to Medicare beneficiaries in Pennsylvania?

Many Medicare beneficiaries receive financial assistance through Medicaid with the cost of Medicare premiums and services Medicare doesn’t cover – such as long-term care.

Our guide to financial assistance for Medicare enrollees in Pennsylvania includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.

Helpful resources for Pennsylvania Medicare beneficiaries and their caregivers

Do you have questions about Medicare eligibility in Pennsylvania? Do you need help understanding your options or getting signed up for Medicare coverage? See the below list of free resources to help you access and manage your Medicare coverage.

  • You can contact APPRISE, Pennsylvania’s State Health Insurance Assistance Program (SHIP), with questions related to Medicare coverage in Pennsylvania. Visit the APPRISE website or call 1-800-783-7067.
  • For Medicare beneficiaries with limited income and assets, Pennsylvania Medicaid might be available to help make coverage and care more affordable. You can contact the Pennsylvania Department of Human Services website for more information or call 1-866-550-4355.
  • Medicare coverage is regulated by both federal and stage agencies, depending on the type of coverage. The Pennsylvania Insurance Department regulates Medigap plans in the state as well as brokers and agents who sell Medicare coverage, and is a great resource for Pennsylvania residents.
  • Visit the Medicare Rights Center. This website provides helpful information geared to Medicare beneficiaries, caregivers, and professionals.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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