Individual and small group health insurance rates in Pennsylvania typically increase each year. The amount of the increase is determined by how much the insurer is requesting, and the amount that is ultimately approved after careful review by the Department (DOI). Any rate change must be fair and appropriate for both the carrier and consumer. Increased market share while retaining profitability and affordability for the consumer is the ultimate goal.
Prior to 2016, the general public could not view requests or findings unless the proposed increase was more than 10%. However, now you can view all results, regardless of the amount of change. And yes, sometimes, Pa health insurance prices reduce. Before a decision is made, several of the most important criteria include underwriting profits and losses, deducible and copay data, coverage changes, administrative fees, and historical and future predicted claim information.
Companies can choose weather to offer Exchange policies in specific states. Many carriers, such as Aetna, Cigna, and UnitedHealthcare, often provide plans is specific states, but also choose to “sit out” may others. Senior coverage, such as Medicare Supplement and Advantage plans, are treated separately.
We have listed below (courtesy of the DOI) the actual requested and approved changes submitted to the State Department of Insurance. These increases and decreases are reflected in 2016 Pa Marketplace plan coverage in the Keystone State. Although many of the companies listed below, such as Highmark, Aetna, and UPMC write a large volume of business, many others issue a much lower number of policies, including Freedom Life and AmeriHealth.
Company Requested Increase Granted Increase
First Priority Life 29.5% 21.5%
Geisinger Health Plan 40.6% 20.0%
Geisinger Quality Options 58.4% 20.0%
Highmark Individual 25.5% 20.1%
Highmark Small Group 15.5% 9.9%
Highmark Benefits Group 13.5% 9.9%
HM Health 35.9% 26.2%
Keystone Health Plan West 36.6% 26.7%
Aetna Individual 5.6% 5.6%
Aetna Small Group 6.1% 5.2%
AmeriHealth 6.77% 6.88%
Capital Advantage Group -2.4% -2.4%
Capital Advantage Ind. 2.3% 1.6%
First Priority Life 9.5% 9.5%
Freedom Life 9.9% 0.0%
Geisinger Small Group 7.2% 7.2%
Geisinger Quality Options 9.88% 9.88%
Health Assurance 3.7% 1.9%
Highmark Advantage Group 9.7% 9.7%
HM Health 9.1% 9.1%
Inter-County Hospitalization 1.75% 1.75%
Keystone Health Plan Central -2.00% -2.00%
Keystone Health Plan East 2.8% 1.9%
Keystone Health Plan West 9.4% 9.4%
UnitedHealthcare Life 9.1% 3.5%
UPMC 0.0% 0.0%
Although same-sex couples can now legally marry in all US states, here in Pennsylvania, gay and lesbian partners were already able to marry for the last year. But now, it is the “law of the land,” as the Supreme Court ruled 5-4 that 14 states will no longer be able to enforce their ban. It took about 20 years of litigation, but the fight appears to be over.
In the majority opinion, Justice Anthony Kennedy proclaimed “no union is more profound than marriage. In forming a marital union, two people become greater than once they were.” The number of same-sex married couples (currently around 400,000) is expected to substantially increase.
Self-insured and self-funded group health plans subject to ERISA requirements may now be forced to offer medical coverage to same-sex spouses. Although this segment of the legislation is a bit vague, employers may choose to avoid risky and expensive litigation and simply offer the benefits. Also, “domestic-partner” coverage may simply continue, since the cost and coverage would be identical.
Discrimination Not Allowed
Since the Keystone State allows these types of marriages already, an insurer can not discriminate against either partner when applying for a policy, or when a claim is paid. Premium tax-credits and potential out-of-pocket expenses must also be treated without discrimination. However, in order to take advantage of subsidies, the couple must file a joint tax return or state that they intend to file together.
NOTE: In 2014, in the US District Court (Middle District of Pennsylvania) overturned the Pa “Marriage Laws” which required marriages to only be between members of the opposite sex. The Judge was John E. Jones III, and an appeal was not filed. Details of the ruling can be found here. The ruling took effect immediately since there was no stay.
Effect On Pennsylvania Health Insurance Coverage
Pa Healthcare Benefits For Same-Sex Couples Is Available
One of the biggest changes will save time, but not necessarily money. Prior to the ruling, many insurers insisted that each person (husband and husband or wife and wife) must be covered separately under two different policies. Although the overall cost may not have been impacted, often the maximum out-of-pocket expense was higher, and billing was more inconvenient. One policy and a single family deductible would, of course, be more desirable.
By consolidating both persons on one Pa health insurance policy, a single deductible will be available from many carriers, including Highmark, Aetna, Keystone, UnitedHealthcare, and many more. Thus, if one partner has a major illness or sickness, and meets the annual deductible and applicable coinsurance, the other partner will have no out-of-pocket expense on covered expenses. UPMC health plans (Western Pa) will also incorporate these changes into their policy designs. NOTE: Not all policies offer a single family deductible.
For example, many existing Silver-tier plans have an individual deducible of $3,000 and a family deductible of $6,000. Thus, if one person is hospitalized and meets the $3,000 single deductible, an additional $3,000 deductible must be met. However, beginning in 2016, depending on the policy and carrier, in the previous scenario, the entire deductible will have been met. This is especially cost-effective when one person has significantly more medical expenses than the other covered person.
Less than 50% of small and large businesses offer medical benefits to unmarried same-sex couples. However, more than 90% offer coverage to spouses. And although the Supreme Court ruling on same-sex marriages does not specifically state that this practice must end, there will undoubtedly be an increase in the number of spouses that can now purchase a group policy.
“Domestic Partner Benefits,” however, may reduce, especially if you wok for a large company. If two partners decide they don’t want to get married, it’s possible the coverage they currently receive, would be less comprehensive than if they married. It’s expected that a simple comparison tool will be offered so employees in this situation cam make an educated and informed analysis.
Social Security benefits will now also be affected. Typically, there are more advantages than disadvantages to being married. Spouses, children, and the estate of the deceased could end up with more funds. Of course, sudden illnesses, divorce, prenuptial agreements, and divorce will now also play a role.
With Open Enrollment beginning again in November (effective date of policies will be January, February, or March of 2016), newer plans and coverage descriptions may be tweaked to include any mandated benefits or required changes. Existing plans can also be adjusted to conform to updated requirements. However, “grandfathered” plans that are not required to adhere to Affordable Care Act legislation guidelines, may remain the same.
April 2016 – Although Open Enrollment just ended, for 2017 effective dates, same-sex couples can apply for coverage under one policy. However, the filing status of your federal tax return could affect federal subsidy eligibility and the actual amount applied to the policy.
Platinum-tier Marketplace plans in Pa provide the best available medical 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 health insurance plans. Your maximum out-of-pocket expenses are low, and you won’t find a better policy anywhere. “No deductible” options are offered in some areas.
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. Special “cost-sharing,” however, is only available to Silver-ter plans. This feature can greatly reduce the deductible and out-of-pocket expenses to moderate and lower-income households.
Coinsurance And Deductibles
Since it is the most expensive “Tier” option, often coinsurance is 0% and deductibles are $1,000 and below. “0 deductible” options are also offered. The dollars you pay to physicians, specialists, hospitals, and other medical facilities are the lowest of all Marketplace policies. Therefore, persons with expensive chronic conditions, ongoing treatment and counseling, or annual recurring surgeries, often find this type of plan the most cost-effective. Also, if multiple expensive non-generic prescriptions are needed, this Tier is the best choice.
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 Gold and Platinum plans.
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. Coinsurance is 10%, which begins after deductible is met. Generic, preferred and non-preferred drugs are only subject to copays ($10, $45, and $90).
Partner,” “Premium” and “Select” networks available. For children, an eye exam, glasses, and dental checkup (one per year-each) are covered. Cosmetic and bariatric surgery are not included in benefits. Also, adult dental and vision benefits are not included.
Advantage Gold $750/$10 (UPMC) – $750 deductible with maximum $3,000 out-of-pocket expenses. Office visit copays are $10 and $45. Most drugs are covered with copays ($10, $45, and $90 copays).
Comprehensive Care Flex Blue PPO 500 (Highmark) – $500 deductible with $1,650 maximum out-of-pocket expenses. Coinsurance is 10% after the deductible. Most prescriptions are subject to only a copay ($5, $20, and $45). Specialty drugs are subject to 50% coinsurance. Policy is offered as “Enhanced” or Standard.” Enhanced deductible is lower ($500 vs. $1,300) and coinsurance is also lower (10% vs. 40%).
Health Savings Blue PPO 1700 (Highmark) – Low $1,700 deductible with maximum $3,250 out-of-pocket expenses. Coinsurance is 10%. Since the cost is significantly more expensive than many other Gold-tier plans, if you are eligible for cost-sharing (Silver-tier only), this policy may not be cost-effective.
my Connect Blue EPO 250G (Highmark) – A Community Blue Flex plan, three separate network categories are available (Preferred, Enhanced, and Standard). Preferred option features $250 deductible with $10 and $60 office visit copays. The Urgent Care copay is $80. Tier 1, 2, 3, and 4 drugs are subject to 15%, 25%, 35%, and 50% of the cost of the prescription.
Healthy Benefits Value 0.0.10 (Keystone Health Plan Central – Capital Blue Cross) – $0 Deductible, although $6,850 maximum out-of-pocket. $10 and $25 office visit copays are nice but odd assortment of RX copys – $6, $42, $67, and $275 copays on generic, brand, non-preferred brand, and specialty drugs!
Health Benefits PPO 0.0.10 (Capital Blue Cross) – Similar to prior plan, although the PPO network is used instead of the HMO network.
Blue Shield Shared Cost 1500 (Highmark) – Multi-State plan with $1,500 deductible and $20 and $40 office visit copays. Deductible is $4,000 and policy is offered in the Gold tier. Generic and Preferred Brand drug copays are $10 and $50.
NOTE: The Highmark Health Savings Blue PPO 1400 is a very attractive Gold-tier option with a low $1,400 deductible and maximum $2,800 out-of-pocket maximum. Coinsurance is 10%. It is also offered in the Western portion of the state. Highmark’s Alliance Flex Blue PPO 1000 (Gold tier) offers a $1,000 deductible and low $10 and $20 office visit copays.
Coventry Gold $10 Copay OAHMO (Aetna) – Low $1,400 deductible with $10 and $40 office visit copays. Generic drug copay is also $10. Out-of-pocket maximum is $5,000.
Choice Marketplace PPO 25/50/100 (Geisinger) – $1,000 deductible with very low generic drug copay of $3. Office visit copays are $25 and $50 with overall $4,000 deductible.
NOTE: Both of these plans are issued in the Gold-tier. There are no Platinum-tier options available in the area.
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.
Leap Specialty (Aetna) – Gold-tier option with $3,000 deductible and $3,000 maximum out-of-pocket expenses. Office visit copays are $10 and $75. Tier 1 and 2 drug copays are $5 and $50.
Highmark Provides Affordable Coverage In Scranton
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. This is one of many reasons why accurately projecting your household income for the following calendar year, can save quite a bit of money.
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. Each year, it is important to re-evaluate and compare new plan options, since so many changed typically occur.