COBRA is available in Pennsylvania if you are employed at a business that has more than 20 full-time employees and you recently lost your job. If your company has less than 20 workers, you may not be eligible for benefits and will have to seek separate coverage for yourself and any additional family member. The Consolidated Omnibus Budget Reconciliation Act, along with state and federal legislation, is designed to help you find affordable Pa health insurance.
However, there are affordable alternatives that will provide medical coverage until you secure another policy through an employer or become eligible for Medicare. Enrolling for a federal Marketplace policy (discussed below) and applying for private coverage are available. Some of your options are also provided under the Continuation Health law.
How Cobra Works
Since 1986, under certain conditions, terminated employees may purchase health insurance coverage without any medical underwriting. No physicals or health-related questions are needed, and no waiting periods or special exclusions will be imposed. Coverage is guaranteed, and the premiums charged will be the same (plus 2%) the employer pays to provide the same benefits to current employees. Your spouse and dependents can also take advantage of the offer.
Medicare-Eligibility Can Impact Your COBRA Options
To obtain benefits, a “qualifying event” must have taken place, and to apply for coverage, you must be the “qualifying beneficiary.” Common situations that qualify include losing group coverage from your employer, losing significant hours at work, divorce or death of your spouse that was the primary insured, and Medicare-eligibility for your husband or wife. There are also several situations where your child can become eligible.
But your premiums may appear to be substantially higher since the employer is no longer paying any part of the cost of the policy. If your working hours were simply reduced, you would not be eligible. Also, if you were guilty of “gross misconduct,” the same would apply. And of course, life and disability benefits would not be included. Typically, by contacting your human resources (HR) department through your employer, you can view specific prices and benefits.
Although you can exclude your family (spouse and/or dependents) from coverage (assuming you are the eligible person), your dependents can not accept coverage alone. For example, if your wife needs coverage but you don’t, both persons would have to accept benefits to have her covered. However, an easier option is utilizing a “Special Enrollment Period” for only the persons that need coverage.
Also, children may be eligible for CHIP (Children’s Health Insurance Program) coverage, which is a very low-cost option with excellent benefits. Thousands of youngsters are actually eligible for benefits, but don’t realize how easily they could qualify. When household income is too high for Medicaid-eligibility, CHIP is a perfect solution. Common plan benefits include immunizations, doctor visits, inpatient/outpatient hospitalization, ER and Urgent Care, dental, vision, and prescription drugs.
NOTE: Seniors that are receiving Medicare benefits (and possibly Medigap coverage in the form of a Supplement or Advantage plan), can not receive COBRA benefits at the same time.
Pa Health Exchange (Marketplace)
Open Enrollment for Exchange plans, features many mandatory benefits and guaranteed-approval. When the Affordable Care Act was passed (and subsequently survived a Supreme Court challenge), a new set of low-cost options immediately became available for persons that lost benefits through their employer. Although an Appellate Court ruled against the Obamacare tax credits in July of 2014, it was later again upheld.
Whether you need to obtain a policy during the official Open Enrollment period (typically from November through January), or outside of that date range, you can take advantage of many of the new provisions in the law, including not having to provide medical details to qualify for coverage. The instant federal tax credit will immediately reduce your premium if you qualify. You can also obtain guaranteed-issue coverage without a federal subsidy, although the rate will be significantly higher.
Missed Pa Open Enrollment? There Are Still Affordable Options.
Missed Open Enrollment?
Since most persons become eligible for COBRA outside of Open Enrollment, a special SEP exemption (Special Enrollment Period) is offered if you lose job benefits. You are provided 60 days to select a plan with full access to the federal subsidy. During this period of time, we can help you choose the best options. Catastrophic, HSA, and comprehensive plans are offered and they can be kept short-term or long-term.
You will not lose any of the benefits or tax credits that are available during the standard Open Enrollment period, and you can pick policies from several companies that have large provider networks in your area. You will also avoid the non-compliance penalty (tax) that is imposed if you have a lapse in coverage. Currently, the tax is 2.5% of household income or $695 per adult and $347.50 per child, whichever is higher. The maximum penalty for an entire family is $2,085. with the penalty increasing each year.
In 2009, a “Mini-COBRA” law was enacted. Under this legislation, workers at small businesses (2-19 employees) can purchase coverage for up to nine months from the date that leave their employer. Spouses and dependents are also eligible to apply for benefits. One of the qualifications is that you must have been working at the company for at least three consecutive months before leaving. Naturally, if you receive Medicare benefits, you are ineligible.
For example, typical health insurance coverage for a family in Western Pa, may be approximately $100-$1,200 per month, depending on deductible amounts, size and eligibility of subsidy, and other copays and coinsurance amounts. For this situation, let’s assume the group policy offered by the employer costs $900 per month. However, if they were paying 50% of the premium, your portion would only be $450 or about $105 per week (since there are four months with extra pay periods).
If you are not able to qualify for a fairly large Obamacare federal tax credit (subsidy) you may be forced to pay the entire $900 when it becomes a private plan. Administrative costs can increase the premium an additional 5%. Of course, if you do not have any serious medical problems, COBRA may not be an ideal solution. And it’s always important to remember to avoid terminating an existing plan without consulting a broker.
Dependents Are Also Eligible
Your dependents (spouse and children) can also enroll, although if you are retired, there may be limitations. However, not every family member has to apply for coverage. For example, if the spouse and children are in perfect health, there may not be a reason to consider COBRA benefits on them, since the rate might be considerably higher than your own personal plan that you purchase on the open market. Your expected household income will be a large factor when determining the best options.
Regardless of which plans are chosen, each policy will be a “guarantee issue” contract with no medical underwriting. So regardless if one member has been previously denied or forced to pay a higher premium, this will no longer occur. Thus, the attractiveness of not selecting a COBRA plan becomes larger. Marketplace policies are also “guarantee-issue” and pre-existing conditions are also covered.
Affordable COBRA Alternatives In Pa May Be Available
What often occurs, is that the primary applicant accepts COBRA coverage at a fairly reasonable cost, based on existing conditions and reduced pricing since the full family rate is not charged. The spouse and children can now choose among dozens of different policies from many Pa insurers. It will then be easy to customize coverage based on the needs of the spouse and kids.
In this scenario, the monthly COBRA premium for two adults and two children might be $1,400, which is very high. However, it may be possible to find an adult/children plan for about $400 and elect single COBRA coverage for another $400. Thus, $600 per month would be saved.
If the household income for that specific year is lower than previous years (because of loss of employment), the Obamacare subsidy may be large enough to provide greater savings.
Different COBRA Options
If office visit and RX benefits are a priority, there will be many affordable options. Also, if your family budget is the most important factor, then a high deductible or catastrophic (if you meet ACA guidelines) plan will be the solution. An important feature is that you don’t always have to place all family members under one policy. Naturally, we help you find the most economical choices, and provide a COBRA question-and-answer guide that may be helpful.
Although a few years ago, the employer-related policy may have provided additional coverage that a private plan did not offer, with the passage of The Affordable Care Act, this is usually no longer true. Two examples are the comprehensive maternity and mental illness benefits that are covered on the policy you buy. There are many other specific benefits, such as pediatric dental, and chiropractor visits, that are often covered under Marketplace plans.
If you are being treated for those conditions, or feel it is important to continue to have those benefits, then COBRA or a private plan will cover expenses. Prior to 2014, many individual policies that you purchased would limit or exclude maternity benefits. However, any new qualified policy is required to be “guarantee-issue” and eliminate the pre-existing condition exclusion clause.
Declining COBRA AND Marketplace Plan Offers
If you choose to decline offers From COBRA and private Marketplace coverage, an “off-Exchange” plan that does not contain any of the mandated benefits required by prior legislation, will be your only choice (assuming you do not qualify for Medicaid or Medicare). Often, these “limited benefit” plans are fairly cheap, but leave gaping holes in catastrophic claims, and often limit drug and office visit coverage. However, a new Open Enrollment period typically begins in November of each year, and you can easily apply for coverage through our website.
UPDATES FROM THE PAST:
September 2014 – With Open Enrollment beginning in less than 2 1/2 months, consumers paying a high COBRA rate will have the opportunity to compare 2015 plans and perhaps select better coverage at a lower rate. Although prices will be slightly increasing from 2014, there may be some worthwhile offers in your area.
If your income is expected to substantially drop in 2015, your subsidy eligibility may change and/or you may qualify for a much larger amount from the federal government. If your current plan is already being subsidized by your employer, and you don’t qualify for a substantial subsidy, it’s likely you should keep your current policy.
October 2016 – Since UnitedHealthcare and Aetna no longer offer Marketplace coverage, Independence Blue Cross (IBX) is the only option in the Philadelphia area.
Medicare Open Enrollment begins on October 15th and continues through December 7th. Effective dates of new plans or changes to existing policies will be January 1st. Pa residents can apply for Part D prescription drug coverage, and also change from a Medicare Advantage contract to original Medicare benefits, or enroll in an Advantage plan, and terminate an existing Supplement contract. Of course, you can also leave all existing plans in place and make no changes.
The single payer concept for Seniors pays about 80% or expenses, leaving the balance to be paid by the applicant. There are four portions to Medicare. Part A consists of hospitalization and related expenses, including your room and surgery charges. Part B is standard medical insurance benefits. Part D is prescription drug benefits, and is provided in several ways. Part C is Medicare Advantage plan coverage, which replaces original Medicare benefits and can provide drug prescription benefits, depending on the contract.
Cover Your Out-Of-Pocket Expenses
Private insurers offer Medigap plans to help pay for may of the out-of-pocket expenses that may not be covered under original government-provided coverage. Prescription drug benefits are provided separately (Part D), although many Advantage contracts include the coverage. NOTE: If your prescriptions changed during 2016 (or new ones were added), reviewing existing drug plans is highly recommended.
Your two “payers” (original Medicare and the private carrier providing the supplement) follow “coordination of benefits” rules to determine which expenses are paid by whom. The “primary” payor is the first to pay expenses up to the limits of the policy. The “secondary” payor pays the balance, although some bills still may be uncovered. A comparison of Medigap plans in Pennsylvania also provides details about which expenses are paid.
Expenses that are medically necessary are generally paid, along with portions of copays, deductibles, and coinsurance. Many preventative expenses are also paid, including (but not limited to) mammograms, lung cancer screenings, nutrition therapy, testing for Glaucoma, and prostrate cancer screenings.
Pennsylvania Senior Medigap Open Enrollment Begins October 15th
Standard Enrollment Period
When you reach age 65 or become eligible for Medicare Parts A and B, your initial Open Enrollment period begins. Otherwise, as previously mentioned, from October 15th through December 7th is the regular period. During this time, you can change your original Medicare coverage to a Medicare Advantage plan. You can also change from an Advantage plan back to original Medicare.
You may also change Advantage plans if your current policy does not include prescription drug benefits, and the new plan does include them. Also, you can change from a plan that offers prescription drug benefits to a plan that omits it. You can also apply for original Part D prescription drug coverage, change to another Part D plan, or simply terminate an existing plan without picking up a new one.
Second Enrollment Period
Generally, if the standard deadline of December 7th is missed, you will have to wait until the following year to request a change from an existing plan. But there is a second Open Enrollment period that begins on January 1st and continues to February 14th. It benefits current Medicare Advantage policyholders since they are allowed to terminate their existing plan, and change to an original Medicare contract. You are not required to remain with the same company.
Also, if you change to original Medicare benefits, a deadline of February 14th is provided to enroll in a Medicare prescription drug plan. Typically, the effective date of benefits is the first day of the month following the date your application is processed.
Medicare Part D Plans Provide Prescription Drug Coverage
Prescription Drug Plans
If you are already enrolled in Part D (prescription drug) coverage, you can continue that plan, unless it is no longer offered. You may also compare other offered options in your area to determine if a more cost-effective policy is available. Many Advantage contracts include these benefits already. Shown below are 12 of the popular prescription drug plans from approved carriers. For this example, we used Allegheny County (Pittsburgh area). Additional information is provided by the Pa DOI.
Humana Walmart Rx Plan
Aetna Medicare RX Saver
Humana Preferred Rx Plan
Symphonix Value Rx
EnvisionRx Plus Silver
EnvisionRx Plus Clear Choice
Express Scripts Medicare Value
First Health Part D Value Plus
Magellan Rx Medicare Basic
AARP MedicareRx Saver Plus
Watch Your Mail
In October, you generally will start receiving materials and information regarding next year’s options, and changes that may have occurred since the last enrollment. As previously mentioned, you are not obligated to change plans. And if you are not notified that your existing plan was terminated or no longer available, the policy will continue if you do not take any action.
However, you should quickly review any paperwork you receive, either from your existing company, or from the Center for Medicare and Medicaid Services (CMS). For instance, The ANOC (Annual Notice Of Change) and EOC (Evidence Of Coverage) correspondence should always be promptly viewed.
Many tools are also available that help you find providers in your area. Often, specialists are more difficult to locate, but with the assistance from our website (and government websites), you can view available different doctors, hospitals, suppliers of medical equipment and other needed supplies, dialysis treatment facilities, home health services, and nursing homes.
APPRISE is a free state-supported program that aids Seniors with counseling and free information. Both paid employees and volunteers are provided to answer questions about various programs, including Medicare, Medicaid, Medigap coverage, and Long-Term Care plans. Presentations are also offered to various groups and organizations. However, since the volunteers are generally not licensed with the Pa Department of Insurance, it remains prudent to continue to utilize reputable and experienced websites like ours, and the independent brokers we represent.
NOTE: We do not endorse specific plans or carriers for Senior products. Also, we are not affiliated with CMS or the Medicare program.
The Pennsylvania Health Insurance Marketplace (Exchange) provides Pa residents the opportunity to purchase affordable high-quality medical plans. No medical questions. No hassle. No denials or cancellations. We know you have questions, so here are some of the answers:
What Is The “Marketplace?”
It’s actually just another name for the Pa Health Insurance Exchange. The two terms are interchangeable. Typically, in a “marketplace,” you shop for the best deals from a variety of different companies. After learning and comparing, you have a much better understanding of the product choices. We help you find the most cost-efficient plans, and we also greatly simplify the enrollment process.
Included in the operation are websites, online resources, and customer service call centers. More than 1 million residents in the state are without coverage, and we are here to help, by providing free comparisons, determining if your medical providers are “in-network,” and also calculating your federal subsidy.
How Do I Find Available Plans?
There are a few ways. Of course, going directly to the .gov website is one option, although delays and logjams have made the enrollment process almost impossible for thousands of visitors. Perhaps the easiest way to view policies is to utilize our free quote feature, and you can view and compare plans in your area.
Remember that different parts of the state will feature different carriers and plans. For example, while Capital Blue Cross may be available in Lebanon, Lancaster, and Harrisburg, you won’t find any of their plans offered in Pittsburgh. The same applies to Geisinger products. However, Aetna and UnitedHealthcare are typically available in most areas.
When Does 2017 Open Enrollment Begin?
On November 1, 2016, enrollment begins for plans with 2017 effective dates. It ends on January 31st, although if you qualify for a Special Enrollment Period exception, you can purchase coverage at any time throughout the year.
How Much Does It Cost To Use These Services?
There are never any costs or fees for utilizing the newly-hired navigators, the 1-800 phone numbers that the government provides or any broker or assistance provided by our website. Any person that attempts to charge a fee is likely not authorized to assist you.
We Help You With Pa Marketplace Plan Selections
For example, we have helped consumers find, compare and understand their best options for more than 35 years and have never collected any fees. However, instead of the three-day training that is required to become a navigator, we have more than three decades of experience assisting consumers obtain quality insurance coverage. That’s why most consumers prefer the free help we provide, instead of using a “navigator” or attempting to contact the government website.
Who Are The Companies That Have Been Approved To Sell Policies Through The Pa Marketplace?
The following carriers are offering policies:
Capital Blue Cross
Independence Blue Cross (Keystone and QCC)
Which Companies Have The Cheapest Pa Health Insurance Rates?
That depends where you live. For example, if you live in the Pittsburgh area (Allegheny or Westmoreland County), Highmark and UPMC (and perhaps Coventry) will offer the least expensive Exchange options. However, if you live in Lancaster County, Geisinger, Capital Blue Cross and Highmark may be the best choices. And in Montgomery County, Aetna and Independence Blue Cross have the most competitive prices.
As evidenced by the wide variation in pricing, it’s important to selectively shop (which is what we do best) so you are matched with the policies that best fit within your personal budget. If you move from one county to another, your options will change. Also, since rates change each year, choosing a new plan during Open Enrollment is quite common.
I Have A Pa COBRA plan. Can I Cancel The Coverage and Buy An Exchange Plan ?
You can not own both a COBRA plan and another policy at the same time. So, as long as you cancel COBRA benefits at the same time your Exchange contract goes into effect, during Open Enrollment, you can change. It is important to know in advance what your exact premium, federal subsidy, benefits and out-of-pocket costs will be. Also, if you are losing dental or vision benefits, you can choose if you want to replace them. Individual dental policies are offered by many companies outside of the Marketplace.
Will My Policy Go Into Effect Right Away?
If the application is completed by December 15th, you can receive an effective date of January 1st. The deadline for a February 1 effective date is January 15th. And the deadline for a March 1 effective date is January 31st. If you wait until after January 31st to attempt to enroll, you will need an SEP exception to secure a plan. Otherwise, many non-compliant options are available, although coverage may be limited.
I’m Staying With The Same Company. Will I Still Be Able To Use My Physician?
Probably, but it’s important you find out before enrolling. Many doctors and specialists are not participating in all policy plans. We can provide that information, or you can contact your physician or provider. Online directories are helpful, but often are not fully updated until March or April. Also, many carriers (UPMC for example), have several different networks that are applicable to specific plans.
Most Pa Plans Cover Generic And Non-Generic Drugs
I Currently Take Two Generic Medications And Two Non-Generic Medications. Are They Covered?
Each policy must provide a list or link of the formulary drugs that are covered. There is other additional information regarding usage, availability, mail-order and of course, cost. You can view a link to this list at the time you are viewing specific details about each plan.
Generic prescriptions generally do not have a high out-of-pocket cost. But if you take multiple non-generic prescriptions, it is important to discuss the specific policies that offer the lowest copays and/or deductibles. Appeals are possible if you are prescribed a drug that is not listed under your benefits. NOTE: Bronze-tier contracts usually place a deductible on non-generic prescriptions.
I Am On Medicare. Am I Affected By These Changes?
No. If you are covered by Medicare, you can not apply for Exchange plans. And the legislation that requires that qualified coverage to be purchased is not applicable. However, you can review and compare Supplemental and Advantage plans (Medigap) that will cover many of the gaps in coverage. Senior plans can be customized to match your specific needs, and Part D plans (prescription drug benefits) can also be personalized to best limit your out-of-pocket costs.
Fall Open Enrollment for Medigap plans begins October 15th and ends on December 7th. You can change your existing coverage or purchase an Advantage contract. January 1 will be the effective date of the new policy.
Do I Have To Buy A Policy That Is Through The Exchange?
No. You can purchase coverage inside or outside the Exchange. Plans issued outside of the Marketplace will not receive any subsidy reimbursement so they should only be considered in upper-income households. However, these “outside” plans do have some appealing features.
Applications are much more streamlined and approvals are generally quicker. It’s also possible that the number of available physicians and hospitals may be higher, if an alternative provider-network is used. And for persons that don’t want an “Obamacare” plan, the “off” options are issued directly by the insurance companies with no government involvement or privacy issues. Although specific mandated benefits are still required, we can avoid utilizing the .gov healthcare website.
August 2015 – Anthem and Cigna have agreed to merge, which will create the largest health insurer in the US. Neither carrier issues a significant amount of group or individual plans in Pennsylvania. So why does the American Hospital Association believe that prices in our state (and many others) could potentially increase because of reduced competition?
The fear is that several other mergers may now occur, which would impact premiums of other Pa carriers. Also, state regulators could recommend that specific services be eliminated because of monopoly concerns. This merger follows that Aetna-Humana agreement, which has a larger effect on local households, since Aetna has a fairly large local market share.
July 2016 – With the Presidential election in three months, changes may be coming. The current system is floundering, with several carriers (including UnitedHealthcare) planning on staying away from many State and Federal Exchanges. Other companies suffered massive underwriting losses and have requested large rate increases for 2017 plans. Also, C0-Ops have continued to perform poorly, and we expect several more to fail within the next 12 months.