Introduction to Medicare Part C in Pennsylvania (Medicare Part C)

Medicare Advantage (a.k.a. Medicare Part C, or Medicare “replacement”) is a comprehensive form of Medicare supplement insurance which aims to protect you from all of the known gaps in Medicare Parts A and B. While an Advantage policy will cover your Medicare benefits, coverage gaps, and allow you to add additional coverages all under the same policy, you will have to deal with provider network restrictions. We’ll discuss the details of Medicare Part C here in this article.

Federal Regulations for Medicare Advantage

One of the reasons people refer to Medicare Advantage as Medicare “replacement” is because it will, essentially, replace your federal Medicare benefits. Advantage plans are regulated by the government and, by law, must provide you with a minimum level of coverage. But your claims will be paid out by a private company – not the government. Usually, though, you won’t have to worry about a company trying to sell you insufficient coverage. The appeal of an Advantage policy for many seniors is the fact that many plans provide more coverage than Medicare Parts A and B.

Medicare Advantage Enrollment In Pennsylvania

Medicare Advantage is fairly popular within the state of Pennsylvania. Right around 41% of Medicare-qualified seniors have currently replaced their federal Medicare benefits with Medicare Advantage. Below, you can see a chart which ranks Pennsylvania Medicare Advantage plans from most to least popular:

Plan Type Enrollment Percentage
HMO Plans 59%
Local PPO Plans 13%
Special Needs Plans 11%
Regional PPO Plans 9%
Private Fee-For-Service Plans 5%
Other (Cost Plans, MSA’s, etc.) 3%

Plan Coverage & Cost

The amount of coverage you purchase, as well as your age and location, will make a significant impact on your monthly premiums. Below is a list of approximate quotes for seniors in your area. Remember, though, that these are estimates. You have to contact a licensed insurance agent in order to get the most accurate quote.

Most Popular Medicare Advantage Plans in Pennsylvania

If you want to know how good a Medicare Advantage plan is in your area, look no further than our five star rating system. We examine things like customer service ratings, their history of chronic care management, financial stability, and more when we evaluate companies using our system. The more stars they earn, the more confident you can feel that you’re choosing and purchasing a plan which will be able to meet your medical needs long-term.

Helpful Medicare Advantage Tips & Tricks

Doctor/Provider Network Restrictions

Almost all doctors and hospitals will accept Medicare – but that is not the same for Medicare Advantage. Your Advantage plan, as mentioned earlier, will come with a network of doctors and facilities which accept your insurance plan, called a provider network. Some of these networks are more restrictive than others. HMOs, for example, are smaller and have much higher restrictions when it comes to getting medical care. Other, larger networks may have several providers for you to choose from, or allow you to go out-of-network for a modest fee.

  • HMO Plans – With a Health Management Organization plan, you’ll be limiting your access to medical care somewhat in exchange for greater affordability. You can receive emergency medical care out-of-network without worrying about exorbitant out-of-pocket costs. But in all other cases, you must choose a primary care physician and only receive care from other doctors or facilities if your primary gives you a referral.
  • PPO Plans – If you belong to a Preferred Provider Organization, it means that you’ll have more freedom to get the care you want from wherever or whomever you want to get it. Just keep in mind that going outside of your network of preferred providers will cost you more; but it is unlikely to cost you as much as it would to go out of network with something like an HMO.
  • PFFS Plans – Choosing a PFFS plan (Private Fee- For-Service) gives you the option to get care from doctors, hospitals, and facilities that you choose – provided they and your insurance company can agree on a fair price. But these prices are determined on a case-by-case basis. And the price that these entities agree on today might not be the same terms they agree upon six months from now. You’ll have to stay on your toes and make sure everyone is in agreement on the terms of service every single time you get care on a PFFS plan.
  • Special Needs Plans – Do you have a chronic health condition that is expensive to treat? Are you also on a very limited income? Either or both of these factors can make you eligible for a Special Needs Plan. In order to keep these plans affordable in the face of daunting medical costs, you’ll be restricted to a small network of doctors and facilities which functions similarly to an HMO. But you will be able to receive emergency care at little or no cost to you if you have no choice but to go to an out-of-network doctor or facility. You may also be able to negotiate non-emergency out-of-network treatment if you can plead a good case to your insurance company.

Doctor/Providers List

  • HMO Plans – Most Medicare Advantage plans function in an identical manner to that of a private health insurance plan. They also have the same health care benefits as Original Medicare (or more, depending on the plan). a Medicare Advantage HMO is no exception. You have the same rights to low-cost, out-of-network emergency care as you would with a regular HMO, and you will also be required to settle on a primary care physician and to only get care outside of their office if they issue you a referral. Going out of network is usually associated with exorbitant costs, even on a Medicare Advantage HMO plan.
  • PPO Plans – A PPO plan works about the same way, whether it’s under Medicare Advantage or whether you’re paying for it as a private citizen. You can get care from anyone or anywhere you want; but you will be paying a premium for out-of-network care. If you can afford to do so and you feel the care you receive is worth it, then a Medicare Advantage PPO plan may work very well for you.
  • PFFS Plans – A PFFS plan under Medicare Advantage is when your insurance company negotiates with your doctor, hospital, or facility of choice on payment terms on a case-by-case basis. Sometimes everyone will agree, but not always. It’s up to you to stay on top of your health care needs and your health care providers and your insurance company to make sure everyone is on board. If you don’t, you could end up getting blindsided by unexpected medical bills for out-of-pocket costs. This is true, even with a Medicare Advantage plan.
  • Special Needs Plans – Medicare providers have extensive experience with seniors who have chronic conditions that need special attention. Private health insurance companies who offer Special Needs Plans have similar expertise. When the two team up together, you get a Medicare Advantage special needs plan which is great for seniors who have expensive health care needs for their chronic conditions on a limited budget. Just make sure you get your care in-network if you want to avoid enormous out-of-pocket costs for going out-of-network. But there are, of course, exceptions for emergency care; and you might have a chance to negotiate for out-of-network care at a reduced cost if you can persuade your insurance provider that it’s worth it.

One last thing about Medicare Advantage and medical networks: you need to make sure your preferred doctors and facilities are in your network before you decide on a plan! And you can do that quickly and easily with Medicare.gov’s Physician Search Tool.

Drug, Vision and Dental Coverage

One advantage you get with a Medicare Advantage plan is that you have the option to add additional coverage such as vision straight onto your health care policy. That way, you can manage your health and vision needs all at the same time through the same provider. With a Medicare supplement insurance plan or Original Medicare, you don’t have that option and would likely have to get vision care from a private network. It’s not prohibitively expensive to do so, but many seniors prefer the convenience of having everything on the same policy.

Dental coverage under Medicare Advantage works in the same way. All you have to do is contact your insurance provider, ask them to add dental coverage to your Medicare Advantage policy, and then follow their instructions when choosing which dentists and orthodontists to get care from. In some rare cases, these additional coverages may not be available in your area. Be sure to check with all of the Medicare Advantage providers you are evaluating to see if they offer these coverages near you.

Enrollment Options & Best Time To Enroll

To enroll in Medicare Advantage, you must first enroll in Medicare Parts A and B. After you are officially enrolled, and still within your IEP (see below), it will be much easier to qualify for a Medicare Advantage plan. You may even be automatically approved for coverage. However, waiting to enroll could make the process more complicated. You might have to answer questions about your health, or even take a physical exam. And you’re more likely to get rejected for coverage. In addition, people with serious pre-existing conditions (ESRD is among them) will have a harder struggle when seeking a Medicare Advantage plan. For more information on getting covered with a serious medical condition, talk to your state department of insurance, or a local insurance agent near you. Also, take a look at our Medicare Advantage Enrollment Options page.

  • Initial Enrollment Period: Within your first 6 months of Medicare enrollment, you can enroll in a Medicare Advantage policy.
  • Annual Enrollment Period (AEP): From October 15th through December 7th each year, you are free to change or cancel your Medicare Advantage and part D drug plan.
  • Special Enrollment Period (SEP): Any sort of special circumstance in which you may need to change or get new coverage outside of a regular enrollment period, such as moving out of your service area, losing your employer/plan coverage, or your provider ceasing coverage in your area.

What Medicare Advantage Plan Is Best For Me?

To get the best Medicare Advantage plan available, you need to find a company that can provide you with the services you need. You need these services to come at a price you can afford. And you also need a company that can accurately and competently anticipate your future medical needs, whatever they may be.

Unfortunately, all of that is easier said than done. And the fact that your enrollment period is such a limited amount of time doesn’t make things any easier. But we can try our best to make your shopping experience as quick, efficient, and effortless as humanly possible. Just reach out and contact us – we are here and happy to help.

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