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.
In Pennsylvania, infants, young adults, and teenagers can obtain affordable health insurance coverage from more than a dozen reputable companies. With help from recent changes in legislation and policy upgrades, these plans guarantee major medical benefits along with many other comprehensive features. Marketplace plans with federal subsidies or non-Obamacare options are available.
We provide detailed information, reviews, and a simplified and easy enrollment process for all available Pa policies for young persons, along with expert and unbiased advice. Special policies are offered to students, single parents, and anyone that is no longer eligible to keep their existing plan. In certain circumstances, you can also remain on your parent’s plan if you are married (see below).
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. Although remaining on the policy is an option to consider, in many situations when a federal subsidy is available, enrolling for an individual plan may be a better choice.
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 Exchange is part of the Affordable Care Act (Obamacare) and features many low-cost plans that require no medical underwriting with pre-existing conditions covered. Open Enrollment usually occurs in November and continues for three months. However, if you are dropped from an existing plan or meet other various criteria, you can purchase coverage at any time through an SEP (Special Enrollment Period). Exceptions include losing credible group (employer-provided) benefits, reaching age 26, moving to a different service area, and divorce.
The “catastrophic” option is the cheapest available policy for young persons. Unless you meet low-income (financial hardship) 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 coverage. It is ideal for a healthy student that wants to minimize costs. However, only three office visits are included without having to meet a deductible. Therefore, children that tend to visit a doctor or specialist quite often, should not purchase plans in this tier. Also, not all carriers offer catastrophic contracts.
Catastrophic Plans Offered In Pennsylvania
UPMC Advantage Catastrophic $6,850/$0 (Partner, Select, and Premium Networks)
Keystone Healthy Benefits Value HMO 6850
Geisinger Health Plan marketplace Value
Highmark myBlue Access $6,850
Independence Blue Cross Personal Choice Catastrophic
Affordable Comprehensive Pa Healthcare Plans
Young working professionals may prefer a more comprehensive plan that still is budget-friendly. Pre-existing conditions are covered, including major illnesses, such as heart disease, diabetes, and cancer. We have listed below several affordable options offered as Marketplace contracts. Prices shown are for a single 26 year-old living in Allegheny County with income of $27,000. Although income is too high for federal subsidy qualification, prices are still fairly low. Rates shown are monthly:
$134 – UPMC Advantage Bronze $6,200/$35 – Copay on all pcp office visits.
$135 – Highmark Connect Blue EPO 5500 – Copays on all pcp and specialist visits.
$146 – UnitedHealthcare Compass 6500 – Copays on all pcp and specialist visits (lower specialist copay than previous plan).
$150 – UPMC Advantage Silver $3,250/$10 – Low $10 pcp office visit copay and deductible is only $3,250.
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 offer “cost-sharing,” if applicable. Lower deductibles, copays, and maximum out-of-pocket expenses are possible along with 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. Also, if current treatment consists of expensive non-generic drugs, a Platinum or Gold-tier plan will limit your out-of-pocket expenses.
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 $150 per month. Thus, several plans are available for under $100 per month, including the following options:
$24 – Keystone HMO Bronze – $50 and $100 office visit copays.
$27 – Aetna Leap Basic – $6,450 deductible and then 100% coverage.
$38 – UnitedHealthcare Bronze Compass $6500 – $45 and $100 office visit copays.
$63 – Keystone HMO Silver Proactive Value – $10 and $20 office visit copays with $4 generic drug copay. Low $500 deductible with cost-sharing.
$80 – Keystone HMO Silver Proactive – Similar to previous plan but with $0 deductible and higher maximum out-of-pocket expenses.
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). And of course, if you forget to enroll, or suddenly realize you are without coverage, a short-term option may be one of the best available choices.
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. Additional carriers offer a $500 deductible option.
Approval typically take less than 24 hours and depending on the company, you can also obtain instant coverage and receive 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. All policies can be terminated at any time upon written request. A small application fee (typically about $20) is often required.
The Bad: Perhaps “Bad” is a bit too harsh. Pre-existing conditions are not covered. Since Obamacare does not apply to these types of policies, carriers can exclude conditions and/or specific benefits. 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 2.5% 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. You can apply at any time since there are no Open Enrollment deadlines. Also, medical assistance is offered to workers with disabilities.
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. However, if you are treated for an emergency condition, and admitted to the ER or hospital, typically, your expenses are considered “in-network.”
Healthy Pa – Pennsylvania’s Medicaid Expansion
Healthy Pa is the state’s Medicaid reform program with a 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. Federal funding financed the entire cost of the expansion until 2017. At that time, the government began paying 95% of costs, with the percentage gradually dropping to 90% in 2020 and later years. Changed in household income that impact eligibility still must be reported.
Primary and specialty care is provided, drug and prescription benefits, and behavioral health coverage, which typically was not provided on individual plans prior to 2014. Family planning is also included and of course, pre-existing conditions are covered. Each year, however, your eligibility should be re-examined, especially if your household income substantially increased.
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.
NOTE: It is possible (and fairly common) that when applying for Marketplace benefits, to retain the federal subsidy, dependents will have to enroll under the CHIP program while the parents maintain conventional coverage. For example, a family of four (40 year-old parents and two teenagers) living in Allegheny County with $35,000 of household income, will need to place kids in CHIP to keep a $3,264 subsidy. Income of $60,000 does not qualify for a subsidy since both children would be CHIP-eligible.
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 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.
August 2015 – More benefits will be provided to CHIP members so that coverage closely matches other Marketplace plans. Without the increase in benefits, some families may have been subject to the non-compliance tax penalty. Although rates will increase, the change is not expected to be significant.
Implementation of these changes will begin in December and will impact about 150,000 children. Some of the expanded benefits include 100% coverage for qualified preventative benefits (annual physicals, check-ups etc…), and increased coverage for hearing aids and dental procedures.
May 2016 – Student medical plans for the upcoming academic year will be available in a few months. Rates will increase for most school plans, and maximum out-of-pocket expenses and/or deductibles may also go up.