Medicare Plans in Pennsylvania: Coverage and Costs (2026)

If you're turning 65 in Pennsylvania or helping a parent sort out Medicare, you're facing four parts, dozens of plan choices, and costs that reset every January. The standard Part B premium for 2026 is $202.90 a month, the Part D donut hole is gone for good, and Pennsylvania adds something most states don't: PACE and PACENET, state-funded programs that help pay for prescriptions on top of Medicare.

This guide walks through every piece of Medicare as it works for Pennsylvanians in 2026, what it costs, the plan options in this state, and how to get help paying for it.

In This Guide

• Key Takeaways
• Original Medicare: Parts A and B
• Medicare Advantage in Pennsylvania (Part C)
• Medicare Part D: Prescription Drugs
• PACE and PACENET: Pennsylvania's Extra Drug Help
• Medigap in Pennsylvania
• Help Paying for Medicare in Pennsylvania
• If You Have Both Medicare and Medicaid
• Medicare Enrollment Periods
• Free Medicare Help: PA MEDI
• Frequently Asked Questions

About these numbers: The premiums and deductibles below come from CMS for calendar year 2026, effective January 1. Medicare costs change every year. For the most current figures, contact Medicare at 1-800-633-4227 (1-800-MEDICARE) or PA MEDI at 1-800-783-7067.

Original Medicare: Parts A and B

Original Medicare is run directly by the federal government, and it comes in two parts.

Part A (Hospital Insurance)

Part A covers inpatient hospital stays, limited skilled nursing facility care, hospice, and some home health care.

The hospital deductible went up $60 from 2025. A benefit period starts the day you're admitted and ends 60 days after you leave. Get readmitted after that, and the deductible applies again.

Part B (Medical Insurance)

Part B covers doctor visits, outpatient care, preventive services, durable medical equipment, and mental health care. It doesn't cover routine dental, vision, or hearing.

• Monthly premium: $202.90 (higher if your income is above $109,000 single or $218,000 married, under the income-related adjustment)
• Annual deductible: $283
• After the deductible: you pay 20% of the Medicare-approved amount for most services

Part B is technically optional, but nearly everyone signs up. Delay past your enrollment window without other creditable coverage and you'll owe a late penalty of 10% for every 12 months you could have had it, for as long as you keep Part B.

Medicare Advantage in Pennsylvania (Part C)

Medicare Advantage plans are an alternative to Original Medicare, sold by private insurers. They cover everything Parts A and B do, and most bundle in Part D drug coverage along with extras like dental, vision, and hearing.

Pennsylvania is one of the largest and most plan-heavy Medicare markets in the country. The state has roughly 3 million Medicare beneficiaries, the fifth-most of any state, and Medicare Advantage is popular here: nationally about 54% of people with Medicare were in an Advantage plan in 2025, and parts of Pennsylvania run well above that, with Allegheny County (Pittsburgh) near 74%. Choice is unusually wide too. In 2025, beneficiaries in ten Pennsylvania counties could pick from 80 or more Advantage plans, and Cumberland County, near Harrisburg, had 87 plans, the most of any county in the United States.

For 2026, the average Medicare beneficiary nationally can choose from about 32 Medicare Advantage plans with drug coverage. Most Pennsylvanians see more than that.

The Major Insurers in Pennsylvania

The big Medicare Advantage names in Pennsylvania are UPMC for Life, Highmark, Aetna, Humana, and UnitedHealthcare. Western Pennsylvania is largely a two-system market: UPMC and Highmark each run their own hospitals and doctor networks around Pittsburgh, so the plan you pick can decide which health system you can use. That makes one step non-negotiable here.

How These Plans Work

• You keep paying your Part B premium ($202.90) on top of any plan premium, though many plans charge $0 extra.
• Plans run on networks (HMO, PPO, or HMO-POS). Confirm your doctors and hospital are in-network before you enroll, which matters a lot in the Pittsburgh area's UPMC-versus-Highmark split.
• Every plan caps your annual out-of-pocket spending. Original Medicare has no such cap.
• Extras vary widely. Compare the dental, vision, hearing, and transportation benefits, not just the premium.

Use the Medicare Plan Finder at medicare.gov to compare plans by ZIP code. Enter your doctors and prescriptions and it shows which plans cover them and your estimated cost.

Medicare Part D: Prescription Drugs

Part D covers outpatient prescription drugs. You can get it as a standalone plan paired with Original Medicare, or built into a Medicare Advantage plan.

The Inflation Reduction Act eliminated the old coverage gap, the donut hole, so that higher-cost middle stage is gone. Part D now moves through three phases:

1. Deductible: you pay full price until you meet your plan's deductible (up to $615 in 2026).
2. Initial coverage: you pay copays or coinsurance while your plan and drug makers cover the rest.
3. Catastrophic: once your out-of-pocket spending reaches $2,100, you pay $0 for covered drugs the rest of the year.

That $2,100 cap is the number that matters most in Part D. It was $2,000 in 2025 and rises with inflation. The base premium is $38.99 a month, though actual plan premiums vary, and increases are capped at 6% a year through 2029. People who qualify for Extra Help often pay much less, sometimes nothing.

PACE and PACENET: Pennsylvania's Extra Drug Help

This is where Pennsylvania stands apart. The state runs two pharmaceutical assistance programs for residents 65 and older, PACE and PACENET, funded largely by the Pennsylvania Lottery and run by the Pennsylvania Department of Aging. They don't replace Part D. They sit on top of it, paying toward the prescription costs Medicare leaves you.

Eligibility runs on your prior-year income, and there's no asset test:

PACE serves the lowest-income enrollees with the most help; PACENET covers a higher income band and works alongside your Part D plan. Both coordinate with Medicare Part D, Medicare Advantage drug coverage, employer or retiree plans, and VA benefits to bring down what you pay at the pharmacy counter.

One protection worth knowing: a cost-of-living moratorium, most recently extended by Act 49 of 2025 through December 31, 2027, keeps more than 20,000 enrollees from losing benefits just because a Social Security raise nudged their income over the limit. So if a small Social Security increase put you barely over the line, you may still qualify. Apply by phone at 1-800-225-7223, online, or by mail.

Medigap in Pennsylvania

Medigap policies are sold by private insurers to fill the gaps in Original Medicare: the deductibles, coinsurance, and copays. They work only with Original Medicare, never with Medicare Advantage. Pennsylvania's Medigap market is overseen by the Pennsylvania Insurance Department, which runs a consumer hotline at 1-877-881-6388 if a carrier gives you trouble.

Pennsylvania offers the federally standardized plans, labeled A, B, C, D, F, G, K, L, M, and N. Plans C and F are closed to anyone who became Medicare-eligible on or after January 1, 2020. Plan G is the popular choice for people newly eligible: it covers the Part A deductible, Part A and Part B coinsurance, and skilled nursing coinsurance, leaving only the $283 Part B deductible on you.

Your one strong opening is the federal Medigap Open Enrollment Period, the six months that begin when you're 65 and enrolled in Part B. During that window an insurer has to sell you any plan at the standard rate regardless of your health. After it closes, Pennsylvania does not give you another automatic shot.

No Birthday Rule in Pennsylvania

A handful of states, like California and Oregon, let you switch Medigap plans every year around your birthday with no health questions. Pennsylvania is not one of them. There's no birthday rule and no annual guaranteed-issue window here. A bill to create a 60-day birthday-rule window was introduced in the 2025-2026 legislative session, but it is not law as of 2026, so don't count on it. Outside your six-month open enrollment, an insurer in Pennsylvania can review your health and turn you down or charge more, unless a federal guaranteed-issue trigger applies, such as your Medicare Advantage plan leaving your area. The practical takeaway: choose your Medigap plan carefully during that first window, because switching later isn't guaranteed.

Medigap or Medicare Advantage?

You can't hold both. Choose Medigap and you stay on Original Medicare with the freedom to see any provider who takes Medicare nationwide, at a higher monthly premium. Choose Medicare Advantage and you trade some of that freedom for a network and a lower upfront cost. Because Pennsylvania has no birthday rule, the Medigap decision carries more weight here than in states that let you change plans yearly.

Help Paying for Medicare in Pennsylvania

If you're on a fixed income, two federal programs, run through the state, can cut your Medicare costs sharply.

Medicare Savings Programs

Pennsylvania runs the Medicare Savings Programs through the Pennsylvania Department of Human Services, and you apply at your county assistance office or online through COMPASS. They pay some or all of your Medicare premiums and cost-sharing based on income.

QMB is the most generous, covering your Part B premium and your deductibles and coinsurance, which can top $3,000 in savings a year. All three programs share a resource limit of $9,950 for an individual and $14,910 for a couple in 2026. The income limits above are tied to the federal poverty level and update each spring, so confirm the current figures with your county assistance office before you rule yourself in or out.

Extra Help for Part D

Extra Help, also called the Low-Income Subsidy, pays Part D premiums, deductibles, and copays for people with limited income and resources.

• Resource limits: $16,590 for an individual, $33,100 for a married couple
• If you qualify for QMB, SLMB, or QI, you're automatically enrolled in Extra Help

Apply through Social Security at ssa.gov or call 1-800-772-1213.

If You Have Both Medicare and Medicaid

Many people who have Medicare also qualify for Medicaid, called Medical Assistance in Pennsylvania, and the state coordinates care for these dual eligibles in a specific way. Long-term services, like nursing-home care or help at home, run through Community HealthChoices, Pennsylvania's statewide managed long-term care program, delivered by three insurers.

On the Medicare side, dual eligibles can enroll in a Dual Eligible Special Needs Plan, a type of Medicare Advantage plan built for people who have both programs. Pennsylvania aligns these D-SNPs with the three Community HealthChoices plans, so one insurer can coordinate your Medicare and Medicaid coverage together.

If your needs are more intensive and you'd qualify for a nursing home but want to stay in the community, Pennsylvania's LIFE program, the state's version of the federal PACE model, wraps your Medicare and Medicaid into one fully integrated plan with a single care team. (Note the name clash: Pennsylvania's PACE pharmacy program is a different thing from the federal PACE model, which the state calls LIFE.) For the full picture, see our guide to the LIFE program in Pennsylvania.

Medicare Enrollment Periods

Miss a deadline and you can face coverage gaps or permanent penalties. The key dates:

Changes you make during Annual Open Enrollment take effect the following January 1. That's when most people review their plan and switch.

Free Medicare Help: PA MEDI

You don't have to figure this out by yourself, and you don't have to pay a broker to help. Pennsylvania's PA MEDI program, short for Pennsylvania Medicare Education and Decision Insight and known until 2021 as APPRISE, gives free, unbiased Medicare counseling. It's run by the Pennsylvania Department of Aging and delivered locally through the state's 52 Area Agencies on Aging.

A PA MEDI counselor can help you:

• Understand your Medicare options and what each part covers
• Compare Medicare Advantage, Part D, and Medigap plans side by side
• Apply for Medicare Savings Programs, Extra Help, and PACE or PACENET
• Sort out billing problems, denials, and appeals
• Work out how Medicare fits with Medical Assistance if you have both

Call 1-800-783-7067, weekdays from 8 a.m. to 5 p.m., and you'll be routed to a certified counselor near you.

Learn More

• Pennsylvania Medicaid: Programs and Coverage
• Community HealthChoices in Pennsylvania
• The LIFE Program in Pennsylvania
• Pennsylvania Medicaid Eligibility and Income Limits
• How to Pay for Senior Care in Pennsylvania
• Caregiver Support in Pennsylvania

Find personalized help comparing your Medicare options in Pennsylvania at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.