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About Medicare Advantage plans in Pennsylvania

If you’re a Pennsylvania beneficiary with Original Medicare (Part A and Part B), you may be wondering about your coverage options. Medicare Advantage (Medicare Part C) plans provide another way for beneficiaries to get their Medicare benefits. Offered through private insurance companies that are approved by Medicare, these plans must offer at least the same level of coverage that you’d have through Original Medicare, Part A and Part B. However, one benefit of Medicare Part C is that Medicare Advantage plans can provide coverage for benefits that Original Medicare doesn’t cover.

Original Medicare, Part A and Part B, covers a variety of hospital, skilled nursing facility, and medical benefits. However, the federal program doesn’t cover everything, and you’ll generally pay out of pocket when it comes to routine vision or dental services, hearing, or wellness programs (unless you have other insurance that covers these items). In addition, Original Medicare beneficiaries who want prescription drug coverage must get it through a stand-alone Medicare Prescription Drug Plan, since Medicare Part A and Part B prescription drug coverage is limited.

In contrast, Medicare Advantage plans may offer coverage for benefits like hearing, wellness programs, routine vision or dental care, and even prescription drugs. These extra benefits are in addition to the level of coverage you’d have through Original Medicare.

There are several types of Medicare Advantage plans; the specific plan options available to you will depend on location. Some of those options may include:

  • Health Maintenance Organizations (HMOs): One of the most popular types of Medicare Advantage plans, HMOs require members to get health-care services through network providers (although you’ll still be covered for emergency or urgent care). You’ll get most of your care through a primary care doctor and will need referrals if you need to see a specialist.
  • Preferred Provider Organizations (PPOs): Another popular type of Medicare Advantage plan, PPOs offer more provider flexibility while still following a managed-care model. Your copayments and coinsurance costs will be lower if you use providers within the plan’s preferred provider network, but you can also use non-network doctors and pay higher cost sharing. You don’t need a primary care doctor or referrals for specialist care.
  • Special Needs Plans (SNPs): These plans limit enrollment to Medicare beneficiaries who meet certain eligibility criteria, including those who live in an institution (such as a nursing home); have Medicare and Medicaid; or have certain chronic illnesses. Special Needs Plans cater plan benefits to meet the unique needs of its members, which may include certain coordination services, specialized provider networks, or wellness programs.
  • Medical Savings Account (MSA): These plans combine a health plan with a medical savings account. You’ll typically need to reach a high deductible before the plan begins to pay for covered medical costs. Each year, the plan deposits money into a savings account, which you can use to pay for covered medical expenses before you’ve reached your deductible.
  • Private Fee-for-Service Plans (PFFS): Unlike HMOs and PPOs, these plans don’t have provider networks. Instead, you’re allowed to use any provider that will accept the PFFS plan’s terms and conditions, on a case-by-case basis, and agree to treat you.

Medicare Advantage Prescription Drug plans in Pennsylvania

Some Medicare Advantage plans include prescription drug benefits. These plans are called Medicare Advantage Prescription Drug plans and combine medical and prescription drug coverage within a single plan. Keep in mind that not every Medicare Advantage plan includes prescription drug coverage, so always check with the specific plan.

Before enrolling in a Medicare Advantage Prescription Drug plan, it’s important to make sure that the plan covers your prescription drugs. Medicare plans that include prescription drug coverage can vary when it comes to the medications they cover and their costs. One easy way to find out if a Medicare Advantage Prescription Drug plan covers your prescription drugs is to check the plan’s formulary, which is a list of all the medications covered by the plan. The formulary may change at any time. You will receive notice from your plan when necessary.

Comparing Medicare Advantage plans in Pennsylvania

Before enrolling in a Medicare Advantage plan, it is important to compare all available plan options in your location. The availability and cost of your Medicare plan options may differ depending on your county of residence. Some Medicare Advantage plans may have monthly premiums as low as $0; however, even if your service area offers a Medicare Advantage plan with a $0 premium, remember that you’ll need to keep paying your Medicare Part B premium, along with any cost sharing that the plan requires.

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