What Is the Best Medicare Supplement Plan in Pennsylvania?

Medicare Supplement Plans, also known as Medigap, are private insurance policies that help cover out-of-pocket costs not paid by Original Medicare (Parts A and B). These costs include deductibles, copayments, and coinsurance. Medigap policies work with Original Medicare, providing additional financial protection and predictability for healthcare expenses.

Basics of Medicare Supplement Plans

Medigap plans supplement Original Medicare (Part A and Part B), which covers most healthcare costs but leaves beneficiaries responsible for deductibles, copayments, and coinsurance. Medigap plans help bridge these gaps, reducing out-of-pocket expenses.

Medigap plans do not work with Medicare Advantage (Part C) plans; individuals cannot have both. Medigap plans are standardized across most states, meaning a Plan A from one insurer offers the same basic benefits as a Plan A from another. While benefits are consistent, premiums vary significantly between companies. The primary purpose of Medigap is to provide a more predictable financial outlook for healthcare costs by covering the patient’s share of costs after Original Medicare has paid its portion.

Standardized Medigap Plans in Pennsylvania

Pennsylvania adheres to federal standardization rules for Medigap plans, offering policies identified by letters A through N. Each plan provides specific benefits to cover out-of-pocket costs left by Original Medicare.

Plan A is the most basic Medigap plan, covering Medicare Part A coinsurance and hospital costs for an additional 365 days after Medicare benefits are exhausted, Part B coinsurance or copayment, the first three pints of blood, and Part A hospice care coinsurance or copayment. Plan B offers the same benefits as Plan A, plus coverage for the Medicare Part A deductible.

Plans C and F are generally considered the most comprehensive Medigap plans, covering many out-of-pocket costs, including the Medicare Part B deductible. Due to federal law, these plans are no longer available for individuals eligible for Medicare on or after January 1, 2020. If you were eligible before this date, you can still purchase or keep Plan C or F. Plan F covers all Medicare-approved out-of-pocket costs. Plan C offers similar comprehensive coverage but does not cover Medicare Part B excess charges.

For those ineligible for Plans C or F, Plan G is a popular comprehensive alternative, covering all benefits that Plan F covers except the Medicare Part B deductible. Plan D provides coverage similar to Plan G but does not cover Medicare Part B excess charges. Plan N covers Part B coinsurance at 100%, except for a copayment of up to $20 for some office visits and up to $50 for emergency room visits that do not result in inpatient admission. Plan N also does not cover the Part B deductible or Part B excess charges.

Plans K and L are cost-sharing plans, covering a percentage of certain costs. Plan K covers 50% of the Part B coinsurance, Part A deductible, skilled nursing facility coinsurance, and hospice care coinsurance, with an annual out-of-pocket limit. Plan L covers 75% of these same costs, also with an annual out-of-pocket limit. Once the out-of-pocket limit is reached, the plan pays 100% of covered services for the remainder of the year.

Key Factors for Selecting a Medigap Plan

Choosing a Medigap plan involves evaluating personal circumstances and healthcare needs. A primary consideration is balancing premium costs with coverage scope. Comprehensive plans, like Plan G, typically have higher monthly premiums but offer greater protection against unexpected out-of-pocket expenses. Plans with lower premiums often require beneficiaries to pay more in deductibles, copayments, or coinsurance.

Anticipated healthcare usage plays a significant role. Individuals expecting frequent doctor visits or potential hospital stays might find a comprehensive plan financially advantageous, as it reduces their direct costs per service. Those anticipating minimal healthcare needs might prefer a plan with lower premiums, willing to bear more out-of-pocket costs when services are used.

An individual’s financial situation also influences the choice, assessing the ability to afford higher monthly premiums for predictable costs versus absorbing potentially higher out-of-pocket expenses for less comprehensive coverage. If foreign travel emergency coverage is important, Plans F, G, M, and N offer this benefit with a lifetime limit. It is also prudent to consider the reputation and financial stability of the insurance company offering the Medigap policy, as this can affect customer service and claims processing.

Enrollment and Eligibility in Pennsylvania

The most favorable time to enroll in a Medigap plan in Pennsylvania is during the Medigap Open Enrollment Period. This one-time, six-month period begins the month an individual turns 65 and is enrolled in Medicare Part B. During this period, insurers cannot deny coverage, impose waiting periods for pre-existing conditions, or charge higher premiums based on health status.

Outside this initial open enrollment period, medical underwriting may apply. This means an insurer can use health information to decide whether to accept an application, charge a higher premium, or impose a waiting period for pre-existing conditions. However, guaranteed issue rights allow individuals to purchase a Medigap policy without medical underwriting in specific situations.

Common scenarios activating guaranteed issue rights include losing employer-sponsored group health coverage, losing coverage from a Medicare Advantage plan leaving the service area, or moving out of a Medicare Advantage plan’s service area. Individuals also have guaranteed issue rights if they drop a Medicare Advantage plan within the first 12 months of joining it for the first time. In these situations, insurers must sell certain Medigap plans (A, B, C, D, F, G, K, or L) without considering health status.