Medicare Plans in Pennsylvania: Coverage and Costs (2026)

If you're turning 65 in Pennsylvania or helping a parent sort out Medicare, you face 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 Medicare itself doesn't: PACE and PACENET, state-funded programs that help pay for prescriptions on top of Medicare.1,2

In This Guide

• Key Takeaways
• Original Medicare: Parts A and B
• Medicare Advantage Plans in Pennsylvania (Part C)
• Medicare Part D Prescription Drug Plans in Pennsylvania
• 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 and CMS publishes the new figures each fall at medicare.gov, so check there before you budget for a later year.1 To talk through your coverage with a person, call 1-800-MEDICARE (1-800-633-4227), staffed 24 hours a day, 7 days a week except some federal holidays; TTY users call 1-877-486-2048.7 PA MEDI counselors answer Pennsylvania Medicare questions free at 1-800-783-7067, weekdays 8 a.m. to 5 p.m.6

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.8

The hospital deductible went up $60 from 2025, to $1,736 per benefit period.1 A benefit period starts the day you're admitted and ends once you've gone 60 days in a row without inpatient hospital care or skilled care in a SNF. Get readmitted after that, and the deductible applies again.1

Part B (Medical Insurance)

Part B covers doctor visits, outpatient care, preventive services, durable medical equipment, and mental health care.9 Part B doesn't cover routine dental, vision, or hearing. Most Advantage plans add some of them, but check the specific plan.10,11

• Monthly premium: $202.90 (higher if your income is above $109,000 single or $218,000 married, under the income-related adjustment)1
• 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 qualifying for a Special Enrollment Period or a Medicare Savings Program 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.12

Medicare Advantage Plans 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, except hospice, which Original Medicare keeps covering, and most bundle in Part D drug coverage along with extras like dental, vision, and hearing.11

As of March 2026, CMS counted 3,031,420 Pennsylvanians with Medicare: 1,650,493 were enrolled in Medicare Advantage and other health plans, and 1,380,927 stayed in Original Medicare.13 Within Pennsylvania, though, the mix swings hard from county to county. In Allegheny County (Pittsburgh), 194,287 of 283,438 beneficiaries were in Medicare Advantage and other health plans; in Chester County, in the Philadelphia suburbs, it was 37,443 of 114,759.13

Choice is wide here. CMS lists 334 Medicare Advantage plans in Pennsylvania for 2026, up from 316 in 2025, and every Pennsylvanian with Medicare has access to at least one, including one charging a $0 monthly premium. The average Advantage plan premium in the state changed from $24.26 a month in 2025 to $22.99 in 2026.13 KFF finds the counties with the most plan options are predominantly in Pennsylvania and Ohio, and that Lancaster County's 82 Advantage plans are the most of any county in the country.13

So in much of Pennsylvania the task usually isn't finding an Advantage plan, it's narrowing a crowded field down to the one whose network actually covers your doctors and hospital.

How Many Plans and Insurers You'll Choose From

KFF's analysis of the 2026 CMS landscape files finds that the average Pennsylvania beneficiary can choose from 66 Medicare Advantage plans, offered by an average of 10 insurers.13 That's an average per beneficiary, not a statewide list: CMS counts 334 plans in Pennsylvania, KFF 190. KFF counts only plans open to general enrollment, leaving out special-needs and employer plans.13

Insurers don't all contract with the same hospitals and doctors, and in Advantage the network is the whole ballgame: HMOs send you to in-network providers, while PPOs let you go outside at a higher cost. Emergency care, out-of-area urgent care, and temporary out-of-area dialysis are covered whether you get them in or out of the network.11

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. CMS notes that some plans may have a $0 premium and may help pay all or part of your Part B premium, so check that on the plan's benefit summary.1,11
• Plans run on networks (HMO, PPO, or HMO-POS). Confirm your doctors and hospital are in-network before you enroll, including the specialists and hospital you'd actually use, not just your primary care doctor.11
• Plans may require prior authorization, meaning plan approval before a service or item is covered, which Original Medicare generally does not.11
• Every plan caps your annual in-network out-of-pocket spending, federally limited to $9,250 in 2026, and many set it lower. Original Medicare has no cap of its own, and CMS's full sentence is that there is no yearly limit on what you pay out of pocket unless you have supplemental coverage such as Medigap, Medicaid, employer, retiree, or union coverage.11
• Extras vary widely. Compare 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 Drug Plans in Pennsylvania

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.2 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).14
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.2 It was $2,000 in 2025. The base premium is $38.99 a month, though actual plan premiums vary. 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, financed with state lottery funds and overseen 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.3

Eligibility runs on your gross income from the previous calendar year:3

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.3

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 when a Social Security raise is the only reason their income went over the limit. It protects people already enrolled as of December 31, 2024, so if a cost-of-living increase alone has since pushed you over the line, your coverage can continue.3 Apply by phone at 1-800-225-7223, online, or by mail. For the full walkthrough, see our guide to PACE and PACENET in Pennsylvania.

Medigap in Pennsylvania

Medigap policies are sold by private insurers to fill the gaps in Original Medicare: the deductibles, coinsurance, and copays. The Pennsylvania Insurance Department oversees the Medigap market and runs a consumer hotline at 1-877-881-6388 if a carrier gives you trouble.4

The Pennsylvania Insurance Department lists plans A, B, C, D, F, G, K, L, M, and N as the most common here.4 Plans C and F are closed to anyone who became Medicare-eligible on or after January 1, 2020.5 Those people can buy Plan G instead: it covers the Part A deductible, Part A and Part B coinsurance, and skilled nursing coinsurance, leaving you only the $283 Part B deductible.15,1

Your strongest opening is Pennsylvania's open enrollment: under 31 Pa. Code § 89.778, 6 months from your first month of Part B, at any age, including under 65.5 The federal Medigap Open Enrollment Period requires that you be 65 or older, so if you bought Medigap under 65, ask PA MEDI whether you get another chance at 65.4 During your open enrollment an insurer must offer you every Medigap plan it sells, and can't use medical underwriting or your health history to refuse you, charge you more, or start your coverage late.4 One limit survives the window: an insurer may still decline to cover out-of-pocket costs tied to a pre-existing condition for up to six months, though it can't impose that wait if you had at least six months of continuous prior creditable coverage.15,5

No Birthday Rule in Pennsylvania

A few states, like California and Maryland, let you switch each year around your birthday to a Medigap plan with equal or lesser benefits, with no health questions.16 Pennsylvania is not one of them.4 Outside your six-month open enrollment, the Pennsylvania Insurance Department's own guidance warns there is no guarantee a company will sell you a policy, and insurers may apply medical underwriting, unless a guaranteed-issue right applies, such as your Medicare Advantage plan leaving your area or a Medicare Advantage trial right.4 So choose your plan carefully during open enrollment; switching outside it isn't guaranteed.

Medigap or Medicare Advantage?

A Medigap policy can't pay an Advantage plan's copays, coinsurance, deductibles, or premiums, and while you're in one it's illegal for anyone to sell you Medigap unless you're switching back to Original Medicare. Choose Medigap and you stay on Original Medicare, free to see any provider who takes Medicare nationwide, at a higher monthly premium. Choose Advantage and you trade some of that freedom for a network and a lower upfront cost.11

You do get one federal do-over. If this is your first Advantage plan and you aren't happy with it, federal law gives you a trial right to buy a Medigap policy and a separate drug plan if you return to Original Medicare within 12 months of joining; if you dropped a Medigap policy to join, you may be able to get that same policy back if the company still sells it, or another policy sold by a Pennsylvania insurer if it doesn't. Wait past that window and you may not be able to get the old policy back, and in some cases you may not be able to get any Medigap policy.11

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 under the name Healthy Horizons. DHS takes applications online through COMPASS, in person at your county assistance office, by phone at 1-866-550-4355, or by mailing that office the paper PA 600 form. They pay some or all of your Medicare premiums and cost-sharing based on income.17

DHS sets the QMB line at the federal poverty level plus a $20 deductible, so apply rather than rule yourself out if your income lands near it. DHS words the SLMB and QI-1 ceilings exclusively, as less than $1,616 and less than $1,816, where the federal tables state those same figures as the limits themselves. At exactly $1,616 or $1,816 the two do not agree, so apply and let the county assistance office decide.17

QMB is the most generous of the three: it pays your Part A and Part B premiums plus your Medicare deductibles and coinsurance, so on the Part B premium alone it takes $202.90 a month off your costs.17,1 Healthy Horizons has four categories and their resource limits differ. QMB Medicare Cost-Sharing, SLMB and QI-1 each carry the federal limit of $9,950 for an individual and $14,910 for a couple in 2026; QMB Categorically Needy, which also brings medical coverage through Medical Assistance, is capped at $2,000 and $3,000.17 The limits above are tied to the federal poverty guidelines, revised every year, and they are the federal standard rather than an absolute cutoff, because states can disregard certain income and resources. Every figure is measured against income and resources as the state counts them, not against everything you own, and neither DHS nor the federal tables say which resources Pennsylvania counts. Confirm with your county assistance office and apply rather than rule yourself out if you land somewhat over.

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. Under Extra Help the plan premium and the plan deductible are both $0, but the premium half comes with a condition worth knowing before you choose a plan: Medicare pays the premium subsidy against your service area's regional benchmark premium, so if you pick a plan that costs more than the benchmark, you owe the difference yourself.18

• Income limits: $23,940 a year for an individual, $32,460 for a married couple, which is 150% of the 2026 federal poverty guidelines. Not every dollar counts toward that test, so apply rather than rule yourself out on income alone18
• Resource limits: $18,090 for an individual, $36,100 for a married couple living together. The lower $16,590 and $33,100 apply only if you tell Social Security none of your resources will pay for funeral or burial18
• If you qualify for QMB, SLMB, or QI, you're automatically deemed eligible for Extra Help and should not file a separate Extra Help application; QDWI, the fourth savings program, does not carry it17

Apply through Social Security at ssa.gov or call 1-800-772-1213.18

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 dual eligibles' care 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.19

On the Medicare side, dual eligibles can enroll in a Dual Eligible Special Needs Plan, an Advantage plan built for people with both programs. Pennsylvania aligns these D-SNPs with the three Community HealthChoices plans, so one insurer can coordinate your Medicare and Medicaid coverage together.19

If you're 55 or older, need a nursing-home level of care, and can be safely served in the community, Pennsylvania's LIFE program, the state's version of the federal PACE model, covers all your Medicare- and Medicaid-covered care and services in one program.19 You must also live in a LIFE provider's area and meet the county assistance office's financial rules or pay privately.19 (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:20

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

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 is run by the Pennsylvania Department of Aging and delivered through the state's 52 Area Agencies on Aging.6

A PA MEDI counselor can help you:

• Understand Original Medicare, Medigap, Medicare Advantage plans, and prescription drug plans21
• Compare Part C, Part D, and Medigap plan costs in your local area21
• Get help with Medicare Savings Programs and Extra Help21,6
• Sort out Medicare notices, billing concerns, and appeals21
• Understand Medicare and Medicaid benefits and eligibility if you have both6

Call the PA MEDI Helpline at 1-800-783-7067, weekdays from 8 a.m. to 5 p.m., or call your local PA MEDI program.6

Key Pennsylvania Medicare Contacts

Learn More

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.