Pa Health Insurance Exchange enrollment allows you to purchase low-cost medical coverage without answering any medical-related questions. You do not have to take a physical, and regardless of what pre-existing conditions you have (or had), your Pennsylvania Marketplace health insurance plan will cover the cost (subject to copays, coinsurance, and deductibles). You may also qualify for a government subsidy that could pay as much as $10,000 of your premium each year, depending on your household income.
But what about applying and enrolling for a plan? What about the glitches, the delays, the frustration and hair-pulling? Actually, most of those issues have disappeared, and with our professional assistance, obtaining quality Marketplace coverage at the most affordable price is guaranteed. With most enrollments, we have reduced the time needed from an hour to less than 20 minutes. And of course, there are never charges or fees to pay when you apply for coverage.
What If I Missed Open Enrollment?
You aren’t alone since millions of Americans either forget to apply, or procrastinate to the point that the deadline has passed. However, you can still buy a policy, and in many situations, if you qualify for an exemption, the benefits, prices, and provisions will be the same as if you didn’t miss OE. There is also no “late fee,” although after three months of neglecting to secure a qualified plan, you may be subject to an IRS penalty of up to 2.5% of your household income.
A “Special Enrollment Period” allows residents of the state to purchase subsidized and unsubsidized policies if they meet specific criteria. For example, if you reach age 26, and are no longer eligible for parent’s coverage, an SEP situation exists. Likewise, if your employer terminates coverage or you lose your group benefits as a result of leaving the workplace, once again, an SEP will be available (for approximately 60 days).
There are several additional situations that allow Pa consumers to take advantage of guaranteed approval and federal subsidies after Open Enrollment. If you are pregnant, when your baby is delivered, he/she will be eligible for almost immediate coverage. Also, if you divorce, and subsequently lose your existing benefits, you qualify for an SEP.
If you don’t meet the requirements of the SEP, you can apply for a very inexpensive temporary policy, which usually costs less than $100 per month. For younger persons, the premium is often less than $60. However, short-term contracts, although approved within 24 hours, have maximum benefit caps, and do not contain all benefits required to be considered “qualified” coverage.
Also, The Department of Health and Human Services (HHS) has recently moved to limit short-term plan coverage to a maximum of three months without the possibility of renewal. This change can potentially leave healthy persons without medical coverage, if they miss OE deadlines.
The Beginning Of The Application Process (It Doesn’t Take Long!)
We ask a few questions so we have the necessary information to determine the best plan options. The only information required is the age of all persons to be covered, the household income (to determine the subsidy level), your county of residence, and your smoking status. No questions will be asked about your medical history, what prescriptions you take, or any surgeries that need to be scheduled.
If you have just been diagnosed with a major illness, or prescribed an expensive specialty drug, it does not impact your premium. Also, if you have scheduled a surgery that will be completed after the new policy begins, it has no impact on the rate you pay.
Your height and weight (BMI) are no longer needed since they have no impact on prices. Unless you don’t meet citizenship or residency requirements, your policy should be quickly approved. If you need immediate medical treatment, there is no waiting period from the effective date.
If you are over the age of 65, then you need to look at Pa Senior Healthcare options, which we discuss in the article linked in this sentence. The Exchanges do not offer coverage to persons that are eligible for Medicare or Medicaid. However, seniors can easily purchase Medigap or Medicare Advantage plans that will pay for many Part A and Part B expenses, along with other uncovered costs.
NOTE: Medicaid expansion (not Medicare) is also providing residents with more low-cost choices. “Healthy Pa” provides premium assistance vouchers that can be used to buy coverage. More than 500,000 consumers will be able to take advantage of this new program, which should be more cost-effective than traditional programs in many other states.
What Companies Are Available For 2016 and 2017 Pa Marketplace Coverage?
Highmark Blue Cross Blue Shield, UPMC, Coventry, UnitedHealthcare, Aetna, Geisinger, Independence Blue Cross Keystone Health Plan Central, Capital Blue Cross, and Highmark BC.
Calculating Your Subsidy
Determining how much money the government will give you to pay your health insurance premium is a very quick calculation. The subsidy is based on the modified adjusted gross income ( MAGI) of your household. Also taken into account is income from anyone listed on your tax return. Thus, your older spouse’s income will be counted, even is he/she is Medicare-eligible.
Members of your household that are not to be covered will actually increase the amount of the subsidy. For example, if your spouse is covered through an employer, although you do not need benefits for them, it will increase your eligible subsidy amount. If you have children that are covered on other policies (or CHIP), but they are listed as your dependents, this can also potentially generate a larger subsidy.
But don’t worry. We perform all of the calculations for you. Typically, it takes less than one minute to determine if you are eligible, and the monthly amount that can be deducted from the premium. NOTE: It is possible that your children may be eligible for CHIP or Medicaid while you can enroll in a Marketplace plan. As your income changes each year, you may also gain or lose eligibility. You may also qualify for a different plan.
Picking A Plan
Platinum. Gold. Silver. Bronze. Catastrophic. Not only are there four Metal options and a catastrophic policy to choose from, but the total number of available policies is usually 40 or more. This is where our three decades of experience helps. Although securing affordable rates is important, the benefits you are most likely to be used, must be covered with the lowest available copays and deductibles. Maximum out-of-pocket expenses are extremely important if any family member is being treated for a serious illness or disease.
NOTE: UnitedHealthcare is slowly exiting the Pennsylvania Marketplace coverage after offering coverage in previous years. UHC is one of the largest carriers in the country, and maintains one of the largest provider networks in the state. They are also one of the few companies that offers a short-term policy that can be purchased any time of the year. However, it does not contain many of the benefits that Metal plans offer. And this type of policy does not count as having “credible” coverage.
We are able to effectively research all available plans and determine (based on your budget, income and health) the best policies for you and every other family member. We explain, in detail, the coverages these policies will provide, and what your likely cost will be for the calendar year (both premium and out of pocket costs). If you have existing conditions, we will show you the plans that pay for most/all of the expenses associated with your condition.
Doctors, Specialists And Hospitals
A healthcare plan is only as good as the network providers you can use. Selecting larger carriers usually means you won’t have trouble finding a doctor within 10-20 minutes of your residence. The companies with the largest networks include Highmark, UPMC, UnitedHealthcare, Aetna, Independence Blue Cross (Keystone), Capital Blue Cross and Coventry.
However, smaller companies, such as Geisinger, should not be ignored if you reside within their service territory. For example, in Dauphin, Lebanon, Lancaster, and nearby counties, Geisinger facilities are readily available, and their rates are usually quite competitive.
Highmark and UPMC have large networks, and in many situations, you may not be able to use a UPMC provider on a Highmark plan, and vice versa. If you live in Allegheny County or the western portion of the state, before enrolling for a Marketplace policy, verify that the doctors and facilities you use, are accepted by the insurer you are applying with.
The Application And Enrollment
Firstly, you don’t have to answer any medical questions. Your height and weight doesn’t matter and your medication information remains private. You will be asked if you use nicotine, but that’s the only information that is somewhat medically related. Since pre-existing conditions are covered, and your cost is not dependent on your health, the actual application is significantly shorter than the typical eight-page form from before 2014.
You may be asked to “verify your identity.” This involves one (or a few) questions requesting you to perhaps identify a street you used to live on, a mortgage company you did business with, or an old phone number that you once used. Although a bit unusual, this step does help with protecting your privacy. This step is ONLY needed when a subsidy is used and the .gov website is involved.
Once the plan is chosen, and the application is completed and submitted, it may take approximately 3-15 days to receive written confirmation from the insurer. Certain companies tend to be a bit quicker than others. For example, Highmark and Aetna seem to be among the fastest Pa carriers to send out billing statements and ID cards. You can also manually pay a bill online with our assistance.
You can terminate coverage at any time and also modify and/or apply for a different plan at the end of every year during a new Open Enrollment. It is possible that additional carriers will be available during the next period. While you have coverage, you will never be subjected to the hour-long waits at the government website or customer-service number. NOTE: Admittedly, the wait times are much shorter in 2015 compared to 2014. But our own direct-enroll link is still much faster.
Simply call or email us. As your broker-of-record, we’ll be able to quickly help you with your Pa Health Care Exchange issues or questions.
July 2014 – More than $5 million of refunds will be sent to customers in Pennsylvania that purchased individual or group policies in 2013. Why? The “80% MLR” (Medical Loss Ratio) rule requires companies to spend at least 80% of their revenue on patient-care expenses. Any excess spending on administrative expenses, salaries and other unapproved costs must be refunded.
UniteedHealthcare’s Golden Rule will send checks for about $1.7 million while Aetna will refund about half of that amount. Many other large companies, such as UPMC and Highmark, met the 80% MLR rule. The average refund will vary, but is typically between $50 and $100.
October 2014 – If the Ebola crisis in Africa becomes an epidemic in the US (and specifically Pennsylvania), Marketplace plans contain no exclusions that would prohibit necessary treatment. Vaccines, as they become available, and hospital quarantines are typically a covered expense.
Adding additional money to the state budget for public health emergency preparedness is being discussed, especially since current allocated budget amounts are at their smallest level in more than 10 years. But as the state of Texas knows and understands, Ebola can easily transfer from one state to another, without proper precautions.
November 2014 – Prices from all major companies, including Highmark, Aetna, Keystone and Coventry are expected to be released within the next 10 days. Plan choices in 2015 will change from 2014, along with deductibles and copays for many policies. December 15th is the deadline for obtaining a start date of January 1.
December 2014 – Less than one week remains to secure a January 1, 2015 effective date. So far, the most popular low-cost plans we are enrolling include Advantage Bronze $6,000/$25 and Advantage Silver $1,750/$30 (UPMC), SharedCost Blue PPO 5500 and Health Savings Blue PPO 2750 (Highmark), and Bronze $20 Copay (Coventry).
June 2016 – 2017 rate-increase requests have been received by the Pa DOI. Some of the largest are Aetna’s 26.41% for their HMO Small Group plans, Aetna’s 41.93% for Group Fee-For-Service plans, Highmark’s 40% for many of their individual plans, and Geisinger’s 41.36% for individual health plans. Independence Blue Cross has requested a 20%-24% hike for its individual plans. UPMC rate increases are expected to be between 6% and 17%. You can view all requests here.