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Pennsylvania Health Insurance Marketplace

With most of the Affordable Care Act’s major provisions now in effect, the nation’s health insurance marketplace has undergone a significant transformation. Obamacare impacts individuals, families and small business owners alike. Most Americans are required to have minimum essential coverage unless they qualify for an exemption; however, the law is designed to make health insurance more accessible and affordable with income-based financial assistance and one-stop shopping via state-based and federally facilitated exchanges. Meanwhile, the private marketplace remains a place to shop for quality, affordable health insurance plans that meet ACA requirements.

The following guide offers a glimpse at the various types of ACA-compliant health insurance in Pennsylvania, including individual and family health plans, small group health plans, coverage for high-risk applicants, mini-COBRA continuation coverage, Medicaid, and CHIP.

Health and healthcare in Pennsylvania

Pennsylvania ranked 28th in United Health Foundation’s 2014 America’s Health Rankings. Its strengths included a high rate of high school graduation, high immunization coverage among adolescents, and a low percentage of uninsured population. Challenges included a high rate of drug deaths, high levels of air pollution, and low per capita public health funding.1

Pennsylvania individual and family health insurance

When the Obamacare health insurance exchanges opened for 2014 enrollment, Pennsylvania elected to become part of the federally facilitated marketplace, Individuals and families living in Pennsylvania may purchase health insurance coverage through the state’s federally facilitated exchange and in the private marketplace.

Those who buy health insurance through may be eligible for income-based subsidies, including premium tax credits that may be applied to any metal plan and cost-sharing subsidies that apply to silver plans. Individuals who go without health insurance may face a tax penalty known as the shared responsibility payment.

The U.S. Department of Health and Human Services reported that 318,077 individuals in Pennsylvania selected a marketplace plan through the exchange from Oct. 1, 2013, through April 19, 2014.2 In 2015, the number of individuals in Pennsylvania enrolled in a marketplace plan increased to 472,697 during the open enrollment period.3

Pennsylvania’s health insurance exchange: |
Pennsylvania Department of Insurance: Pennsylvania Insurance

Pennsylvania small group health insurance plans

In Pennsylvania, small businesses with 50 or fewer employees may purchase small group health insurance plans through the federally facilitated Small Business Health Options Program, SHOP Marketplace, at and in the private marketplace. Small businesses that use SHOP and have 25 or fewer employees may qualify for a Small Business Healthcare Tax Credit.

Self-employed individuals with no employees must apply for an individual health insurance plan on or away from

Pennsylvania state COBRA variations for small groups

The Consolidated Omnibus Reconciliation Act (COBRA) allows those employed by businesses with 20 or more employees to continue their group health insurance plan for a limited time should they lose coverage due to qualifying events such as termination of employment due to reasons other than gross misconduct, a reduction in work hours, divorce or legal separation, and loss of dependency status. To learn more about the federal COBRA program, visit

In some states, those who work for a small business and lose health insurance coverage due to a qualifying event may qualify for health insurance continuation through mini-COBRA programs. State mini-COBRA programs allow those who work for a small business and lose health insurance coverage due to a qualifying event to continue coverage, too. These programs generally work like the federal COBRA continuation coverage, but their terms may vary. Pennsylvania’s small group COBRA continuation variations are as follows:4 5

Mini-COBRA option Yes
Eligible group sizes 2 to 19
Maximum continuation period – standard 9 months
Maximum premium Increase 105 percent (entire premium cost plus administrative fees)
State legislation reference Act 2 of 2009
More Information 877-881-6388 (PA Insurance Department Consumer Hotline) |
Additional notes Employees and their dependents must have been continuously insured under the group policy for at least three months prior to the qualifying event.Employers must notify employees within 30 days of loss of group health plan eligibility due to a qualifying event.

Pennsylvania high-risk pools

It used to be that health insurance companies could deny applicants or charge them more based on health history and preexisting conditions. When the Affordable Care Act was passed in 2010, many states created federally funded preexisting condition insurance programs or accepted federal funding to assist with similar high-risk pool programs they already operated.6

The Affordable Care Act prohibits this practice for health insurance plans considered minimum essential coverage with effective dates beginning Jan. 1, 2014, and later. As such, the PCIPS and state high-risk pools created to provide health insurance for those once considered uninsurable are being phased out.

Pennsylvania Medicaid

Medicaid is a state health insurance program for low-income individuals under age 65, pregnant women, children, disabled individuals, and seniors over age 65; it is partially funded by the federal government. In 2014, states were given the option to accept additional federal funding and expand their Medicaid program eligibility to those who make up to 138 percent of the federal poverty level.

Pennsylvania opted not to expand its Medicaid program in 2014, but in August 2014, Gov. Tom Corbett signed a deal to expand Medicaid to as many as 600,000 Pennsylvanians in 2015. Gov. Corbett then lost re-election to now Gov. Tom Wolf, who is reversing the decision, putting Pennsylvania’s Medicaid system back to non-expansion standards 7

The information below is specific to Pennsylvania’s Medicaid program, which is known as Medical Assistance:

Medicaid expansion No
Governing agency Centers for Medicare & Medicaid
Administrator Pennsylvania Department of Public Welfare
Where to apply| options beyond online application).
Phone number 866-550-4355
More Information
Eligibility8 Determined by caseworkers for the Department of Public Welfare; varies by program; some groups covered include low-income individuals and families, individuals with disabilities, children and women.
Open-enrollment period Year-round in all states

Pennsylvania CHIP

The Children’s Health Insurance Program is a partnership between the states and federal government. CHIP provides health insurance to uninsured children who meet certain eligibility guidelines. The information below is specific to Pennsylvania’s health insurance program for low-income children:

Program name CHIP
Where to apply |
Phone number 800-986-KIDS (5437)
Eligibility9 Low-income, uninsured children under 19 who are not eligible for Medical Assistance, are U.S. citizens or qualified non-citizens, and are residents of Pennsylvania

1 United Health Foundation. 2014 America’s Health Rankings Annual Edition. “Annual State Health Rankings.”

2 Kaiser Family Foundation

3 Kaiser Family Foundation

4Pennsylvania Insurance Department. “Mini-COBRA.” N. D. Retrieved from.

5The General Assembly of Pennsylvania. House Bill No. 1089. April 21, 2009. Retrieved from

6 National Conference of State Legislators. Coverage of Uninsurable Pre-Existing Conditions: State and Federal High-Risk Pools. Updated April 2014. Retrieved from

7 The Advisory Board Company. “Where the states stand on Medicaid expansion” July 22, 2015.

8 Pennsylvania Department of Public Welfare. “Learn About COMPASS.” Retrieved from

9 Ibid