What makes Medicare different in Pennsylvania
- Networks matter more than usual: Pennsylvania has several large regional health systems, and Medicare Advantage plans don't all include the same ones. Contract disputes between insurers and health systems have changed members' access before.
- Medicare Supplement access under 65: Pennsylvania requires Medigap insurance companies to sell you a policy during your open enrollment period, even if you're under 65 and on Medicare because of a disability.
- State prescription programs: PACE and PACENET help eligible residents 65 and older with prescription costs.
- Public employee and school retiree programs: state and school retirees have their own rules and plan options once they become eligible for Medicare.
- A large rural population: many of the state's oldest counties are rural, where plan choices and provider access can differ from the Pittsburgh and Philadelphia areas.
Medicare Advantage in Pennsylvania: start with the network
Medicare Advantage plans in Pennsylvania include HMO and PPO options, and the plans available to you depend on your county. Because so much of the state's care is organized around large health systems, the most important question is often whether your doctors and hospitals are in a plan's network.
Western Pennsylvania: UPMC and Allegheny Health Network
In the Pittsburgh area, UPMC and Allegheny Health Network are the two major systems, and their relationship with insurers has a long history of network disputes. Some Medicare Advantage plans offer broad access to both, while narrow-network plans may have limited access to one of them. If you have a preference, confirm access for the exact plan you're considering.
When an insurer and a health system part ways
Networks can change mid-course. When UnitedHealthcare's Medicare Advantage contract with Lehigh Valley Health Network ended, thousands of Pennsylvania members lost in-network access to that system's providers. The Pennsylvania Department of Aging announced a special enrollment opportunity so affected members could choose another Medicare Advantage plan or move to Original Medicare and buy a Medicare Supplement policy without medical underwriting.
Elsewhere in the state, you'll see systems such as Penn Medicine and Jefferson Health in the Philadelphia region, and Geisinger, WellSpan, and Penn State Health across central Pennsylvania. Not every plan includes every system, so it's worth checking before you enroll. Medicare at 65 is not affiliated with these health systems.
If you have both Medicare and Medical Assistance (Pennsylvania's name for Medicaid), your Medicaid coverage is generally provided through Community HealthChoices, and you may be able to choose a Dual Eligible Special Needs Plan offered by a Community HealthChoices plan. Learn how Medicare Advantage works.
Medicare Supplement (Medigap) in Pennsylvania
Medicare Supplement plans in Pennsylvania use the same standardized lettered plans found in most states, such as Plan G and Plan N, but premiums vary by insurer and by where you live. The Pennsylvania Insurance Department publishes a list of companies licensed to sell Medicare Supplement policies in the state.
Insurers price policies in different ways. Some use community rating, where the premium isn't based on age; some base it on your age when you buy; and some raise it as you get older. Ask which method an insurer uses, because it affects how your premium may change over time.
Your Medigap open enrollment period is a one-time, six-month window that starts the month you first enroll in Part B. If you don't buy a policy during that window, you may pay more, have fewer options, or be turned down.
Protections Pennsylvania spells out
- Under 65 with a disability or ESRD: Medigap insurance companies must sell you a policy if you're in your open enrollment period.
- A 30-day review period: if you return a new policy within 30 days of receiving it, the insurer must refund your premium in full.
- Leaving Medicare Advantage: you can apply for a Medicare Supplement policy before your Medicare Advantage coverage ends, so there's no gap in coverage.
- Guaranteed renewable: an insurer can't cancel your standardized policy because of health problems as long as you pay the premium.
Learn how Medicare Supplement plans work.
Prescription help: Part D, PACE, and PACENET
Pennsylvania offers two state prescription assistance programs, PACE and PACENET, for residents 65 and older who meet income limits. Rather than replacing Medicare Part D, they work alongside it and other drug coverage, including retiree and employer plans, Medicare Advantage, and Veterans' benefits, to lower what you pay out of pocket for medicine. If your income is limited, you may also qualify for federal Extra Help.
Retiring from a Pennsylvania public employer or school district?
- State employee retirees: if you're in the Retired Employees Health Program (REHP), you and your dependents must enroll in Medicare as soon as you become eligible to remain in the program.
- School employee retirees (PSERS): the Health Options Program isn't automatic, so you must actively enroll. Options for Medicare-eligible retirees include Medicare Supplement plans, Medicare Advantage plans from several insurers, and Part D prescription plans.
- Premium help: eligible PSERS retirees may qualify for Premium Assistance toward their health insurance premiums.
Confirm the details of your situation with your retirement system before your retirement date. Retiring from a private employer? See how Special Enrollment Periods work when employer coverage ends.
Help paying Medicare costs in Pennsylvania
Pennsylvania's Medicare Savings Programs are administered by the Department of Human Services. They help pay Medicare premiums and, in some cases, Medicare deductibles, coinsurance, and copayments. You can apply online through COMPASS, the state's benefits application site. If you've been denied before, you can reapply.
Rural Pennsylvania, state lines, and snowbirds
- Rural counties: plan choices can be more limited, and the nearest in-network hospitals and specialists may be a long drive away.
- Near a state line: if you see doctors in New Jersey, New York, Ohio, Maryland, Delaware, or West Virginia, check whether those providers are in a plan's network.
- Spending winters away: most Medicare Advantage plans use local networks, while Original Medicare with a Medicare Supplement policy works with providers nationwide that accept Medicare.
- Moving to Pennsylvania: if your Medicare Advantage or Part D plan doesn't serve your new area, you generally get a Special Enrollment Period to choose a new plan.
Weighing your options? Compare Medicare Advantage and Medicare Supplement, or start with our Turning 65 guide.