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Rights – Laws

Pennsylvania policyholders have access to some of the nation’s top rated health plans, and these insurers are each required to follow the provisions of the Affordable Care Act, HIPAA, and other laws. Insurance companies cannot rate up however their underwriting guidelines permit, or decline people for coverage, as they once did. Additional laws protect consumers, making it more difficult to lose your coverage without good reason, and providing a fair enough amount of benefits with certain major medical plans. There are many changes provided through federal health care reform, and Pennsylvania insurers must follow many of these laws in an effort to insure more people throughout the state.

Policyholders in Pennsylvania have the right to file an appeal if a claim has been unjustly denied by your health plan, and you can request they foot the bill and correct their error. If another sort of issue arises with your health plan, be it customer service or coverage, you can make a complaint to your insurer or report the issue to the insurance department directly. Whether you support or oppose the Affordable Care Act, the laws will provide many more Pennsylvanians the opportunity to get insured, and have access to the services they need.

Individual insurers in Pennsylvania currently abide by a few essential laws, which dictate how they issue coverage. The following regulations are important to know as a plan member.


Guaranteed Renewability

Pennsylvania is now a guaranteed issue state, and also is required to guarantee renewal of your health plan each year. This provides assistance for individuals who want their coverage kept consistent, and more importantly, the law makes it impossible for an insurer to rescind your plan for no good reason. You will lose your coverage if you have knowingly lied on your application, stopped paying premiums, or committed fraud, though an insurer cannot cancel your plan for health reasons.


Pre-Existing Conditions

Prior to health reform in Pennsylvania, insurers were permitted to decline individuals, increase their rates, or limit their coverage if they had a medical condition. Pre-existing conditions were judged by the objective standard, which means if you were diagnosed, treated, or received medical advice regarding a health problem, it went on your application and you may not be eligible for coverage. Insurers could look back 60 months into your medical history for such conditions, and were able to issue exclusion periods up to 12 months long for care related to your health problem. Carriers were also permitted to add an elimination rider to your plan if they do not want to pay for any treatment of your condition.

Each of these statewide provisions became obsolete in 2014, however. Under the ACA, these obstacles have been removed and even sick people can purchased individual health insurance in Pennsylvania. Insurers cannot increase premiums due to the community rating provision, nor can they issue elimination riders or exclusions. Benefit limitations still exist, but insurers can’t specifically exclude benefits related to your condition under the nondiscrimination law.


Mandatory Benefits

For some comprehensive health plans on the private market, Pennsylvania requires insurers to include certain benefits. Various House and Senate bills have led to making a series of services available to Pennsylvanians who need them through insurance. Differing from the essential health benefits required by health reform, these services are already in place for disease prevention and care for conditions. Under health reform, a set of ten essential health benefits is required by qualified (individual) health plans sold on and off the exchange. The following benefits are currently observed by insurers in Pennsylvania:

  • Acupuncture
  • Autism spectrum disorders
  • Bleeding disorders
  • Cancer prevention and early detection
  • Clinical trials for cancer
  • Colorectal cancer screening
  • Contraception drugs and supplies
  • Diabetes management and supplies
  • Dental anesthesia
  • Hearing aids
  • Hepatitis B vaccination
  • Home health care
  • Infertility diagnosis and treatment
  • Mail order prescription medications
  • Medical foods
  • Newborn hearing exams
  • Osteoporosis
  • Prostate cancer screenings
  • Prosthetics
  • Temporomandibular joint disorder (TMJ)





1. Kaiser State Health Facts. Individual Market Portability Rules.

2. Pennsylvania Health Care Cost Containment Council. Mandated Benefits Review.