Medicare in Pennsylvania: Eligibility, Costs, & More

Millions of Pennsylvanians are age 65 and over, and many others have health conditions that might qualify for Medicare. As a result, it’s common to have questions about Medicare coverage and how to take advantage of this important benefit.

As of 2020, approximately 2.7 million Pennsylvania residents were enrolled in some type of Medicare, including:

• Original Medicare: 1,551,270
• Medicare Advantage: 1,215,262

Understanding eligibility requirements, knowing how to apply and manage costs, and figuring out what plan is right for you can be a challenge. This article will answer important questions about Medicare in PA and help you make the choices that are right for you.

How to Apply for Medicare in PA

Most Americans receive Medicare Parts A and B automatically when they are eligible. Together these are known as Original Medicare. However, that’s not all there is to Medicare. You might want to consider Medicare Part C, known as Medicare Advantage, or adding drug coverage or even Medigap to Original Medicare.

If you don’t receive Parts A and B automatically, you’ll want to enroll. That way you’ll avoid late enrollment penalties and get the maximum flexibility in choosing a plan. To enroll in Medicare:

• Contact your local Social Security office
• Call 1-800-772-1213 to enroll over the phone
• If you retired from a railroad, call the Railroad Retirement Board at 1-877-772-5772
• Sign up for Part A online at www.socialsecurity.gov and Part B using Form CMS-40B

To sign up for drug coverage, known as Medicare Part D, you’ll want to contact private insurance companies that offer coverage. You can compare plans and ensure that the prescriptions you need are covered. You may also want to contact insurance companies that offer Medigap, since that coverage can help you pay for your out-of-pocket costs with Original Medicare.

Another option is to enroll in Medicare Part C, known as Medicare Advantage. This plan replaces Original Medicare and is offered by private insurance companies. Be sure to compare costs and benefits before making a decision.

Medicare Costs in Pennsylvania

How much is Medicare in Pennsylvania? There are a variety of costs to keep in mind.

Each part of Medicare covers different needs. Medicare Part A is hospital insurance for inpatient hospital stays. Medicare Part B is medical insurance for going to the doctor, getting medical equipment, or getting preventive care.

Part D covers prescription drugs. Medicare Part C is a full replacement for Medicare that includes the benefits of Parts A and B, along with D in most cases. You may also get additional benefits.

For most Americans, Medicare Part A is free. This is based on how long you or your spouse paid Medicare taxes while you were working. Medicare Part B has a monthly premium, and the premium may be higher if you have a higher income.

If you choose to get Medicare Part D and/or Medigap, those will each have a separate monthly premium as well.

Medicare Part C has a monthly premium, but you may be able to find a plan where you don’t pay more than you would have for Part B.

All parts of Medicare have a deductible that you cover first before the insurance coverage begins. After the deductible, you will have copayments or coinsurance. For example, with Medicare Part D you will have a copayment each time you need a prescription, and with Medicare Part B you’ll pay 20% of your medical costs after the deductible.

Medicare Eligibility in PA

How do you qualify for Medicare in PA? Medicare is intended to provide health coverage for those who generally can’t get it through an employer. This includes older Americans and those with specific health conditions or disabilities.

To qualify for Medicare, you need to be an American citizen or permanent resident who has lived in the country for at least five years. Also, you need to meet at least one of the following conditions:

• You’re age 65 or older
• You’re under 65 but disabled and receiving disability benefits from Social Security or the Railroad Retirement Board
• You have end-stage renal disease (ESRD)
• You have Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease

As we mentioned earlier, many Americans receive Original Medicare automatically when they qualify, but it’s important to fully review your options before deciding what coverage you want and need.

What is the Income Limit for Medicare in PA?

There is no upper-income limit that disqualifies you from receiving Medicare benefits. However, if you have a higher income, your monthly premiums for Medicare may be higher.

If your income is low, you may qualify for extra help paying for your Medicare coverage. There are four kinds of Medicare Savings Programs that you might qualify for, depending on your income and assets.

Best Medicare Advantage Plans in Pennsylvania

Many Medicare beneficiaries choose a Medicare Advantage plan instead of Original Medicare. You get all of your coverage in one, instead of having multiple monthly premiums, and your out-of-pocket costs may be more predictable. At the same time, you may also get extra benefits that Original Medicare doesn’t cover, such as vision, dental, or hearing coverage.

It’s important to compare plans and understand the limitations before you make your final decision. For example, Original Medicare is a national program and you can use any doctor that accepts Medicare. However, Medicare Advantage plans tend to be local and require you to use a specific medical network of doctors. Before choosing a Medicare Advantage plan, make sure the doctors and prescriptions you need are included and that you’re comfortable staying in the medical network.

There’s no one perfect Medicare Advantage plan for everyone, but you can find the right one for you by comparing costs and benefits.

What's the Best Medicare Supplement Plan in Pennsylvania?

A Medicare Supplement Plan, or Medigap, can help you pay for your out-of-pocket costs when you have Original Medicare. For example, your deductible or coinsurance can be partly or fully covered.

It’s best to get Medigap when you are first eligible for Medicare because your initial enrollment period gives you guaranteed acceptance to a Medigap plan. After that enrollment period, you may be denied Medigap depending on the insurance company’s underwriting requirements.

There are several Medigap plans, lettered A through N. Each plan of the same letter is the same no matter who provides it — the only difference is price. Different letter plans provide different benefits. What is the best Medicare Supplement Plan in PA? Only you know. You’ll want to compare the monthly premium to the benefits you receive before you decide which letter plan to choose.

Learn More About Medicare in Pennsylvania

This article answered many common questions about Medicare in Pennsylvania, but it’s a complex topic. If you’d like to learn more about what plans are available in your area and how to make the best decision for you, we’re here to help. Contact us today to talk to a licensed agent.