Pennsylvania Health Insurance

Overview

If you live in Pennsylvania and either buy your own health insurance or are currently uninsured, this guide is for you. It will help you:

  • Determine whether you may qualify for a credit to help you pay for health insurance under the Affordable Care Act (also known as Obamacare)
  • Compare private health plans using U.S. News & World Report's health insurance ratings for Pennsylvania

If you are enrolling for an Obamacare subsidized insurance plan through Healthcare.gov or a broker, the official deadline to sign up for health coverage in 2014 was March 31st. If you signed up by March 31, you would be covered by May 1 and avoid paying a penalty for not being insured.

* Note that federal officials let you get qualified coverage after March 31 IF you started an application by March 31 and finish by April 15.

Do I Qualify for a Tax Break on Health Insurance?

Use the calculator below to determine whether you qualify to receive a tax credit (called a subsidy) that you can use to pay for health insurance. The calculator will also help steer you toward health insurance options that may be best for your needs.

What Plan Type is Right For Me?
How Many Need Coverage
Total Annual Income
 
 

You may qualify for Medicaid, a free, state-sponsored health insurance program. Call 800-318-2596 or go to the Health Insurance Marketplace website to find out if you can enroll in Medicaid.

You qualify for a subsidy (tax credit) that will save you money if you buy a plan on Pennsylvania's new insurance marketplace, called Health Insurance Marketplace. Plans should be offered there starting October 1, 2013. While your subsidy will cover part of the monthly premium for any of the marketplace's plans, a plan that's in the "silver tier" probably offers the best deal. That's because you also qualify for a second subsidy that increases the value of benefits you'd get from any silver plan.

You qualify for a subsidy (tax credit) that will save you money if you buy a health plan on Pennsylvania's new insurance marketplace, called Health Insurance Marketplace. Plans should be offered there starting October 1, 2013. Your subsidy will cover part of the monthly premium for any of the marketplace's plans, known as Qualified Health Plans.

You don't qualify for a subsidy. You can either buy a plan on the Health Insurance Marketplace website or click the button below to compare U.S. News-rated plans in your state's private insurance market. Plans on Health Insurance Marketplace will generally offer more health coverage than plans in the private market, but they also tend to cost more in monthly premiums. The Health Insurance Marketplace website should offer plans beginning October 1, 2013.

Any children in your household may be eligible for Medicaid. Call 800-318-2596 or go to the Health Insurance Marketplace website to find out if your children are Medicaid-eligible.

See Plans

If You Qualify: Plans That Cost Less

Under the Affordable Care Act, you might qualify for a subsidy to help pay for your health insurance. If you qualify, the subsidy can be used to reduce the cost of your monthly premium or can be taken as an annual tax credit. To take advantage of a subsidy, you must choose a health plan that has been approved by the federal government and the government of Pennsylvania. These plans, known as Exchange Plans, meet a set of standards that aim to eliminate benefit loopholes to make sure that people with pre-existing conditions are not being denied coverage. 

Note: you had until March 31 to enroll for coverage for the rest of 2014 (enrolling on March 31 would cover you starting May 1). If you missed this date, with few exceptions, you will pay a penalty.

If You Don't Qualify: Private Plans

If you don’t qualify for a subsidy, you can still choose among the Health Exchange Plans, or consider one of the many private health insurance plans available in Pennsylvania’s private marketplace. We have rated these private plans on a 1-star to 5-star basis, with 5-star plans providing the most comprehensive coverage.  What’s the biggest difference between a private market health plan and a government-approved one? The trade-off is usually cost. Insurance companies can charge less for private plans with less-extensive network coverage or fewer benefits, which makes more-affordable options available to you.

Do I Have To Buy Health Insurance?

You may have heard that everyone in Pennsylvania must have health insurance in 2014 or pay a penalty – Obamacare's so-called “individual mandate.” With a few exceptions, this is true. For 2014, not carrying insurance will cost $95 per adult plus $47.50 per child (up to $285 per family) or 1 percent of your family’s income, whichever is more. 

U.S. News generally recommends getting health insurance of some kind, even if it is only catastrophic coverage. That's because unexpected medical expenses can easily bankrupt anyone who is uninsured.

Where To Buy Health Insurance

Pennsylvania's Official Marketplace

Health Insurance Marketplace is Pennsylvania’s official portal for buying an Obamacare Health Exchange Plan under the Affordable Care Act. To sign up online for coverage on Health Insurance Marketplace, be prepared to fill out a form that could take 30 minutes or longer. To complete the process quickly, have this info handy:

  • Social security numbers for everyone in your household
  • Your employer’s name and address
  • Your most-recent pay stub or recent records of your wages
  • Information about other types of income you receive, such as alimony, unemployment benefits or a pension

 

Insurance Companies and Brokers

Some people prefer to buy health insurance directly from an insurance company or through a broker. Thanks to strict regulation, you'll pay the same price for a plan regardless of where you buy it – whether on the Health Insurance Marketplace website, through a broker or directly from an insurer – and regardless of whether you sign-up via phone, online, or by filling out paper forms.

U.S. News & World Report has teamed up with eHealth.com, an online broker licensed to sell health insurance, to help you buy the health plan you want. The eHealth customer service team can answer questions, determine whether you're eligible for a subsidy and help you apply for insurance.

Qualified Plans on Health Insurance Marketplace

Beginning October 1, 2013, each state was required by law to have a new online marketplace where residents can buy health insurance. In these marketplaces, most states will offer five tiers of Obamacare Health Exchange Plans: platinum, gold, silver, bronze and catastrophic. Platinum plans will offer the highest level of coverage but tend to cost more in monthly premiums. Bronze plans will cover only a bare minimum of health care expenses but tend to have low premiums. If you are relatively healthy and want to pay less up front, consider a lower-tier plan such as bronze or silver.

You should also look at a Health Insurance Marketplace plan if you are lower-income, because the government will give financial help on a sliding scale to pay for premiums, and better benefits if you select a silver-tier plan. If you have not already done so, we can tell you if a Health Insurance Marketplace plan makes sense given your income on the State Overview tab, under the heading, "Do I Qualify For a Tax Break?"

Read ACA and Health Insurance: Which "Metal" Tier is Right for You? for more advice on choosing between metal tiers.

Participating Companies

Nationwide, the cheapest Silver plan is being offered by Highmark in Pittsburgh, Pa. The plan costs $134 a month for a 27 year-old and uses the Highmark Community Blue Network, a relatively small network created by the insurer to keep premium prices low, reports Kaiser Health News. Compared with Highmark’s broader network of 11,000 doctors and 63 hospitals (available on more expensive Obamacare exchange plans), the Blue Network includes 8,000 doctors and 54 hospitals. The University of Pittsburgh Medical Center (UPMC) is not included within the limited network. Those who seek providers through UPMC may purchase a more expensive Highmark plan for $197 that includes the hospital. 

Western Pennsylvania

In Western Pennsylvania, only UPMC, Highmark and Coventry are available to those purchasing exchange plans. The reimbursement contracts between Highmark and UPMC expire after 2014, which means that those with Highmark insurance will face high out-of-network charges to access UPMC doctors and hospitals, reports The Pittsburgh Tribune.

Philadelphia

In Philadelphia, Independent Blue Cross has introduced priced-based tiers for providers and hospitals with two new HMO plans, the Blue Cross’ HMO Proactive plans. Consumers have access to the entire network, but have to pay more for providers or hospitals in tiers two and three, according to The Philadelphia Inquirer. In tier one, consumers have access to 50 percent of hospitals, 40 percent of primary-care doctors and 40 percent of specialists in IBC’s network. For 2014, Jefferson Hospital System, Pennsylvania Hospital and Mercy Health System are all in tier three. 

Aetna. One of the largest U.S. insurance companies, Aetna has over 22 million medical members. Its network includes more than 1 million health care professionals and over 5,300 hospitals nationwide. Pennsylvania residents who buy an Aetna exchange plan may not have access to the entire network of doctors and hospitals. Aetna offers HMO and PPO exchange plans in Catastrophic through Gold tiers. 

Blue Cross of Northeastern Pennsylvania. Established in 1938 in Wilkes-Barre, Pa., Blue Cross of Northeastern Pennsylvania serves over 550,000 residents in 13 counties in northeastern and north central Pennsylvania. BCNEPA is one of numerous insurers that have created retail stores to attract and serve members. Its first opened in June 2012 in Stroudsburg, and a second store, in Lackawanna County, opened the following summer.  BCNEPA offers PPO exchange plans in every tier. 

Capital BlueCross. Also established in 1938, Capital BlueCross serves residents in twenty-one counties across central Pennsylvania and the Lehigh Valley. Its network includes over 18,000 physicians and 39 hospitals. Capital BlueCross offers PPO exchange plans in Silver and Gold tiers. 

Geisinger Health Plans. Established in 1985 and based in Danville, Pa., this nonprofit, health maintenance organization (HMO) serves residents in forty-four counties across central and northeastern Pennsylvania. Geisinger Health Plans is one of the largest rural HMO providers in the U.S., according to the company. Its network includes over 4,400 primary care doctors and 39, 400 specialists as well as 104 hospitals. Geisinger offers PoS and PPO exchange plans in every tier. 

HealthAmericaOne. A subsidiary of Coventry Health Care, a company owned by Aetna, HealthAmericaOne offers statewide health coverage to Pennsylvania residents as well as coverage in the following counties in Ohio: Belmont, Columbiana, Harrison, Jefferson, Mahoning and Trumbull. HealthAmericaOne offers HMO exchange plans in Catastrophic through Gold tiers. 

Highmark Health Insurance Company and Highmark Health Services. Established in 1977, the nonprofit is the largest insurer in Pennsylvania and West Virginia. Highmark is an independent licensee of the Blue Cross and Blue Shield Association, the oldest U.S. health insurance system. The Blue Cross and Blue Shield Association offers coverage in all 50 states, the District of Columbia and Puerto Rico and has 37 Blue Cross and Blue Shield companies that serve over 100 million members (one third of all Americans), according to the company. Nationally, Blue Cross and Blue Shield companies have contracts with over 96 percent of hospitals and 91 percent of providers. Pennsylvania residents who buy a Blue Cross and Blue Shield exchange plan may not have access to the entire network of doctors and hospitals. Highmark offers PPO exchange plans in every tier. 

Independence Blue Cross. Independence Blue Cross is the largest health insurer in southeastern Pennsylvania and the largest insurer in Philadelphia, serving over 2.1 million residents. IBC is also an independent licensee of the Blue Cross and Blue Shield Association. Pennsylvanians who buy a Blue Cross and Blue Shield exchange plan may not have access to the entire network of doctors and hospitals. Independence Blue Cross offers HMO and PPO exchange plans in every tier. 

Keystone Health Plan Central. Keystone is a health maintenance organization (HMO) serving residents in 21 counties in Central Pennsylvania and the Lehigh Valley. KHPC is a subsidiary of Capital Blue Cross which is also an independent licensee of the Blue Cross and Blue Shield Association. Its network includes over 11,000 physicians and hospitals. Keystone offers HMO exchange plans in Catastrophic through Gold tiers. 

UPMC Health Plan. The integrated global health enterprise is owned by the University of Pittsburgh Medical Center (UPMC), a nationally ranked U.S. healthcare system and the second largest insurer in western Pennsylvania. The company serves approximately 2.2 million Pennsylvania residents. UPMC Health Plan Connect Service and Sales Centers are located in six shopping malls in Pittsburgh and Erie. Its network includes more than 11,500 physicians and 135 hospitals in Pennsylvania and parts of Ohio, West Virginia and Maryland, according to the company. UPMC Health Plan offers HMO and PPO exchange plans in Catastrophic through Gold tiers. 

Need More Help?

The Pennsylvania Insurance Department exists to help residents resolve issues with their insurance company, locate a doctor or other provider within their network, appeal a denial of service, and resolve billing problems with insurers and providers. The office can be reached at 877-881-6388 or emailed through an online contact form. Residents can file an insurance complaint by mail.

Health Insurance Guide

U.S. News offers information on how to buy health insurance and publishes plan ratings for every state. If you’re over 65, see the guide to Medicare plans. Otherwise, start by looking up the Health Insurance Guide for your state.

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2014-05-01