Roughly 61 percent of Pennsylvanians receive healthcare through their employers. If you are one of the 39 percent whose employers don’t provide healthcare, you have to navigate through many options to get medical coverage in Pennsylvania.
Luckily, the Keystone State has plenty of affordable healthcare options. In this guide, we’ll go over some useful facts about health insurance in Pennsylvania, including available plans, associated costs, and eligibility requirements. The main points we’ll share are:
- Pennsylvania healthcare basics,
- Health insurance companies in Pennsylvania,
- Affordable Care Act plans and how they apply to Pennsylvanians,
- Short-term health plans and other Pennsylvania ACA alternativess,
- Small business healthcare resources in Pennsylvania,
- Medicaid for low incomes, and how Pennsylvanians can sign up if they qualifyy,
- Valuable information about who to contact for PA health insurance needs.
Medical Coverage in Pennsylvania
Thanks to government rules and an increase in providers, more Pennsylvanians have access to healthcare than ever before. Whether your insurance is provided through an employer, a family member’s plan, or bought individually, many options exist, so it’s important to understand the differences and benefits of each alternative.
How Many Pennsylvanians are Insured?
Of Pennsylvania’s 12.6 million residents, around 94 percent have some form of health insurance. You might get coverage from an employer, a federal program like Medicaid or Medicare (not included in this chart), or some other means. This leaves 5.6 percent of the state, or around 750,000 Pennsylvanians, without insurance.
Pennsylvania Health Insurance Companies
In 2019, residents of 31 counties have more provider choices in the individual market. Furthermore, each insurer that served the state in 2018 has continued to do so in 2019. A healthy, competitive market, such as the one in Pennsylvania, supports a wide range of healthcare options and plans. It also helps drive the cost down, making it more affordable.
Gov. Tom Wolf stated, “[we’re] committed to ensuring that Pennsylvanians remain informed about their growing options and have access to quality, affordable health insurance.” The following companies currently offer subsidy-eligible ACA insurance plans in Pennsylvania:
Capital Blue (Capital Advantage, Keystone Health Plan)
Geisinger Health Plan (First Priority Health)
Independence Blue Cross (Keystone Health Plan East, QCC)
UPMC Health Options
PA Health & Wellness
However, some insurers only service certain regions, so availability may be subject to your county of residence. In 2019, 31 of Pennsylvania’s 67 counties let you choose between at least two competing, ACA-participating health insurers.
Other major Pennsylvania insurers include:
If you are shopping around for Pennsylvania health insurance, whether or not you qualify for ACA subsidies will affect the number of health insurance companies you’ll consider.
Affordable Care Act Plans in Pennsylvania
Federal regulations ensure that Affordable Care Act plans meet certain basic benefit standards. These benchmarks allow Pennsylvania residents to get coverage regardless of factors like pre-existing physical or mental conditions. However, there are some differences between policies.
Pennsylvania Metal Plan Breakdown
Affordable Care Act plans have “metal level” classifications. Each one indicates the percentage of medical expenses covered. The plan levels are as follows:
Bronze level plans cover 60 percent of medical costs.
Silver level plans cover 70 percent of medical costs.
Gold level plans cover 80 percent of medical costs.
Platinum level plans cover 90 percent of medical costs.
In Pennsylvania, the average lowest cost metal plan premiums for 2019 are:
Bronze – $357
Silver – $462
Gold – $495
The average benchmark premium in Pennsylvania is $484.
When Can You Sign Up for Pennsylvania ACA Plans?
Typically, Pennsylvanians can only start an ACA plan during the national Open Enrollment Period, which runs from November 1 through December 15. However, certain life events may extend this period. For instance, you may qualify for a Special Enrollment Period after the loss of employer-provided insurance, a marital status change, or a move.
Obamacare Alternatives in Pennsylvania
Short-Term Health Insurance
Short-term health insurance offers limited medical protection. These plans can last for up to 364 days at a time in Pennsylvania, and can be renewed for up to 36 months in total. Like most states, Pennsylvania follows federal guidelines for the length of short-term plans.
While the affordability is appealing, you may not be able to get short-term coverage if you’re dealing with a serious pre-existing medical condition; nor would these plans be appropriate in that case. Short-term health plans cover most basic medical issues, but they do not cover everything that an ACA plan would. Pennsylvania has multiple short-term providers, so you have a better chance of finding one that meets your needs.
If you need consistent treatment or have a pre-existing condition, a short-term health plan may not give you sufficient protection. Conversely, if you are in good health and only require emergency coverage for a set period of time, temporary health insurance may work well in your situation.
Christian Health Plans
Christian health plans, or faith-based healthcare, allow a group of people to share medical expenses. Recipients agree to uphold certain lifestyle choices while belonging to the group. Three of the four largest Christian health plans – Christian Healthcare Ministries, Medi-Share, and Samaritan Ministries – sign up members in Pennsylvania.
Supplemental Insurance Coverage
Supplemental insurance plans provide specialized coverage for specific areas of care, like dental or vision services, that may be overlooked by major medical insurance. These aren’t comprehensive plans. Rather, supplemental insurance is designed to add onto other health insurance. Sometimes referred to as gap insurance, supplemental insurance can be found by comparing online or using a phone number on the web to connect with a Pennsylvania-licensed agent.
Employer Coverage: Large & Small Businesses
COBRA and Mini-COBRA
Pennsylvania has COBRA for large businesses and a generous interpretation of mini-COBRA plans for smaller workplaces. These allow former employees to purchase insurance through their company after their jobs have ended.
Mini-COBRA lasts for nine months in Pennsylvania. People often choose COBRA to keep their insurance when they’re between jobs. Other requirements in the state of Pennsylvania include:
- Employers must have two to nineteen employees to offer mini-COBRA,
- Employee must have been insured for three consecutive months upon the loss of insurance to qualify for mini-COBRA,
- Qualifying events include: termination, reduction in work hours, divorce, employer bankruptcy, and more.
QSHERA: Pennsylvania shares Qualified Small Employer Health Reimbursement Arrangement, or QSHERA, with the rest of the country. QSHERA is for businesses that have less than 50 employees and do not offer traditional group plans. This cost-sharing insurance plan is funded entirely by your employer. If you qualify for a healthcare subsidy through the ACA and participate in a QSHERA, your employer’s contribution becomes part, or all, of the insurance subsidy, depending on the amount.
Medicaid in Pennsylvania
Pennsylvania became an expanded Medicaid state in 2015. This extended coverage to certain Pennsylvania residents who are above the federal poverty line.
Through Medicaid, more than 700,000 Pennsylvania residents receive healthcare assistance, which is on par with the national average. About 19 percent of Americans receive aid through Medicaid/CHIP, compared to about 20 percent of Pennsylvanians.
About 26 percent of Pennsylvanians live in low-income households, meaning they make less than double the federal poverty line. The criteria for Medicaid eligibility may vary depending on the size of your household. As part of the Medicaid expansion, in Pennsylvania that were ineligible for subsidies may now qualify for insurance.
MyCOMPASS and How to Get Pennsylvania Medicaid
The main factor for Medicaid eligibility is income. For instance, the definition may be $20,780 for a family of three, while it is $12,140 for an individual. The types of income factored into eligibility considerations include the following:
- Social security payments
- Spousal wages, if living in the same home
There are forms of income that do not impact eligibility such as:
- Child support payments
- Supplemental Nutrition Assistance Programs (SNAP) benefits
- Temporary Assistance for Needy Families (TANF)
Pennsylvania manages signups for Medicaid and some other public benefits through a website and app called COMPASS. You can apply for Medicaid and view your existing benefits through this portal.
There are more Medicaid guidelines for qualifying in Pennsylvania; a Department of Public Works caseworker may also play a role in getting your application over the finish line.
Student Health Centers
Students, per ACA standards, can remain on their parents’ health insurance until the age of 26. However, some may find their family’s network doesn’t extend to their Pennsylvania college location, or that other insurance is better suited to their needs.
Many schools require healthcare insurance for enrolled students, and most Pennsylvania institutions have plans available. For example, the University of Pennsylvania requires all full-time students to have comprehensive medical coverage. Students that need to obtain insurance can typically do so through their school. Here’s a list of student health centers at colleges and universities in Pennsylvania:
- Penn State University Health Center
University Park, PA
- University of Pennsylvania
Student Health Service
3535 Market Street (36th and Market)
Suite 100 (floor 1)
Philadelphia, PA 19104
- Temple University
1700 North Broad Street
Philadelphia, PA 19121
Insurance policies offered by schools may have limitations, so it’s wise to consult with your student life office or student medical center while signing up. Also, on-campus medical centers are typically not equipped to handle a wide range of health needs, so some specific services may take you off-campus.
Pennsylvania Health Agencies
There are several local, trustworthy government organizations to turn to for information regarding healthcare coverage in Pennsylvania.
- Pennsylvania Insurance Department
1326 Strawberry Square
Harrisburg, PA 17120
- Pennsylvania Department of Health
184 Donald Ln #1,
Johnstown, PA 15904
- Pennsylvania Children’s Health Insurance Program (CHIP)