Medicare in Pennsylvania: 2025 Guide

Pennsylvania's approximately 3 million Medicare beneficiaries are served by one of the most comprehensive state-level Medicare support ecosystems in the nation. The Keystone State is home to PACE and PACENET — among the oldest and most established State Pharmaceutical Assistance Programs in the country — as well as APPRISE, a well-funded SHIP. Philadelphia and Pittsburgh anchor two of the most competitive Medicare Advantage markets in the Northeast. This guide covers what Pennsylvania Medicare beneficiaries need to know in 2025.

Medicare Advantage Plans in Pennsylvania

Pennsylvania's Medicare Advantage market is one of the largest and most competitive in the nation, with approximately 55% of beneficiaries enrolled in private plans. Philadelphia (Philadelphia County and the surrounding suburban counties) and Pittsburgh (Allegheny County) each regularly offer 60 or more Medicare Advantage plans during Annual Enrollment, representing a wide range of HMOs, PPOs, and Special Needs Plans from major carriers including Highmark/BCBS of Pennsylvania, UnitedHealth, Aetna, Geisinger, and UPMC Health Plan. Pennsylvania's two dominant integrated health systems — Geisinger in central and northeastern Pennsylvania, and UPMC in western Pennsylvania — each operate Medicare Advantage plans tied to their respective provider networks, giving beneficiaries in those regions access to coordinated care options that can be very competitive. Beneficiaries choosing between UPMC and Highmark/AHN plans in Pittsburgh, or between various options in Philadelphia, should pay close attention to network composition, as the regional health systems in Pennsylvania tend to maintain distinct provider relationships.

Central and rural Pennsylvania offer a more limited Medicare Advantage selection, though coverage is generally broader than in the most rural parts of other states, thanks in part to Geisinger's extensive reach into central and northeastern counties. Still, beneficiaries in rural areas such as the North Central Highlands, the Poconos, and the southwestern coal regions should verify plan network adequacy before enrolling. Original Medicare combined with a Medigap supplement plan remains a strong option for those who want the broadest possible provider access, particularly for beneficiaries who travel frequently or who rely on specialty care outside their immediate region.

Pennsylvania expanded Medicaid under the ACA, and the state operates a robust dual-eligible program. Dual Eligible Special Needs Plans (D-SNPs) are widely available in major metro areas for beneficiaries who qualify for both Medicare and Pennsylvania Medicaid. The state's Department of Human Services (DHS) administers Medicaid, and Pennsylvania has worked to streamline dual-eligible enrollment in recent years.

Medicare Savings Programs in Pennsylvania

Pennsylvania expanded Medicaid under the ACA, broadening eligibility for low-income assistance. The state's MSPs — QMB, SLMB, QI, and QDWI — help beneficiaries with limited income and resources pay Medicare premiums and, for QMB enrollees, most deductibles and copayments as well. Qualifying for any MSP automatically qualifies you for the federal Extra Help program for Part D drug costs. Pennsylvania's expanded Medicaid means income thresholds may be more generous than in non-expansion states, and some lower-income Medicare beneficiaries may also qualify for full Pennsylvania Medicaid, which can provide additional benefits and cost-sharing assistance.

MSP applications in Pennsylvania are handled by the Department of Human Services (DHS) through county Assistance Offices (CAOs). You can apply online at compass.state.pa.us, by calling 1-800-692-7462, or in person at your local CAO. Pennsylvania's APPRISE counselors at 1-800-783-7067 can help you understand current eligibility criteria, gather required documentation, and navigate the application process. APPRISE counselors are also well-versed in how MSP enrollment interacts with Pennsylvania's PACE and PACENET programs (see below), so it is worth discussing all potential assistance programs at the same time.

State Pharmaceutical Assistance in Pennsylvania

Pennsylvania operates two of the most well-established State Pharmaceutical Assistance Programs in the nation: PACE (Pharmaceutical Assistance Contract for the Elderly) and PACENET (PACE Network). PACE was one of the first SPAPs in the country, created to help older Pennsylvanians afford prescription medications before the Medicare Part D program existed, and it has been serving beneficiaries for decades. Both PACE and PACENET are open to Pennsylvania residents age 65 and older who meet income limits: PACE covers individuals with income up to approximately $14,500 per year and couples up to approximately $17,700 per year; PACENET covers somewhat higher incomes, up to approximately $27,500 individual and $33,500 for couples (limits are updated periodically — verify current figures with PA DHS or APPRISE). Both programs coordinate with Medicare Part D to reduce out-of-pocket drug costs for enrollees.

PACE and PACENET participants receive a card that can be used at Pennsylvania pharmacies to pay reduced costs for covered medications. The programs act as wraparound coverage that fills gaps left by Medicare Part D, reducing copayments for generic and brand-name drugs. Applications for PACE and PACENET are processed through the Pennsylvania Department of Aging. You can apply by calling 1-800-225-7223, visiting a local Area Agency on Aging, or requesting an application online through the PA Department of Aging website. APPRISE counselors at 1-800-783-7067 can help you determine whether you qualify for PACE, PACENET, or federal Extra Help, and can help coordinate enrollment in the program that provides the greatest benefit for your prescription needs.

Getting Free Medicare Help in Pennsylvania

APPRISE (Apprise Health Insurance Counseling and Assistance) is Pennsylvania's SHIP, operated through the Pennsylvania Department of Aging and delivered locally through Area Agencies on Aging across the state's 67 counties. APPRISE is one of the largest and most well-funded SHIP programs in the nation, with a substantial network of trained volunteer counselors who provide free, confidential Medicare counseling to beneficiaries and caregivers. APPRISE counselors can help you compare Medicare Advantage, Part D, and Medigap plans; apply for MSPs, Extra Help, PACE, and PACENET; understand your rights as a Medicare beneficiary; and resolve billing disputes and appeals. Counselors are completely independent from the insurance industry.

Call APPRISE at 1-800-783-7067 to reach a counselor or find your local Area Agency on Aging APPRISE site. Given Pennsylvania's large senior population, APPRISE has counseling sites throughout the state — including Philadelphia, Pittsburgh, Harrisburg, Allentown, Erie, Scranton, and dozens of smaller communities. During Annual Enrollment (October 15 – December 7), APPRISE experiences very high demand; scheduling your appointment early is strongly recommended. APPRISE also offers Medicare enrollment events, group education workshops, and outreach programs throughout the year, particularly in communities with high concentrations of Medicare beneficiaries.