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Insurance and Healthcare Consultant

Tammy Burns is an experienced health insurance advisor. She is ACA-certified for health insurance and other ancillary, life, and annuity product.

If you live in Pennsylvania, you have several options for getting health coverage. These include Medicare, Medicaid, military health insurance, employer-sponsored coverage, and private health plans.

This guide offers answers to some of the most common questions about health insurance in Pennsylvania.

What to know about insurance in Pennsylvania

  • Marketplace plans: Pennsylvania doesn’t require residents to use its health insurance exchange (Pennie) or shop with a broker to buy health coverage. As of 2021, you can buy one of 38 plans directly from companies authorized to sell health insurance in the state.
  • Open Enrollment: In Pennsylvania, open enrollment runs from November 1st through January 15th. You can buy a new health plan, switch plans, or drop your current coverage during open enrollment.
  • Special Enrollment: Most of the time, you can’t sign up outside of Open Enrollment unless you experience a qualifying event. These events usually result in a loss of coverage or a change in eligibility. Examples of qualifying events include moving to Pennsylvania, giving birth, getting married or divorced, and losing your eligibility for Medical Assistance.
  • Pennie: When you use Pennie to shop for coverage, you can compare multiple plans to determine which one is right for you.
  • Premium tax credit: You can purchase an off-exchange plan if you don’t want assistance paying monthly premiums. Aetna, UPMC Health Coverage, and Keystone Health Plan Central are among the many insurers offering off-exchange plans in Pennsylvania.
  • Coverage types: In 2019, 8% of insured Pennsylvanians had group health coverage, 20.2% were covered by Medicaid, 16.3% were covered by Medicare, 5.1% had non-group coverage, and 0.8% were covered by the military. Nearly 6% of Pennsylvanians had no health coverage in 2019.

How do I enroll in Pennsylvania's health insurance marketplace?

To enroll in Pennsylvania’s health insurance marketplace, visit www.Pennie.com and follow these steps:

  • Click “Get Covered”
  • Click “Register with access code”
  • Enter your access code (from prior HealthCare.gov account) or your Social Security number and check the box next to “I am not a robot”
  • Click “Submit”

Once you set up an account, you’ll be able to use the plan comparison tool to search for plans and find out how much each costs. To view available plans, enter your ZIP code and date of birth. Then, check the appropriate box if you’re a tobacco user or of Native American descent. If you have a spouse or children, enter their dates of birth where indicated. Finally, enter your household income to find out if you qualify for any savings.

After you enter this basic information, you’ll have an opportunity to search for doctors by name. If you have a doctor you love and want to keep, enter his or her name in the text box. Otherwise, click Skip to View Plans. By default, plans are displayed in order of how much you can expect to pay out of pocket for each one.

The following insurance companies offer individual health insurance plans to Pennsylvania residents in Pennie:

  • Capital Advantage Assurance Company
  • Capital Advantage Insurance Company
  • First Priority Health
  • Geisinger Health Plan
  • Highmark Benefits Group
  • Highmark Health Insurance Company
  • Highmark, Inc.
  • Keystone Health Plan Central
  • Oscar
  • PA Health & Wellness
  • QCC Insurance Company
  • UPMC Health Coverage, Inc.

How do I enroll in Pennsylvania individual and family insurance?

Shopping for individual health insurance is a little easier than choosing a family plan because you only need to consider your own needs. When multiple people need coverage, you have to think about their overall health, their specialized health needs, and whether they need to see any specialists.

When you’re ready to shop for health insurance, keep these factors in mind:

  • Your age and sex
  • Personal medical history
  • Family medical history
  • Preferred health care providers
  • Income

Insurance for individuals in Pennsylvania

Your personal health history is important because it can help you decide whether you want to choose a plan based on cost or extent of coverage. If you have a chronic disease, you may want to prioritize plans that will allow you to keep seeing the same specialists or filling the same specialty prescriptions. A low-cost plan may take priority if you don’t have chronic health conditions. You also need to think about your family’s medical history. If a close relative had cancer or heart disease, for example, it might make more sense to choose a plan with a higher monthly premium and a lower out-of-pocket maximum.

The type of plan you choose is also an important consideration.

  • Health Maintenance Organization (HMO) plans typically cost less than other health coverage types and have some restrictions that can affect your ability to access care. For example, you may have to ask for a referral if you want to see a specialist and your network is local.
  • Preferred Provider Organizations (PPOs) don’t require referrals and usually offer nationwide coverage but tend to cost more than HMO plans. Most PPOs also have out-of-network benefits.
  • Point-of-Service (POS) plans combine the features of an HMO with the features of a PPO. You have to ask for a referral to see a specialist, but you can get care from out-of-network providers if you’re willing to pay a larger percentage of the cost.

Insurance for families in Pennsylvania

If you’re shopping for family insurance, you need to take the individual considerations and apply them to every member of your household who needs coverage. In some cases, one spouse is in good health and the other spouse has a chronic medical condition that can be expensive to manage. If this describes your situation, then you may want to look for a plan that has a low deductible and out-of-pocket maximum to minimize your family’s medical expenses.

When you’re shopping for coverage for multiple children, keep their ages and health histories in mind. Some medical conditions are more common in toddlers, while others don’t develop until later in life. If one of your kids already has a medical diagnosis, you’ll need to choose a plan that covers the most common treatments and health care providers for that condition.

How much does health insurance cost in Pennsylvania?

If you want to purchase insurance directly from a Pennsylvania insurance company, it’s important to understand how insurers set rates. As of 2021, age 21 non tobacco rates range from $148.02 to $655.18 per month. If you’re older than 21 or use tobacco products, you can expect to pay more; if you’re younger, you’ll pay less. For family coverage, your premium will depend on how many people are in your family, their ages, and whether they use tobacco products.

When you use Pennie to shop for insurance, you’ll be able to see the monthly premium for each plan, along with other costs. You can also view the plan type and metal tier. The metal tiers (bronze, silver, gold, and platinum) are used to convey information about the cost and level of coverage associated with each plan.

You may be able to reduce your out-of-pocket costs if you qualify for an Advanced Premium Tax Credit or a cost-sharing reduction. To receive a cost-sharing reduction, you must choose a silver plan or above. You can’t get the reduction if you buy a bronze plan.

Average Premiums in Pennsylvania  2018 2019 2020 2021
Most affordable bronze plan $365 $357 $335 $306
Most affordable silver plan $494 $462 $449 $439
Most affordable gold plan $503 $495 $486 $427

  • Bronze plans typically have the lowest premiums but may have high out-of-pocket costs. You’ll also have to pay 40% coinsurance every time you receive medical services. The most affordable bronze plan in Pennsylvania costs $306 per month.
  • Silver plans are midrange, combining a higher premium with lower deductibles and out-of-pocket maximums. Silver plan members pay 30% coinsurance for each service. The most affordable silver plan in Pennsylvania costs $439 per month.
  • Gold and platinum plans have higher premiums than silver plans but also tend to have lower deductibles, lower copays for medical services, and lower coinsurance requirements. With a gold plan, you’ll pay 20% of the cost of each service you receive; the coinsurance requirement dips to 10% if you have a platinum plan. The most affordable gold plan in Pennsylvania costs $427 per month.

What kind of low-income health insurance is available in Pennsylvania?

Pennsylvania has two main types of health insurance for low-income residents: Medicaid and the Children’s Health Insurance Program (CHIP). If you can’t afford to purchase coverage, you may qualify for one of these programs, depending on your financial circumstances.

Medicaid in Pennsylvania

Pennsylvania’s Medicaid program is known as Medical Assistance. If you’re between 19 and 64 years old, the income limit is 133% of the federal poverty level (FPL). Pennsylvania also has Medicaid available if you’re 65 and older, blind, or disabled. The monthly income limit for ABD Medicaid is $816.10 for a household of one and $1,224.30 for a household of two.

Medical Assistance also has financial resource requirements you must meet to qualify for coverage. Countable resources include cash, money in checking or savings accounts, life insurance, real property that isn’t your primary residence, and stocks. The resource limit for Pennsylvania’s aged, blind, and disabled Medical Assistance program is $2,000 for a single individual and $3,000 for a married couple.

To apply for Medical Assistance, visit the COMPASS website to fill out an application. If you don’t want to apply online, you can call 1-866-550-4355, schedule an appointment at your nearest County Assistance Office, or download a paper application and mail it to the local office.

CHIP PA

CHIP PA provides health coverage for Pennsylvanians under 19 years of age. To qualify for this program, a child must be:

  • A resident of Pennsylvania
  • A U.S. citizen, qualified alien, or U.S. national
  • Uninsured
  • Ineligible for Medical Assistance

The cost of coverage depends on household size and annual income. Free CHIP has no monthly premium and $0 copays, and the annual income limit ranges from $20,222 for a household of one to $111,780 for a household of 10. Low-cost CHIP has premiums ranging from $53 to $86 per month and copays ranging from $5 to $25 per service. The income limits range from $27,692 for a household of one to $168,744 for a household of 10. Full-cost CHIP has a premium of $239 per month and copays ranging from $15 for a doctor visit to $50 for an ER visit. There’s no income limit for this type of CHIP coverage.

To apply for CHIP PA, fill out a COMPASS application, call 1-800-986-KIDS (5437), or download a paper application and mail it in.

What are Pennsylvania's Medicare options for seniors and people with disabilities?

Pennsylvania has several Medicare options available to older adults and people with qualifying disabilities.

  • Original Medicare combines Hospital Insurance with Medical Insurance, known as Part A and Part B. If you choose this basic form of coverage, you may want to reduce your out-of-pocket costs by purchasing Medicare Part D and/or Medicare Supplement Insurance. Part D plans are sold by private insurance companies to help you pay for prescriptions, which are not covered by Medicare. Medicare Supplement Insurance (Medigap) covers expenses such as coinsurance payments, copays, and deductibles, reducing your overall out-of-pocket costs.
  • Unlike Original Medicare, Medicare Advantage is sold by private insurance companies, so monthly premiums vary based on which plan you choose and which company you buy from. These plans bundle Part A and Part B with extra benefits; many Medicare Advantage Plans also include Medicare Part D. In 2019, Pennsylvania had 160 Medicare Advantage Plans

To apply for Medicare, fill out the online application at the Social Security Administration website.

Eligibility and Enrollment
Eligibility To enroll in Original Medicare or Medicare Advantage, you must meet certain eligibility requirements. First, you must be a U.S. citizen or permanent resident. You must also be at least 65 years old or have a disability that causes you to receive SSDI benefits for at least 24 months. You may also qualify for Medicare at a younger age if you have end-stage renal disease.
Enrollment Your initial enrollment period starts three months before you turn 65 and ends three months after your 65th birthday month. If you don’t enroll then, you can sign up during open enrollment.

You may also qualify for a special enrollment period if your eligibility changes outside the normal enrollment period. You can shop for Part D and Medicare Advantage Plans on the Medicare website.

Medicare Resources

If you need help enrolling, contact a counselor at Pennsylvania Medicare Education and Decision Insight (PA MEDI).

Are there short-term health insurance plan options in Pennsylvania?

Pennsylvania allows insurance companies to sell short-term, limited-duration health insurance plans. These plans don’t qualify as minimum essential coverage and may cost you more in the long run than purchasing traditional health insurance. Short-term plans don’t have to cover preexisting conditions and may have higher out-of-pocket costs.

CoreHealth Insurance and Golden Rule Insurance Company sell short-term plans in Pennsylvania. You can apply for one of these plans regardless of your age, but note that insurers are allowed to deny you coverage for having a preexisting condition. Additionally, short-term health plans don’t have to cover essential health benefits, such as prescriptions, maternity care, and emergency care.

Pennsylvania follows the federal guidelines for short-term coverage, which state that a short-term plan can have a term of up to 364 days. You also have the option of renewing the plan for up to three years of coverage in total.

Pennsylvania Insurance FAQs

Does Pennsylvania require health insurance?

No, Pennsylvania doesn’t require health insurance. Technically, all Americans are required to have health coverage under the Affordable Care Act, but the tax penalty for lacking coverage has been eliminated. Therefore, even if you don’t have the required coverage, you don’t have to pay a tax penalty.

Do I have to use the Health Insurance Marketplace in Pennsylvania?

Pennsylvania, along with 13 other states and the District of Columbia, has its own health insurance exchange. If you want to buy an exchange plan, you’ll use Pennie, not HealthCare.gov. You must use Pennie to shop for health coverage if you want to get a tax credit to help pay your monthly premiums.

What types of alternative health insurance plans (like cost sharing plans) are available in Pennsylvania?

Pennsylvania is one of 30 states to exempt health care sharing ministries (HCSMs) from its state insurance codes. Unlike traditional health plans, HCSMs don’t have to cover preexisting conditions, cap members’ out-of-pocket expenses, or cover essential health benefits. HCSMs are allowed to set lifetime limits on coverage.

Do I need health insurance if I have an HSA/FSA?

Health savings accounts and flexible spending accounts make it easier to save money for your out-of-pocket medical expenses, but these accounts are not a substitute for health insurance. The average daily cost of a hospital stay was $2,607 in 2020. If you don’t have health coverage, just a few days in the hospital could cost more than you have saved, leaving you to pay the difference.

Do I need short-term disability coverage in Pennsylvania if I have health insurance?

Health insurance only covers services like preventive care, diagnostic services, and treatment for illnesses and injuries. If you’re unable to work due to a serious illness or injury, it won’t pay your mortgage or utility bills. You may want to purchase short-term disability coverage, which replaces a percentage of your lost wages, ensuring you have money to pay your bills.

Do I need long-term disability coverage in Pennsylvania if I have health insurance?

Long-term disability (LTD) coverage kicks in anywhere from three to 26 weeks after an injury renders you unable to work. During this waiting period, you can use short-term disability coverage to replace some of your income. When your LTD coverage goes into effect, it will replace 50% to 70% of your lost wages. Since LTD coverage replaces a large percentage of your income, it’s a good idea to purchase it even if you already have a health plan.

What does CHIP PA cover?

CHIP covers a wide range of medical services, including doctor visits, immunizations, prescriptions, rehabilitation therapies, and mental health care. It also pays for durable medical equipment.

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