Platinum-tier Marketplace plans in Pa provide the best available coverage to individuals, families and small-business owners. The combination of low deductibles, copays and coinsurance, along with rich comprehensive benefits, makes these policies the “Cadillac” of Pennsylvania healthcare plans.
What Is A Platinum Plan?
When the “Patent, Protection And Affordable Care Act” (Obamacare) became law in 2010, (and upheld in a Supreme Cort ruling in 2012), a standardized method of comparing policies was enacted. “Metal” tiers were created, based on the actuarial value, or what percentage of your medical expenses were expected to be paid by the policy you were enrolling in.
Of all of the Metal tiers, the Platinum options offer the most complete coverage to pay for your medical expenses. Gold, Silver, Bronze, and Catastrophic contracts are also offered. 90% of your anticipated healthcare expenses (actuarial value) are expected to be paid, which included copays, coinsurance and deductibles.
Since it is the most expensive “Tier” option, often coinsurance is 0% and deductibles are $1,000 and below. “No deductible” options are also offered. Out-of-pocket expenses are the lowest of all policies, and thus, persons with expensive chronic conditions, ongoing treatment and counseling, or annual recurring surgeries, often find this type of plan the most cost-effective.
NOTE: Typically, these types of options are not the most appropriate for young adult medical coverage, unless there are severe chronic conditions present. If your child is under the age of 30, a more suitable plan may be a Catastrophic, Bronze, or Silver-tier contract because of lower cost and non-utilization of benefits.
Platinum Health Insurance Plans In Pa Are The Most Comprehensive
Plans, Benefits And Prices
Below, we have listed the most comprehensive medical plans in Pennsylvania. All policies are offered by major carriers that are approved for Marketplace business. Platinum-level contracts most closely approximate the best employer-sponsored group coverage that is offered through several large companies. NOTE: In many situations, choosing a Gold-tier or Silver-tier (with cost-sharing) will be a more cost-effective choice. For the purpose of this article, we are focusing only on Platinum plans.
Comprehensive Care Blue PPO 500 (Highmark) – $500 deductible with $1,650 maximum out-of-pocket maximum. Office visits are subject to the deductible and an additional 10% coinsurance. Generic, brand and specialty drugs only pay $5, $20 and $45 respectively.
Assurant Plan 002 (Assurant) – $0 Deductible (Can’t get any better!) with low $25 copay on office visits,including specialists. Fairly low $30 copay on brand name drugs. Maximum out-of-pocket maximum is an acceptable $2,000. This plan is also available in other parts of the state.
Advantage Platinum $250-$20 (UPMC) – $250 deductible with impressive $1,500 maximum out-of-pocket expense. $20 copay on primary care physicians, although deductible applies to specialists. $8 generic drug copay. “Partner,” “Premium” and “Select” networks available.
NOTE: Although Aetna/Coventry does not offer Platinum-tier plans in the Pittsburgh area, their Gold copay option is very attractive.
Marketplace Extra 10/50/0 (Geisinger) – No deductible and maximum $2,000 out-of-pocket maximum. Low $10 copy on pcp visits along with $3 generic drug copay. $250 per day hospital charge.
Healthy Benefits Value 0.0.10 (Keystone – Capital Blue Cross) – $0 Deductible, although $6,350 maximum out-of-pocket. $10 and $25 copays are nice but odd assortment of RX copys – $6, $42 and $275 copays on generic, brand and specialty drugs!
Comprehensive Care Blue PPO 500 (Highmark) – Low $500 deductible and only $1,650 maximum out-of-pocket. Office visits must meet deductible although prescription copays are only $5, $20 and $45.
Keystone HMO (Independence Blue Cross) – No deductible and $3,000 maximum out-of-pocket. Office visit copays are only $15 and $30 and all drugs avoid the deductible. Copays are $5, $30, and $40 on the three-tiers of drugs. This plan is one of the cheapest Platinum contracts in the Philadelphia area.
Personal Choice PPO (Independence Blue Cross) – No deductible and $2,500 maximum out-of-pocket. $10 and $40 office visit copays and identical drug coverage as previous plan.
Personal Choice PPO Complete (Independence Blue Cross) – No deductible with $2,000 maximum out-of-pocket. Smaller RX copays ($5, $20 and $30) than previous two plans.
BC of Northeastern Pa Provides Coverage In Scranton
myBlue Access $500 (BC of Northeastern Pa) – $500 deductible with low $1,500 out-of-pocket maximum. No coinsurance and copays on generic and preferred brand drugs.
myBlue Care (BC of Northeastern Pa) – $100 deductible with VERY low $500 out-of-pocket maximum. Copays on all prescriptions.
Marketplace HMO 15/30/0 (Geisinger) – Another $0 deductible plan with $3,000 maximum out-of-pocket cost. Low $15 and $30 office visit copays and lower $3 copay on generic prescriptions. The $3 is one of the lowest available copays for this type of drug.
Choosing The Best Plan…For You
Is a “Platinum” tier option the best choice for you? Not always. Since subsidized “Silver” tier plans feature cost-sharing, for many households, they may be a better fit since they can potentially reduce out-of-pocket expenses by thousands of dollars.
By reviewing your budget, existing medical conditions (if applicable), federal subsidy qualification, and list of doctors and hospitals you prefer, we can recommend the ideal coverage for you.
In Pennsylvania, young adults can purchase affordable health insurance coverage from more than a dozen reputable companies. With help from recent changes in legislation, these plans guarantee major medical benefits along with many other comprehensive features.
We provide detailed information regarding the best available Pa policies for young persons, how to apply for benefits and how long you can stay on a parent’s policy. Special policies are offered to students, single parents, and anyone that is no longer eligible to keep their existing plan.
Coverage Under Parent’s Plan
If your parent’s private healthcare policy is active, federal law stipulates that you can remain covered or enroll on that policy until you reach age 26. This could apply even if you are living at a different residence, married, or still have eligibility to enroll in your employer’s plan. Of course, at any time you can apply for your own individual policy.
If the policy is a qualified group plan through their employer, Pennsylvania legislation extends the age to 30, subject to specific requirements. Some of these requirements include: being unmarried, no children, living in the state or a full-time student, not eligible for other personal plans and not enrolled in CHIP or Medicaid.
Coverage Through The Pa Health Insurance Exchange (Marketplace)
Pa Exchange Plans Cover 100% Of Preventive Expenses
The newly-created Exchanges are part of the Affordable Care Act (Obamacare) and feature many low-cost plans that require no medical underwriting with pre-existing conditions covered. Open Enrollment occurs at the end of the calendar year. However, if you are dropped from an existing plan or meet other various criteria, you can purchase coverage at any time.
The “catastrophic” option is the cheapest available policy for young persons. In fact, unless you meet low-income requirements, only applicants under age 30 can buy this specific plan. Prices are low because it is designed to cover major medical claims and places a deductible on most coverages. It is ideal for a healthy student that wants to minimize costs. Some of the cheapest and most popular catastrophic plans are listed below:
Highmark Major Events Blue PPO 6600
UPMC Advantage 6600/0
Aetna Basic HMO
Aetna Basic PPO
Capital Blue Healthy Benefits Value HMO 6350
Coventry Catastrophic HMO 100%
Independence Blue Cross Personal Choice
Geisinger Marketplace Value POS
Northeastern BC myBlue Access
Young working professionals may prefer a more comprehensive plan that still is budget friendly. We have listed below several affordable options offered as Marketplace contracts. We assumed a single 26 year-old living in Allegheny County with income of $25,000. Although income is too high for federal subsidy qualification, prices are still very affordable. Rates shown are monthly:
$111 – Major Events Blue PPO 6600 (Highmark) – $6,600 deductible.
$122 – UPMC Advantage Bronze $6,000/$25 – Despite $6,000 deductible, $25 copay on office visits.
$123 – UPMC Advantage Bronze $5,500/$40 – Similar to prior plan.
$134 – UnitedHealthcare Bronze Compass HSA 4900 – HSA-eligible.
$137 – UPMC Advantage Silver $1,750/$30 – Low $1,750 deductible with $30 copay on office visits and an $8 copay on generic prescriptions.
$138 – UPMC Advantage Silver $0/$50 – No deductible with $50 copay on office visits.
$173 – UPMC Advantage Gold $750/$10 – Low $10 copay on office visits and lower out-of-pocket expenses for major claims.
$181 – Shared Cost Blue PPO 1200 (Highmark) – $20 and $30 copays on primary care physician and specialist visits respectively.
NOTE: Lower incomes will result in smaller premiums and higher subsidies. Depending on the level of the subsidy, a Silver-tier policy may be the best alternative, since “cost-sharing” can save thousands of dollars in deductible and coinsurance costs.
Marketplace Options If You Have Serious Medical Conditions
If there are serious medical conditions that require ongoing and/or expensive treatment, a more robust plan may be more appropriate. The “Platinum,” “Gold,” and “Silver” Metal plans provide much richer benefits with lower out of pocket costs. Although the premium is higher, because of the young age, rates will be fairly economical compared to someone 20 years older.
The Silver plans are the only policies that lower deductibles, copays, and maximum out-of-pocket expense, in addition to including the Obamacare subsidy. This option is a perfect fit for a young adult leaving their parent’s plan with expensive pre-existing conditions, but very little income.
For example, a 26 year-old living in Montgomery County, with an income of $18,000 per year, will qualify for a subsidy of more than $2,000. Thus, several plans are available for under $100 per month, including the Independence Blue Cross Keystone HMO Silver Proactive priced at only $29. There is no deductible and the copay for office visits is $10. If the income is $25,000, the rate increases to $108.
Pa Temporary Health Insurance
A “short-term” plan is a very affordable option that will minimize costs, and provide a policy that will cover you for up to 12 months (some policies may be only six months). It’s an ideal solution if you missed Open Enrollment or are not eligible for an SEP (Special Enrollment Event).
The Good: The price is right and it’s the most economical way to purchase healthcare coverage. For example, a 42 year-old male that lives in Allegheny County, can find rates as low as $47 per month (IHC Group – $5,000 deductible). UnitedHealthcare offers a higher-deductible option for $59 and for $87, a $1,000 deductible is available.
Approval times typically take less than 24 hours. Depending on the company, you can also obtain instant coverage and get a pre-approved ID number. Unlike the Marketplace application, which in the past, can take hours to complete, a short-term form takes about 15 minutes. It can be completed online (the easiest way), by fax or by mail. Also, many “big name” companies offer it.
The Bad: Perhaps “Bad” is a bit too harsh. Pre-existing conditions are not covered. Although the “Affordable Care Act” mandates they be covered, it does not apply to non-mandated policies. So although it would not impact a new sickness or illness, a condition that you are being treated for, will not be included in benefits.
For Cheap Temporary Healthcare, Short-Term Plans Are The Answer
Currently, the tax for not purchasing the required Obamacare coverage, can be as much as 2% of your household income (increases each year). So although a temporary policy provides the coverage you need, you may have to pay a small penalty. Of course, the combination of penalty and your premium is usually far less than expensive than a Marketplace plan without a full subsidy.
Eligible low-income consumers can qualify for Medicaid and the accompanying healthcare benefits. Reimbursement for provided service is payed directly to physicians, hospitals or whomever is treating the patient. Dental and vision benefits are also included.
You can apply by phone, via email (an application is downloaded), through your county office, or through COMPASS, which is the national website for Medicaid enrollment. Eligibility is based on the combination of your household income and number of adults and dependents in the household.
Coverage is excellent with lower deductibles and copays than most Exchange plans. Availability of physicians may be different than previous plans you have been covered on, so verifying your personal doctors and specialists participation is recommended.
Healthy Pa is the state’s new Medicaid reform program that’s goal is to improve benefits and add financial stability. A combination of innovative changes and a private coverage option (PCO) is designed to add personal responsibility and create more employment in the state.
CHIP (Children’s Health Insurance Program) can also be considered in low-income households. It is designed to cover children and young adults that are presently not covered, and are not eligible for “Medical Assistance.” Routine physician visits and vaccinations are always covered, and availability of providers is high. This is extremely important since long waiting periods are common in other states. And also, there is no “waiting list.” Immigrants and grandparents may also be able to secure coverage.
The program is still available despite the creation of the Pa Health Insurance Marketplace. If you are currently not covered, under the age of 19, and not eligible for assistance, you may qualify. In addition to the benefits previously mentioned, hospitalization (both inpatient and outpatient), dental and eye coverage is included. The networks are huge so availability of doctors (and specialists) will not be a problem.
If you are the legal guardian of your grandchildren, you also may be eligible. And just like Exchange plans, pre-existing conditions will be covered, not excluded. However, it is possible that some more serious conditions may be referred to Medical Assistance.
The companies that can provide CHIP are determined by the county that you live in. For example, listed below are participating CHIP carriers in some of the larger Pa counties:
Montgomery, Bucks, and Philadelphia – Aetna, Keystone Health Plan East (IBC), Kidz Partners and UnitedHealthcare.
Allegheny, Beaver, Lawrence, Westmoreland, Washington and Greene – Keystone Health Plan West, UnitedHealthcare and UPMC.
Dauphin, Lancaster, York and Adams – Aetna, Capital BlueCross, Geisinger, Highmark BS, UnitedHealthcare and UPMC.
Franklin, Berks, and Fulton – Aetna, Capital BlueCross, Geisinger and Highmark BS.
Bradford, Susquehanna, Lackawanna, Luzerne, and Sullivan – First Priority (BCNEPA), Geisinger and UnitedHealthcare.
Armstrong, Indiana and Clarion – Keystone Health Plan West, UnitedHealthcare and UPMC.
Student Health Plans
Many School-Sponsored Student Health Plans Are Affordable
If you’re a full-time or part-time student and are not covered under a parent or government-provided policy, it’s possible that the college or university you are attending, will offer an affordable plan. Typically, these policies are offered during the summer, and sometimes other times throughout the year, depending upon when you are enrolling for classes.
Most instate and out-of-state college medical plans are Affordable Care Act-compliant. So although there may be many benefits you don’t need (perhaps maternity), they will be covered. You also won’t have to qualify since they are “guarantee-issue” contracts and pre-existing conditions will not be excluded, unless that specific coverage is not included.
But what about the rates? We have listed below the approximate annual cost of student health plans at several of the most popular Pa universities. Prices are for single (one person) policies. Adding a dependent or spouse will substantially increase the premium. The provider is also listed.
California State/Nationwide – $1,888
Drexel/Aetna – $1,901 and $2,631
Duquesne/Highmark BCBS – $1,767
Penn State/Aetna – $2,838
Pitt/UPMC – $2,460
Shippensburg/Nationwide – $1,888
Slippery Rock/Nationwide – $1,888
Temple/Keystone – $2,820 and $4,740
University Of Pennsylvania/Aetna – $3,140
Villanova/ UnitedHealthcare – $1,545
Student and young adult health insurance in Pennsylvania is very affordable and easy to apply for. It only takes a moment to compare multiple plans from the top-ranked companies in the industry.
December 14 2014 – Medicaid eligibility is often the principal determinant of whether a young person receives a large federal subsidy or must accept Medicaid coverage. For example, a 23 year-old with income of $18,000 will receive a subsidy of about $145 per month. Thus, several plans will be available at under $100 per month. And actually, there are several options offered at rates less than $50 per month.
However, if the income is only, accepting Medicaid or purchasing a more expensive unsubsidized policy are the only options. However, obtaining a denial from Medicaid could possible result in subsidy-eligibility.
2015 Pa Health Insurance Exchange enrollment allows you to purchase low-cost medical coverage without answering any medical-related questions. You don’t have to take a physical and regardless of what pre-existing conditions you have (or had), your Pennsylvania Marketplace health insurance plan will cover it. You may qualify for a subsidy that could pay as much as $10,000 of your premium each year, depending on your household income.
But what about applying and enrolling for a plan? What about the glitches, the delays, the frustration and hair-pulling? Actually, most of those issues have disappeared, and with our professional assistance, obtaining quality Marketplace coverage at the most affordable price is guaranteed. With most enrollments, we have reduced the time needed from an hour to less than 20 minutes.
What If I Missed Open Enrollment?
You aren’t alone since millions of Americans either forget to apply, or procrastinate to the point that the deadlines have passed. However, you can buy a policy, and in many situations, the benefits, prices, and provisions will be the same as if you didn’t miss OE.
A “Special Enrollment Period” allows residents of the state to purchase subsidized and unsubsidized policies if they meet specific criteria. For example, if you reach age 26, and are no longer eligible for parent’s coverage, an SEP situation exists. Likewise, if your employer terminates coverage or you lose your group benefits as a result of leaving the workplace, once again, an SEP will be available (for approximately 60 days).
There are several additional situations that allow Pa consumers to take advantage of guaranteed approval and federal subsidies after Open Enrollment. If you are pregnant, when your baby is delivered, he/she will be eligible for almost immediate coverage. Also, if you divorce, and subsequently lose your existing benefits, you would qualify for an SEP.
If you don’t meet the requirements of the SEP, you can apply for a very inexpensive temporary policy, which usually costs less than $100 per month. For younger persons, the premium is often less than $60.
The Beginning Of The Process
We ask a few questions so we have the necessary information to determine the best plan options. The only information needed is the age of all persons to be covered, the household income (to determine the subsidy level), your county of residence, and your smoking status. No questions will be asked about your medical history, what prescriptions you take or any surgeries that need to be scheduled.
Your height and weight (BMI) are no longer needed since they have no impact on prices. Unless you don’t meet citizenship or residency requirements, your policy should be quickly approved. If you need immediate medical treatment, there is no waiting period from the effective date.
If you are over the age of 65, then you need to look at Pa Senior Healthcare options, which we discuss in the article linked in this sentence. The Exchanges do not offer coverage to persons that are eligible for Medicare or Medicaid. However, seniors can easily purchase Medigap or Medicare Advantage plans that will pay for many Part A and Part B expenses, along with other uncovered costs.
NOTE: Medicaid expansion (not Medicare) is also providing residents with more low-cost choices. “Healthy Pa” provides premium assistance vouchers that can be used to buy coverage. More than 500,000 consumers will be able to take advantage of this new program, which should be more cost-effective than traditional programs in many other states.
What Companies Are Available For 2015 Pa Marketplace Coverage?
Highmark Blue Cross Blue Shield, UPMC, Coventry, UnitedHealthcare, Aetna, Assurant, Geisinger, Independence Blue Cross (Keystone), Capital Blue Cross, Highmark BC, and Northeastern Blue Cross.
Calculating Your Subsidy
Don’t Gamble With Your Subsidy Calculation. We’ll Do It For You.
Determining how much money the government will give you to pay your health insurance premium is a very quick calculation. The subsidy is based on the modified adjusted gross income ( MAGI) of your household. Also taken into account is income from anyone listed on your tax return.
Members of your household that are not to be covered will actually increase the amount of the subsidy. For example, if your spouse is covered through an employer, although you do not need benefits for them, it will increase your eligible amount. If you have children that are covered on other policies, but they are listed as your dependents, this can also potentially generate a larger subsidy.
But don’t worry. We’ll perform all of the calculations for you. Typically, it takes less than one minute to determine if you are eligible, and the monthly amount that can be deducted from the premium. NOTE: It is possible that your children may be eligible for CHIP or Medicaid while you can enroll in a Marketplace plan. As your income changes each year, you may also gain or lose eligibility. You may also qualify for a different plan.
Picking A Plan
Platinum. Gold. Silver. Bronze. Catastrophic. Not only are there four Metal options and a catastrophic policy to choose from, but the total number of available policies is usually 40 or more. This is where our three decades of experience helps. Although securing affordable rates is important, the benefits you are most likely to be used must be covering with the lowest available copays and deductibles.
NOTE: UnitedHealthcare is offering 2015 Pennsylvania Marketplace coverage after sitting on the sidelines last year. UHC is one of the largest carriers in the country, and maintains one of the largest provider networks in the state. They are also one of the few companies that offers a short-term policy that can be purchased any time of the year. However, it does not contain many of the benefits that Metal plans offer. And this type of policy does not count as having “credible” coverage.
We are able to effectively research all available plans and determine (based on your budget, income and health) the best policies for you and every other family member. We explain, in detail, the coverages these policies will provide, and what your likely cost will be for the calendar year (both premium and out of pocket costs). If you have existing conditions, we will show you the plans that pay for most/all of the expenses associated with your condition.
Doctors, Specialists And Hospitals
A healthcare plan is only as good as the network providers you can use. Selecting larger carriers usually means you won’t have trouble finding a doctor within 10-20 minutes of your residence. The companies with the largest networks include Highmark, UPMC, UnitedHealthcare, Aetna, Independence Blue Cross (Keystone), Capital Blue Cross and Coventry. However, smaller companies, such as Geisinger, should not be ignored if you reside in their territory.
As many of you know, Highmark and UPMC have large networks, and in many situations, you may not be able to use a UPMC provider on a Highmark plan, and vice versa. If you live in Allegheny County or the western portion of the state, before enrolling for a Marketplace policy, verify that the doctors and facilities you use, are accepted by the insurer you are applying with.
The Application And Enrollment
Need Help With Pa Healthcare Enrollment? Call Or Email Us!
Firstly, you don’t have to answer any medical questions. Your height and weight doesn’t matter and your medication information remains private. You will be asked if you use nicotine, but that’s the only information that is somewhat medically related. Since pre-existing conditions are covered, and your cost is not dependent on your health, the actual application is significantly shorter than the typical eight-page form from before 2014.
You may be asked to “verify your identity.” This involves one (or a few) questions requesting you to perhaps identify a street you used to live on, a mortgage company you did business with, or an old phone number that you once used. Although a bit unusual, this step does help with protecting your privacy. This step is ONLY needed when a subsidy is used and the .gov website is involved.
Once the plan is chosen, and the application is completed and submitted, it may take approximately 3-15 days to receive written confirmation from the insurer. Certain companies tend to be a bit quicker than others. For example, Highmark and Aetna seem to be among the fastest Pa carriers to send out billing statements and ID cards. You can also manually pay a bill online with our assistance.
You can terminate coverage at any time and also modify and/or apply for a different plan at the end of every year during a new Open Enrollment. It is possible that additional carriers will be available during the next period. While you have coverage, you will never be subjected to the hour-long waits at the government website or customer-service number. NOTE: Admittedly, the wait times are much shorter in 2015 compared to 2014. But our own direct-enroll link is still much faster.
Simply call or email us. As your broker-of-record, we’ll be able to quickly help you with your Pa Health Care Exchange issues or questions.
July 25 2014 – More than $5 million of refunds will be sent to customers in Pennsylvania that purchased individual or group policies in 2013. Why? The “80% MLR” (Medical Loss Ratio) rule requires companies to spend at least 80% of their revenue on patient-care expenses. Any excess spending on administrative expenses, salaries and other unapproved costs must be refunded.
UniteedHealthcare’s Golden Rule will send checks for about $1.7 million while Aetna will refund about half of that amount. Many other large companies, such as UPMC and Highmark, met the 80% MLR rule. The average refund will vary, but is typically between $50 and $100.
October 19 2014 – If the Ebola crisis in Africa becomes an epidemic in the US (and specifically Pennsylvania), Marketplace plans contain no exclusions that would prohibit necessary treatment. Vaccines, as they become available, and hospital quarantines are typically a covered expense.
Adding additional money to the state budget for public health emergency preparedness is being discussed, especially since current allocated budget amounts are at their smallest level in more than 10 years. But as the state of Texas knows and understands, Ebola can easily transfer from one state to another, without proper precautions.
November 5 2014 – Prices from all major companies, including Highmark, Aetna, Keystone and Coventry are expected to be released within the next 10 days. Plan choices in 2015 will change from 2014, along with deductibles and copays for many policies. December 15th is the deadline for obtaining a start date of January 1.
December 10-2014 – Less than one week remains to secure a January 1, 2015 effective date. So far, the most popular low-cost plans we are enrolling include Advantage Bronze $6,000/$25 and Advantage Silver $1,750/$30 (UPMC), SharedCost Blue PPO 5500 and Health Savings Blue PPO 2750 (Highmark), and Bronze $20 Copay (Coventry).