Guide to the Health Insurance Marketplace in PA
Health insurance is available to a wide cross-section of Pennsylvanians through the marketplace, which sells subsidized coverage to individuals, families and small businesses throughout the state. While the state exchange is federally operated, each policy is sold by trusted, private insurers based in Pennsylvania. The marketplace has this title because it is a website where you can shop and research health plans before you buy, and then apply for the plan of your choice (much like our site, which predates this part of health reform). You can also find out if you qualify for premium tax credits to lower the monthly cost of coverage.
On the exchange, you can buy coverage varying in cost based on what fits your budget. Each carrier offers qualified health plans, which comply with the Affordable Care Act by providing a comprehensive set of “essential health benefits” such as prescription coverage, maternity care and mental health services. Additionally, each QHP must be offered in four tiers of coverage with different actuarial values, or total costs of covered services paid by your plan. As the same benefits and coverage levels are offered by every Pennsylvania insurer, you can select your carrier based on the best premium rate and network for your needs.
Plan Coverage Levels
When you shop for marketplace plans, you’ll be able to choose from four “metallic” coverage tiers, named according to their cost and also their value when it comes to receiving health care. Bronze plans have the least expensive premium, but they’ll cost you more out-of-pocket when paying for medical services. On the other hand, Platinum plans cover the largest portion of your medical expenses but they have much higher premiums. Regardless of the plan you choose, if you’re eligible for tax credits, you can apply your subsidy to any tier of coverage on the exchange.
To find out if you qualify for a subsidy to help you pay for health insurance on the exchange, your income and household size are considered. If your income falls between 100 and 400 percent of the current poverty line, you may be eligible for premium assistance, and if you earn up to 250 percent of FPL, you might receive a subsidy for cost sharing, as well. Cost sharing includes coinsurance, copays and deductibles, but not premiums.
Estimate your potential subsidy with the Health Reform Subsidy Calculator, or call an agent at 888 803 5917. Tax credits are determined by income in relation to the cost of coverage in your region, and how great a percentage of income the second cheapest silver plan in your area will be for you.
Many Pennsylvania health insurance companies participate on the exchange, with a Blue Cross Blue Shield Association plan for each region, as well as other HMOs and PPOs. The following companies sell individual and family coverage on the state marketplace.
- BlueCross of Northeastern Pennsylvania
- Capital Blue Cross
- Geisinger Health Plans
- Highmark Health Insurance Company
- Highmark Health Services
- Independence Blue Cross
- Keystone Health Plan Central, A Capital Blue Cross Company
- UPMC Health Plan
Every plan on the Pennsylvania Health Insurance Exchange is required to feature a core set of ten “essential health benefits” as required by the health care law. These benefits include services ranging in cost from free to a flat copay to a percentage of coinsurance. While every insurer must offer to cover these services, the cost may vary depending on the carrier and the service, with the exception of preventive care which is always free.
Essential health benefits, or EHBs, include:
- Inpatient hospital services
- Prescription drugs
- Maternity and newborn care
- Ambulatory patient services
- Mental health and substance abuse services, including behavioral health care
- Emergency care
- Laboratory tests
- Pediatric care, including dental and vision
- Preventive, wellness, and chronic disease management services
- Rehabilitative and habilitative services and devices
SHOP for Small Businesses
Small business owners in Pennsylvania can also use the Small Business Health Options Program (SHOP) on the marketplace to buy insurance for themselves and their workers. Tax credits are available to quaint businesses with up to 25 full-time equivalent workers (30 hours per week or more) who earn a maximum of $50,000 per year per person. If an employer qualifies, they can reduce their premium contribution by up to 50 percent. The highest tax credit is awarded to businesses with less than 10 employees who earn up to $25,000 per year.
How to Apply
There are several ways to enroll in coverage through the marketplace, including in person at an enrollment center or with a licensed agent, over the phone, by paper, or online. You can call and request a paper application at 800-318-2596, the federal marketplace customer service hotline.
Additionally, you can apply with East Coast Health Insurance, as our licensed agents are qualified to sell coverage on the exchange. Call an agent at 888 803 5917 to discuss your options and eligibility for subsidies.
Compare PA Marketplace Plans
Below is a cost comparison tool for research purposes and to take some of the mystery out of how these marketplace plans work. You can estimate your subsidy and view your potential plan costs based on your county, age, family size and income. As you cannot purchase coverage through this tool, we recommend calling an East Coast Health Insurance agent if you decide to buy a plan.
*The above disclaimer pertains to the creator of this comparison tool, not East Coast Health Insurance, a licensed broker of insurance products.