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Medicare in Pennsylvania

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

At a glance: Medicare health insurance in Pennsylvania

Medicare enrollment in Pennsylvania

2020 Medicare enrollment datesAs of November 2018, there were 2,685,909 Pennsylvania residents enrolled in Medicare. That’s almost 21 percent of the state’s population, compared with a little more than 18 percent of the United States population enrolled in Medicare. 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 its residents enrolled in Medicare.

16 percent of Pennsylvania’s Medicare beneficiaries were eligible due to a disability as of 2017 (as opposed to being eligible due to their age), which was the same as the nationwide average.

Medicare Advantage in Pennsylvania

Medicare beneficiaries can choose to get their coverage via Original Medicare (directly from the federal government) or via private Medicare Advantage plans. In Pennsylvania in 2017, 41 percent of Medicare beneficiaries were enrolled in Medicare Advantage plans, compared with an average of 33 percent nationwide. The other 59 percent of Pennsylvania’s Medicare beneficiaries had selected coverage under Original Medicare.

Pennsylvania stands out as having among the most robust Medicare Advantage markets in the country. Plan availability varies by county, but nearly every county in Pennsylvania has at least 30 plans available in 2019 (Pike County has only 17, but every other county has at least 30, and Bucks County has 71 plans available).

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. And as of 2019, 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 switch 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.

According to data compiled by AHIP, 660,544 Pennsylvania residents had Medigap coverage as of 2016.

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.

Based on rate filings in SERFF, it appears that all of the insurers that are currently marketing Medigap plans in Pennsylvania are charging the same premiums for people under 65 and people who are 65 years old. We have not located a specific state regulation or statute requiring this, but in states where Medigap insurers are allowed to charge higher premiums for people under 65, they invariably do so.

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.

Medicare Part D in Pennsylvania

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. But unless a person has employer-sponsored drug coverage that’s at least as good as Medicare Part D coverage, they’ll need to obtain either a stand-alone Medicare Part D plan, or purchase a Medicare Advantage plan that includes Part D prescription drug coverage.

In 2019, there are 30 stand-alone Part D plans for sale in Pennsylvania, with premiums that range from about $15 to $156/month.

As of late 2018, there were 1,120,464 Medicare beneficiaries in Pennsylvania with stand-alone Part D coverage, and another 962,112 had Part D coverage integrated with Medicare Advantage plans.

Medicare spending in Pennsylvania

In 2016, Original Medicare spent an average of $9,714 per Pennsylvania beneficiary, with the data standardized to account for regional differences in payment rates (the data did not include costs for Medicare Advantage enrollees).

Nationwide, average per beneficiary Original Medicare spending was $9,533 per enrollee, so Medicare spending in Pennsylvania was about 2 percent higher than average. On the ends of the spectrum, there were three states (Florida, Louisiana, and Texas) where Original Medicare’s per-beneficiary spending was more than $11,000, while in Hawaii it was just $6,441.

You can read more about Medicare in Pennsylvania in our state Medicare guide. You can also contact APPRISE, Pennsylvania’s State Health Insurance Assistance Program (SHIP), with questions related to Medicare coverage in Pennsylvania.

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 Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.