Pennsylvania catastrophic major medical insurance is the least expensive form of healthcare coverage. Usually, costs are about 25%-50% less than standard policies and as much as 60% less than employer-sponsored medical plans (assuming the employer is not paying any of the premiums). Personal high-deductible medical rates in the Pittsburgh, Harrisburg, Scranton, Reading, and Philadelphia areas have remained attractive when compared to other large nearby cities. “HDHP” plans are required if you purchase an HSA account. Policies are available privately and through employer group coverage.

While Keystone State health insurance rates have been slowly spiraling upward, many individuals and families are turning to “high deductible” or “catastrophic” plans to minimize their cost. The potential savings can be huge, especially over the lifetime of the policy. Also, rates tend to increase less on policies with higher amounts. By selecting deductibles of $4,000, $5,000, $7,000, or $8,550, premiums can dramatically reduce. If you currently are being treated for a serious ongoing illness, it may not be wise to increase your potential out-of-pocket costs.

Several types of plans (non-compliant short-term) may also require multiple deductibles to be met during the calendar year. Depending upon the plan, a deductible may apply to inpatient and outpatient hospital visits, and perhaps a separate deductible for prescription drugs. For example, Pa Part D plan deductibles range from $0 (Blue Rx PDP Complete, AARP Medicare Rx Preferred, SecureRx Option 1, and SilverScript Plus) to $445 (Clear Spring Health Premier Rx, Elixir RxPlus, WellCare Wellness Rx, and Cigna Secure-Essential Rx).

Open Enrollment In Pa

However, because of annual Open Enrollments (OE), you can safely change your policy each year, regardless of any existing medical conditions or future surgeries or treatment that is needed. The OE period for 2021 effective dates were November 1 – January 15th. However, COVID-related legislation extended the period to mid-August. New plans may be introduced in 2022, depending on the type of legislation that is approved by the current Administration.

Additional non-compliant plans without maternity and mental health benefits may become available, although they will not likely cover pre-existing conditions. These types of plans generally do not offer unlimited medical benefits, and instead feature annual or lifetime caps, ranging from $250,000 to $2 million. During the year of coverage, if chronic medical conditions or ongoing treatment appears, a Marketplace plan through the Pennie Exchange should be considered for the upcoming January 1 effective date.

We provide and analyze low-cost plans that provide high-quality coverage. We specialize in comparing the most respected companies in the state, such as Aetna, UnitedHealthcare, Independence Blue Cross, Highmark, Geisinger, Keystone, Ambetter, Capital Blue Cross, UPMC, Cigna, Oscar, and Humana. The most important features to compare are the deductible, maximum out-of-pocket expenses, inclusion of essential benefits, and list of network providers. HSA-eligible plans are also offered.

Several carriers, including Humana, Cigna, Aetna, and UnitedHealthcare, offer a wide selection of Senior Medicare plans, but not private policies to persons under age 65. Medicare Advantage, Supplement, and Part D prescription drug plans are offered during Senior Open Enrollment periods (October 15th to December 7th), and at the time an applicant reaches age 65. Signing up for Parts A and B is often a requirement to apply for certain benefits. Several Medigap options cover persons that are eligible for both Medicaid and Medicare (Dual Applicants). A Part G high deductible (HD) option is also offered from several carriers.

How Does It Work

The concept of major medical coverage is simple. Typically, a “deductible” must be met before any benefits are paid. Naturally, the higher the deductible and “maximum out-of-pocket expenses,” the lower the rate. In Pennsylvania, companies will offer deductible options (Pennie Exchange and Non-Exchange) from $500 to $12,500. A few carriers, may offer higher choices, such as a $20,000 family option (available “off” Exchange). While we strongly encourage lowering your premium, a $20,000 option should only be used in special situations.

Compliant (Obamacare)  plans can offer deductibles only as high as $8,550 per person ($17,100 per family). Although lower deductibles are offered ($0-$2,000), it’s important to consider the maximum out-of-pocket expense limit, which becomes more relevant if a major medical expense occurs. Coinsurance is generally applicable when the deductible is lower than the out-of-pocket maximum. Each year, maximum allowed deductibles and out-of-pocket expense limits increase, although the amount is fairly mild. Last year, the maximum deductible was $8,150 for individual policies.

Non-compliant short-term plans often feature $10,000 deductible options. Maximum out-of-pocket costs can reach $15,000 or higher, and policies may have to be renewed with underwriting approval. Instead of renewing, if during the OE Period of November 1-December 15th, a Marketplace plan can be selected that will cover all pre-existing conditions. Many short-term plans have a 360-day maximum, so a small gap of coverage throughout the year may impact an existing condition.

If you develop a serious illness, it could be quite costly. Although Marketplace and Group plans are guaranteed-renewable, short-term plans typically require underwriting approval to extend coverage.  Once you start reducing the deductible, it becomes less cost-effective, especially over a 5-15 year period. Often the plans you are offered through your employer will feature lower deductible and out-of-pocket amounts that are not available on private plans. Supplemental plans (AFLAC and other carriers) offer gap coverage to help pay the out-of-pocket cost of high deductibles.

After the deductible has been satisfied, most policies have a “coinsurance” that must be paid. This is the percentage of the balance of the healthcare expenses that the policyholder is responsible for. The most common coinsurance is 20%, although 30%, 40%, and 50% options are sometimes used on less expensive plans.

0% coinsurance plans have no out-of-pocket costs once you have paid the deductible. This option is popular on many employer-sponsored contracts. Pa Marketplace plans feature many policies with the 0% coinsurance option. Available 0% coinsurance plans are listed below:

Highmark Together Blue Major Events EPO 8550

Highmark my Direct Blue Major Events EPO 8550

Highmark Together Blue EPO Bronze 6900 HSA

Highmark my Direct Blue EPO Bronze 6900 HSA

Geisinger Marketplace All-Access QHDHP PPO 6850

Geisinger Marketplace All-Access Value

Capital Blue Cross Catastrophic PPO 8550/0/75

Ambetter Essential Care 2 HSA

Ambetter Balanced Care 24

Ambetter Balanced Care 25 HSA

Independence Blue Cross Personal Choice EPO Bronze Basic

Independence Blue Cross Personal Choice EPO Bronze Reserve

Independence Blue Cross Personal Choice EPO Catastrophic

Oscar Secure

UPMC Advantage Catastrophic $8,550/$0

Pennsylvania Health Savings Accounts feature 0% coinsurance on many policies. The structure is quite simple and very popular. After the deductible has been met, covered benefits are paid at 100%. (Qualified preventive benefits are never subject to deductibles or coinsurance). An HSA differs from a true “major medical” policy because it offers superior benefits after the deductible. We consistently compare the difference in premium and coverage from the top companies. Simply call or email us and we’ll provide personal recommendations for your situation. It is, of course, possible, that an HSA is not your best choice. For example, if frequent visits to your primary-care physician, specialists, and the ER are common, a copay plan with a lower deductible may be more cost-effective.

Sample Major Medical Insurance Rates

Our hypothetical family is a married 50 year-old couple with two children. Their household income is $50,000 (modified adjusted gross income). Their medical conditions do not affect the price of coverage. Monthly rates listed below are for the least expensive “Bronze” Metal plans in selected counties:

$44 – Bucks

$44 – Chester

$44 – Philadelphia

$60 – Somerset

$61 – Bedford

$68 – Luzerne

$68 – Bradford

$78 – Elk

$161 – Mifflin

$161 – Snyder

$188 – Allegheny

There are numerous variables to consider in this example, such as the ages and health of the insured, policy coverage details, pre-existing conditions and underwriting guidelines. Also, rates in other areas of the state, such as Pittsburgh or Philadelphia, will be different. And many Blue Cross plans are only available in specific areas, such as Independence Blue Cross in Southeastern Pa, Capital Blue Cross in the central part of the state and Highmark Blue Cross Blue Shield in Western Pennsylvania. Geisinger is not available in all areas of the state.

Major medical coverage is a great option for many applicants, and not very suitable for others. We’re always willing to help you determine which type of policy is best for your unique situation. Please call us, contact us (see contact information at the top of the page) or view rates now by using our quote box at the top of the page. Naturally, there is never any cost or obligation when you use our website.