Stats on Medicare in Pennsylvania

• As of late 2022 more than 22% of PA residents were enrolled in Medicare
• About 49% of PA Medicare beneficiaries are enrolled in Medicare Advantage plans
• Over 700,000 PA residents have Medigap plans 
• Medigap Plan F is the most popular Medigap plan in PA

Medicare is a federal health insurance program designed for people aged 65 and older, as well as some younger people with disabilities or certain health conditions. If the person you care for qualifies for Medicare based on their age, they need to enroll during the 7-month Initial Enrollment Period (IEP). This begins 3 months before the month they turn 65 and ends 3 months after the month they turn 65. If they miss their IEP, they can enroll during the General Enrollment Period (GEP), which is January 1 - March 31 of each year. But there are significant financial penalties for enrolling after the IEP. More on this in a bit.

To qualify for Medicare coverage, they also have to be a U.S. citizen or an alien who has been lawfully admitted for permanent residence and has resided in the United States for 5 continuous years leading up to submitting their Medicare application.

How to Apply for Medicare in Pennsylvania

Enrollment in Medicare can either be automatic or manual, and the process varies depending on the enrollee’s situation.

Automatic Medicare Enrollment Process

If the person you care for has already been receiving Social Security retirement benefits for at least 4 months before turning 65, they'll be automatically enrolled in Medicare Part A and Part B when they turn 65 (we’ll dive deeper into the various parts of Medicare in just a bit). And they'll receive their Medicare card about three months before their 65th birthday or during the 25th month of receiving Social Security Disability Insurance (SSDI) benefits.

If they haven’t been receiving Social Security retirement benefits at least 4 months before turning 65, they'll need to actively sign up for Medicare during their Initial Enrollment Period.

If the person you care for is still working at 65 and covered by their or their spouse’s employer health insurance, they may be able to delay enrollment in Part B without penalty. They can then enroll in Medicare during a Special Enrollment Period when they stop working or lose their employer coverage.

Manual Medicare Enrollment Process

There are five steps to enrolling manually in Medicare. 

1. Gather required information. This includes:
   
   • Proof of name
   • Proof of date of birth
   • Social Security number
   • Proof of citizenship or permanent residency

2. Select an enrollment method. There are three options
   
   • Online through the Social Security Administration website (www.ssa.gov)
   • By phone at 1-800-772-1213 (TTY: 1-800-325-0778)
   • In-person at a local Social Security office

3. Choose Medicare coverage. We’ll talk about the coverage options in detail a bit later. 
   
   • Original Medicare (Part A and Part B)
   • Medicare Advantage plan (Part C)
   • Consider adding Part D prescription drug coverage and/or a Medicare Supplement (Medigap) plan

4. Complete the enrollment process by submitting any required documentation.

5. Review the enrollment confirmation provided by the Social Security Administration. 

The person you care for will receive their Medicare card in the mail about 2-4 weeks after their application has been approved. The approval process can take 6-8 weeks or more.

Late Enrollment Penalties

If your loved one doesn't sign up for Medicare during the IEP, and they don't qualify for a Special Enrollment Period, they may have to pay late enrollment penalties when they do enroll. The longer they wait to enroll, the higher the fines. And some of these fines will be charged every month for the entirety of their coverage. So best bet: don’t miss the IEP. 

What Does Medicare Cover in Pennsylvania?

A very important step in the Medicare enrollment process is deciding among the Medicare coverage options. About half of current Medicare beneficiaries access coverage through Original Medicare (Parts A, B and often D and Medigap or supplemental plan). The other half access coverage through a Medicare Advantage plan (Part C). Let’s break them down.

Original Medicare

On Original Medicare, the person you care for pays for services as they receive them, typically with a deductible and 20% coinsurance for Medicare-approved services. They can choose any healthcare provider that accepts Medicare (about 99% of all healthcare providers), with no referrals necessary. 

Original Medicare is composed of two main parts, Part A and Part B. Each part covers different types of health care expenses. They may also choose to purchase prescription drug coverage (Part D) and a Medicare Supplement Insurance (Medigap) policy (Parts F-N) to cover the costs that Medicare Parts A and B don’t pay. 

Medicare Part A

Medicare Part A (Hospital Insurance) covers:

• inpatient hospital stays 
• care in skilled nursing facilities 
• hospice care 
• some home health care after a hospitalization or skilled nursing facility stay

Importantly, Part A has no out-of-pocket maximum. So there’s no limit to how much a person may spend on these types of healthcare costs.

Medicare Part B

Medicare Part B (Medical Insurance) covers:

• certain doctors' services 
• outpatient care 
• durable medical equipment 
• preventive services 
• Ongoing home health services for participants who meet eligibility criteria* 

Again, Part B has no out-of-pocket maximum.

*To learn if the person you care for qualifies for ongoing home health services covered by Medicare Part B, and if you qualify to be paid to provide that care, learn more about how RubyWell helps PA family caregivers get paid.

Medicare Part D

Medicare Part D (Prescription Drug Coverage) helps cover the cost of prescription drugs and many recommended vaccines. 

Medicare Plans F, G, and K-N

Medicare Plans F, G, and K-N: (Medicare Supplement Insurance or Medigap) help pay your loved one’s share of out-of-pocket costs in Original Medicare, eg: deductibles and coinsurance. 

The different plan letters refer to different levels of coverage. These optional plans can “underwrite,” meaning they can consider pre-existing health conditions, except when the person you care for first becomes eligible to apply for Medicare. 

Medicare Advantage (Medicare Part C)

You may have noticed that there was no “Medicare Part C” in the list above. That’s because Part C refers to Medicare Advantage (MA). These are Medicare-approved plans offered by private companies that bundle Part A, Part B, and usually Part D coverage together. 

They often also offer additional benefits not covered by Original Medicare, such as vision, hearing, dental, and more. These plans cannot “underwrite,” meaning they cannot consider pre-existing health conditions when the person you care for applies for coverage. 

Most MA plans operate like an HMO or PPO, in that your loved one has to choose from a network of approved health care providers in order to receive the maximum benefit amount. And they’ll need a referral from their primary care physician in order for a visit to a specialist to be covered. 

A PPO allows them to go outside the network at a higher cost. Many PPO plans don’t require a referral or prior authorization to see a specialist, but do require it for at least some services. Your loved one is not allowed to add a Medigap policy to a MA plan.

Who is Eligible for Medicare in Pennsylvania?

Medicare is only available to U.S. citizens or permanent legal residents who have lived in the U.S. for at least 5 consecutive years. Since it’s a federal program, eligibility rules are the same for every state. They’re based on age, disability, or medical condition.

Age-based Eligibility

Pennsylvanians aged 65 or older are eligible for Medicare.

Medical Condition-based Eligibility

Pennsylvanians who have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig's disease, can qualify for Medicare before age 65.

Disability-based Eligibility

Some Pennsylvanians may qualify for Medicare before age 65 if they’ve received Social Security Disability Insurance (SSDI) payments or Railroad Retirement Board disability benefits for 24 months.

How Much Does Medicare Cost in PA?

Premium and deductible costs for Medicare change each year. For the most current cost information, go to the Medicare costs page at Medicare.gov.

Part A Medicare Costs

If you or your spouse paid Medicare taxes while working for a certain period, you won’t have to pay a monthly premium for Part A. But you will be responsible for a deductible and copayments for hospital days over 60 days. If you aren’t eligible for premium-free Part A, you may be able to buy it, with a monthly premium of either $278 or up to $505 (in 2025) depending on how long you or your spouse worked and paid Medicare taxes.

In 2025, the Part A deductible is $1,676 per benefit period. 

A benefit period begins the day you’re admitted as an inpatient to a hospital or skilled nursing facility. And it continues throughout your stay and any subsequent stays, as long as there isn't a break of 60 consecutive days between inpatient care.

Part B Medicare Costs

Everyone pays a monthly premium for Part B, with a monthly premium of 185 in 2025 and a deductible of $257/year. 

After you meet your deductible, you’re typically responsible for 20% coinsurance for Part B services. 

Part D Medicare Costs

Everyone who chooses to purchase a Medicare Prescription Drug plan (Part D) pays a monthly premium. 

Part D premiums vary by plan and averaged approximately $55.50 in 2024 with a deductible of no more than $545/year.

Thanks to the 2022 Inflation Reduction Act, as of January 1, 2025, Medicare beneficiaries won’t pay more than $2,000 for prescription drugs during a given plan year.

Medigap (Parts F-N) Costs

Medigap policies are available for purchase from private insurance companies, and the costs vary widely based on the coverage offered and the insurance provider. 

The average monthly premium for Medigap policies was $186.49 in 2023. To get the most accurate and up-to-date pricing, speak with multiple insurers in your area. 

Medicare Advantage (Part C) Costs

If you choose a MA plan, you still need to pay the Medicare Part B premium, which is currently $185/month. If you don’t qualify for premium-free Part A, you’ll have to pay for Part A as well. Then, depending on the MA plan, you may pay an additional Part C monthly premium. Remember, MA plans are offered by private insurance companies, and provide different supplemental benefits. So Part C premiums can vary widely. In 2024, the average monthly plan premium for all MA plans was $18.50.  In 2025, some Medicare Advantage plans are offering reductions in the Medicare Part B premium.

​Medicare Advice from a Medicare Expert

“Choose the plan that’s right for you,” says Gustavius Smith, CEO of Rxcare.ai, a technology company dedicated to simplifying Medicare for both beneficiaries and brokers. “My best advice for selecting Medicare coverage is to start by asking a friend for the name of a trusted Medicare broker. However, this should be the last time you rely on friends, relatives, or acquaintances for Medicare advice.”

If you can’t get a referral, Smith suggests attending a Medicare educational seminar hosted by a licensed broker in your area. These seminars are designed to provide unbiased information, allowing you to ask questions in a pressure-free environment. The Medicare & You handbook provided by CMS is a great resource for confirming what you learn in the seminar.

“Then, create a Medicare.gov account and schedule a one-on-one session—either in person or online—with the broker you met at the seminar,” continues Smith. “This broker will guide you in selecting the best Medicare coverage for your needs. And they won’t charge you for this service.”

Pennsylvania Medicare Education and Decision Insight (PA MEDI)

Here in Pennsylvania, families have access to a resource that can help make sense of the Medicare enrollment process. PA MEDI, formerly known as Pennsylvania’s APPRISE, provides free, unbiased, confidential, personalized assistance to residents with questions about Medicare. But it does not sell or recommend Medicare insurance products, insurance agents, or brokers. 

PA MEDI is operated by the Pennsylvania Department of Aging and staffed with trained, certified counselors through Pennsylvania’s 52 local Area Agencies on Aging. You can also call PA MEDI Helpline at 1-800-783-7067 with questions.

Frequently Asked Questions About Medicare in PA

How does Medicare work?

Medicare works like other health insurance, in that it covers a portion of certain healthcare expenses. What is covered, and how much coverage is provided, depends on which Medicare option and plans you choose. 

What is Medigap?

Medigap, also known as Medicare Supplement Insurance, is extra insurance you can buy from a private health insurance company to help pay for out-of-pocket costs not covered by Original Medicare Part A and Part B. 

These costs include: 

• copayments 
• coinsurance 
• and deductibles 

Insurance companies can only sell standardized Medigap policies, which are identified by letters (Plans F, G, and K-N). All standardized policies in each lettered plan offer the same basic benefits no matter where you live or which insurance company you buy the policy from. For example: all Medigap Plan G policies offer the same basic benefits, but their cost may vary by insurance provider.

How do I shop for a Medicare Supplement (Medigap)?

1. Decide which plan you want:  Compare the benefits of each lettered plan and choose one that meets your current and future health needs.

2. Research insurance companies:
   • Find companies selling the plan you want in PA.
   • Check with the PA Insurance Department for any complaints against the companies.
   • Contact  PA MEDI for free, unbiased help.

3. Compare prices:  The benefits are standardized across each lettered plan. So the main difference between companies offering the same lettered plan is price. So get quotes from multiple companies. The price differences can be based on a number of factors including:
   • Discounts that may be offered for non-smokers, married individuals, or automatic payment 
   • Medical underwriting
   • Additional perks like gym membership discounts
   • Insurance agent commission
   • Insurance company pricing strategy
   • And more

4. Consider your health status: If you have chronic conditions, you may want a plan that offers more comprehensive coverage.

5. Verify coverage details: Make sure you understand exactly what the policy covers and any limitations.

How can I save money on my Medicare costs?

Medicare Advantage‍

Pennsylvanians may be able to save money by choosing a Medicare Advantage and staying in-network instead of choosing Original Medicare. Many MA plans offer $0 premiums (though you still pay the Part B premium).They often include additional benefits like vision, dental, and hearing coverage. And MA plans tend to have lower expected out-of-pocket costs compared to Original Medicare.

Medicare Savings Programs

Pennsylvania offers Medicare Savings Programs that can help people with lower-income s pay for Medicare premiums, deductibles, and copayments.

• Qualified Medicare Beneficiary (QMB) Program helps pay for Part A and B premiums, deductibles, coinsurance, and copayments. In 2024, the monthly income limit is $1,275 for individuals and $1,724 for married couples.
• Specified Low-Income Medicare Beneficiary (SLMB) Program helps pay for Part B premiums. The 2024 monthly income limit is $1,526 for individuals and $2,064 for married couples.
• Qualifying Individual (QI) Program helps pay Part B premiums, with slightly higher income limits than SLMB.

To apply for these programs, contact Pennsylvania's Office of Medical Assistance Programs. Even if your income is above the limits, you may still qualify, as some states have different limits or don't count certain types of income.

How do I contact Medicare in PA?

Call Medicare Directly: 

You can reach Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, seven days a week, except for some federal holidays. TTY:1-877-486-2048 for assistance.

Get local assistance through PA MEDI: 

You can call the PA MEDI Helpline at 1-800-783-7067, Monday through Friday, from 8 a.m. to 5 p.m. Or contact your Area Agency on Aging to get connected.

Visit Medicare's Website: 

For more information or to chat online with a representative, you can visit medicare.gov. 

How do I protect myself from Medicare fraud?

Carefully review your Medicare Summary Notices (MSNs) and Explanation of Benefits (EOBs) statements to confirm you actually received each service. Check that all the details are correct, including the providers and dates of service. Look for any suspicious charges or services you don't recognize.

Treat your Medicare card like a credit card. Only give your Medicare number to trusted healthcare providers. Be wary of unsolicited calls or visits offering free medical services or equipment.

Learn what Medicare plans can and cannot do before joining a plan.

Stay updated on recent Medicare-related scams and fraud schemes and report suspicious activity. 

• If you suspect fraud, call 1-800-MEDICARE (1-800-633-4227). 
• For issues related to Medicare Advantage or drug plans, contact the Investigations Medicare Drug Integrity Contractor (I-MEDIC) at 1-877-7SAFERX (1-877-772-3379). 
• The Center for Medicare and Medicaid services (CMS) suggests working with Senior Medicare Patrol (SMP) to help report suspected fraud. 

Are there any other government benefits that may be available?

There are numerous government benefits available for aging adults and their family caregivers in Pennsylvania. Some are federal programs and some are state programs. Each has its own eligibility requirements. To start, you can check out the 6 Most Overlooked Government Benefits for Seniors. And stop by the PA.gov Department of Aging website to find local resources. 

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The information in this article is available to support you as you navigate your financial journey through caregiving. If you know other family caregivers in PA, feel free to share the link to this article with them.

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