Pa Health & Wellness individual and single healthcare coverage is offered to residents of Bucks, Montgomery, and Philadelphia Counties that are under age-65. Affordable Bronze, Silver, and Gold-Tier Ambetter plans are available through the Marketplace and can be utilized with a federal subsidy for qualified applicants. Senior Medicare Advantage plans are issued through Allwell to qualified applicants that have reached age 65.
Centene Corporation is the parent company, and helps provide managed care, along with Medicaid benefits in Pennsylvania. As a Fortune 500 company, Centene provides diversified services to private and government programs, including Medicare (Special Needs Plans), Medicaid, CHIP, and several others. Marketplace, Medicare Advantage, and Community HealthChoices are three major sources of benefits provided in the Keystone State.
Open Enrollment for applicants under age 65 (and not eligible for Medicare benefits) begins November 1 and ends December 15th. The Senior Medicare Open Enrollment period begins October 15th and ends December 7th. However, throughout the calendar year, qualifying life events (QLE) can create additional enrollment opportunities.
Health Insurance Marketplace Plans From Ambetter (Under Age 65)
Essential Care 1 – $7,900 deductible with 0% coinsurance. Generic drugs not subject to deductible. Copays are $20 and $60 (mail order).
Balanced Care 11 – $30 (pcp) and $60 (specialist) office visit copays. $30 copay for diagnostic tests. Generic and preferred brand drugs not subject to deductible. Copays are $20 and $50 ($60 and $150 (mail order). $6,000 deductible with 40% coinsurance.
Balanced Care 5 – $40 (pcp) and $80 (specialist) office visit copays. Generic and preferred brand drugs not subject to deductible. Copays are $20 and $60 ($60 and $180 (mail order). $7,350 deductible with 0% coinsurance.
Secure Care 1 with 3 Free PCP Visits – First three pcp office visits fully covered. Generic drugs not subject to deductible. Copays are $10 and $30. $1,000 deductible with 20% coinsurance.
Balanced Care 3 – $30 (pcp) and $60 (specialist) office visit copays. Generic and preferred brand drugs not subject to deductible. Copays are $25 and $50 ($75 and $150 (mail order). $3,000 deductible with 30% coinsurance.
Sample Under Age-65 Monthly Rates
25-Year-Old And $20,000 Household Income
$10 – Essential Care 1
$81 – Balanced Care 11
$86 – Balanced Care 5
$128 – Secure Care 1
$134 – Balanced Care 3
40-Year-Old And $30,000 Household Income
$116 – Essential Care 1
$206 – Balanced Care 11
$213 – Balanced Care 5
$266 – Secure Care 1
$273 – Balanced Care 3
50-Year-Old Married Couple And $40,000 Household Income
$17 – Essential Care 1
$270 – Balanced Care 11
$290 – Balanced Care 5
$438 – Secure Care 1
$458 – Balanced Care 3
50-Year-Old Married Couple With Two Children And $82,000 Household Income
$312 – Essential Care 1
$674 – Balanced Care 11
$702 – Balanced Care 5
$913 – Secure Care 1
$941 – Balanced Care 3
Allwell Medicare Advantage Plans
Allwell Medicare HMO – $0 monthly premium and $0 deductible for medical services and Part D prescription drugs. Maximum out-of-pocket expenses are $6,700. Inpatient hospital copay is $295 for the first 6 days, and the outpatient hospital copay is $350 per visit. Pcp and specialist office visit copays are $0 and $40. Urgent care and emergency room copays are $40 and $90. Lab services and outpatient x-rays have copays of $0-$20 and $40. Tiers 1, 2, and 3 prescription drug copays are $0, $10, and $47. Plan CMS numbers are H2915-003, H2915-005, and H2915-006.
Allwell Dual Medicare HMO – $0 monthly premium and $0 deductible for medical services and Part D prescription drugs. Maximum out-of-pocket expenses of $3,400. Designed to cover applicants that are eligible for Medicare and Medicaid. Low or no out-of-pocket expenses for most benefits. Plan CMS numbers are H2915-001, H2915-002, H2915-007, and H2915-009.
Enrollment is available by phone, online, mail, or fax. The Center for Medicare and Medicaid Services (CMS) assigns a five star quality rating system to Advantage plans. This rating system compares performance and quality for several different categories. Several categories include health and drug plan customer service, drug safety and accuracy of prescription pricing, and member complaints. Allwell’s plans are too new to receive a current rating.
An “Extra Help” program is offered to lower-income households to help pay for prescription drugs. The cost of drugs, including copays, coinsurance, and a deductible are partially-reimbursed. To determine if you qualify, Medicaid, the Social Security Administration, or Medicare can be contacted. Part D prescription drug plans in Pennsylvania are not offered by Allwell, although many other carriers provide these benefits.
If you are 21 or older and receive both Medicaid and Medicare, you probably qualify. You can also qualify by receiving nursing home care paid by Medicaid, or if you receive LTSS in Independence, Aging waivers, or COMMCARE. Medicaid eligibility is determined by the PA DHS.
The medically-necessary services listed below are covered with without a required copay. Prior authorization or a referral may be required.
Pcp office visit
Outpatient non-hospital clinic
Certified RN practitioner
Podiatrist and chiropractor services
X-rays, CT scans, and MRIs
Outpatient ambulatory surgical and hospital short procedure unit
Eyeglass lenses and frames
Physical occupational and speech therapy
Additional provided benefits include a cell phone program with SafeLink Wireless, 3-Month prescription refills, Dental advice, nurse’s help line, vision benefits, and choice of your physician.
Pa Health & Wellness serves the Senior and under-65 market in Pennsylvania. Known for compassionate and coordinated care, Centenne’s innovational products should continue to remain popular. It’s also possible that they will expand into other parts of the Keystone State.