The Pennsylvania Health Insurance Exchange (Pennie) provides affordable quality medical coverage to Pennsylvania residents. Our website is designed to provide you with free online quotes of available plans for single, family or small business policies. We help you compare different guaranteed options from the large and small carriers so you can easily apply and enroll for 2021 Marketplace coverage and understand all of your benefits. The Keystone State now operates its own Exchange, instead of the Federal Government (Healthcare dot gov).
There are no costs, and you can also purchase healthcare benefits through this website both “on” and “off” the Exchange. Our research and unbiased guidance will help you stay informed and receive the federal subsidies you are entitled to receive. You will not have to file a tax return to receive the instant tax credit, since it will be automatically deducted from the cost of coverage. Rates increased by approximately 3.8% and a new carrier (Oscar) was added last year. Highmark also increased the number of counties it offers plans.
We also alert you of any changes that could impact the type of policy you should purchase. Provider networks and company service areas frequently change, which can affect prices of coverage, and availability of policies. Occasionally, newer and previously unavailable plans are introduced by established carriers. These plans may feature deductible and copay options that are not currently available. It is possible that in 2022, a “public option” may become available from the current Administration.
Our Pa Marketplace
Each state has their own state-run or federally-run Exchange. In Pennsylvania, UPMC, Geisinger, Capital Blue Cross, Keystone, Ambetter, Highmark, Oscar, and Independence Blue Cross offer private under-65 policies. Insurers can not deny coverage to applicants. And since approval is guaranteed, applications are short. A licensed broker (and possibly a navigator) can assist in the process, (which we provide) so you are matched with the best plan. We also assist with document requests, income verification, and plan selection.
If the current Administration (or another Administration) introduces new options, we will review each plan and publish rates and benefits on this website. However, it appears that Congress is currently unable to agree on significant legislation, although prescription drug costs may be addressed. Enhancement of short-term plans may be discussed in the future, and additional catastrophic policies may be introduced.
A new state-based Exchange is effective in 2021, and the technology vendor and administrator is GetInsured. The DOI has increased control over the types of plans that are offered, and the open enrollment dates and deadlines can be customized. For example, the 2021 OE period increased by a month since the last day was changed from December 15th to January 15th. January 1 and February 1 effective dates were the two available options.
NOTE: CHIP and Medicaid options are still available for low-income households. If you need our help calculating your eligibility, please contact us. It is possible for one family member to be covered by CHIP, while others enroll in Marketplace policies. Also, as your household income increases (or decreases), your federal aid may be impacted. Sudden changes in household income may require an adjustment to the subsidy you are receiving.
Pa Senior Open Enrollment
Senior Open Enrollment begins on October 15th and ends on December 7th. Medicare Advantage and Supplement plans are not impacted by the ACA Legislation, and Medigap plans in Pennsylvania feature different benefits than plans offered to persons under age 65. Policies are standardized, and thus, easy to compare. A high-deductible option (Plan F) is also offered, and contracts are guaranteed renewable, regardless of existing health problems. Plan G (HD) is offered to persons that became eligible for Medicare in 2020 or later.
Part D prescription drug plans are sold separately, although they are also often included in Pa Medicare Advantage plans. It is possible for one family member to be eligible for Medicare, while other family members purchase conventional private plans for persons under age 65. Medigap contracts are also issued separately, so husband and wife benefits are provided with two policies.
Medigap contracts typically do not cover dental, vision, long-term care, hearing aids, glasses and contacts, and private-duty nurses. However, Advantage plans often include several of these items. You may also purchase private dental or vision coverage from large carriers including Aetna, UnitedHealthcare, Delta Dental, and Humana. Long-term care plans are offered by selected insurers and require extensive medical underwriting.
For the easiest enrollment and safest guidance, one of our own experienced brokers is your best resource. We offer decades of knowledge that ensures you can easily compare and understand the best available policies and receive the highest available subsidy through accurate calculations. If you qualify for a reduced rate, we will explain which plans will receive the biggest discount and how you can easily lower your deductible and copays.
You can quickly compare and apply for the best available options and secure guaranteed coverage. “Pennie” allows you to review subsidized and unsubsidized plans, and enroll in less than 15 minutes. Of course, we’re also available to help you with any of the questions. As a licensed and approved broker for Pennie enrollment, our 40 years of experience helps determine the most appropriate policy, and quickly calculated your instant tax credit (if applicable) that can immediately be utilized to reduce the cost of coverage.
For applicants that miss the enrollment deadline, a qualifying life event (QLE) is needed to apply for a Marketplace plan. This creates an SEP (Special Enrollment Period) and provides approximately 60 days to compare plan options in your area. All eligible household applicants can apply for coverage. Non-Obamacare plans can also be selected, although federal tax credits will not be applied to the premium. Also, non-Obamacare plans can offer maximum out-of-pocket expenses that are higher than the individual Exchange limit of $8,550.
Compared to several years ago, (The first year of Open Enrollment), the process is friendlier, quicker, and the application time has reduced from 90 minutes (in some situations) to about 10-20 minutes. We provide a direct application link that allows you to quickly view the best policy options with a streamlined enrollment. You can also verify that your physicians, specialists, and hospitals are approved providers in your carrier’s network. Urgent Care facilities and stand-alone facilities for diagnostic testing can also be researched for network status.
The ACA (Obamacare)
The Patient Protection And Affordable Care Act is more than 1000 pages, so we always answer your questions and concerns, and help you apply for the most cost-effective plan for your particular circumstances. Policies, carriers, rates, and federal subsidies change each year, so it’s important to properly review options on an annual basis. Ambetter and Oscar are new insurers to the Exchange, and additional carriers may join in future years.
All plans must meet specific qualifications and there may be benefits you don’t want or need but are forced to have. “Essential Health Benefits” must be offered in each Exchange plan. They include many familiar items such as preventive, catastrophic, office visit, ER, maternity, mental illness, and RX coverage.
However, many other items are standard benefits, including child oral and vision care, and many rehabilitative services and products. Self employed persons can easily apply for guaranteed coverage for themselves and family members. A separate “SHOP” Marketplace has been set up specifically for small-business owners. The SHOP exchange does not have an Open Enrollment deadline, and typically includes more participating companies.
Federal Operation Of Website Until 2021
In our state, the federal government (not Pennsylvania) managed and operated the Marketplace until 2021. This was determined eight years ago when Governor Tom Corbett (since replaced by Tom Wolf) announced that the HHS (Department Of Health And Human Services) had not provided enough information regarding costs and organizational structure.
By having the federal government operate the Exchange, substantial tax dollars were saved. Although every year, the state legislature could have made the decision to run the operation themselves. We believe, based on the millions of dollars that were saved each year, allowing the Department of Health And Human Services (HHS) to control and regulate, was a cost-effective idea. Only 12 states operate their own Exchange, and many have experienced major software and website issues.
Although there were many delays and enrollment issues in the early weeks of the operation, broker websites (like ours) use different software, and there is no wait-time to view prices. And the rates we provide are identical (it’s the law) to the .gov website pricing. And we provide simple and easy enrollment options, along with non-Obamacare options.
The 2021 Exchange
In 2021, a Pa state-based Marketplace was created through the Pennsylvania Health Insurance Exchange Fund and House Bill 3. The new Exchange is expected to save taxpayers approximately $80-$100 million each year since the 3% of premium charge will be eliminated. The cost of running a state-based Exchange is about $35 million.
The enrollment process is also state-controlled, along with education, advertising, and outreach. An insurance program was created for persons with major health expenses, and an online Exchange was created (Pennie). Our website helps consumers compare rates and plans, and easily and quickly enroll online.
There are four levels of coverage. They are Bronze, Silver, Gold and Platinum. Each plan features a different level of benefits. The bronze plan, which is the least expensive of the four options, pays approximately 60% of the expected medical expenses that an average person would incur. The silver pays about 70%, the gold about 80% and platinum option about 90%. Naturally, the bronze plans are the cheapest available plans while the platinum options are the most expensive insurance policy offered.
The “Silver” and “Bronze” plans are the most popular, since they combine comprehensive office visit and drug benefits, while still keeping prices fairly low. Specialist and non-generic prescription benefits are included on many of these policies without having to meet a large deductible. However, the least expensive Bronze-tier plans will have a higher deductible without a copay for specialist, ER, or Urgent Care visits. Deductibles are typically $6,000-$8,200 for Bronze plans.
Special “cost-sharing” Silver-plan provisions are offered if your household income falls within specific guidelines. For example, a married couple (ages 43 and 42) with 45,000 of household income and living in Allegheny County, will be eligible for a subsidy of about $3,300 per year. The subsidy increases as your age and the number of dependents increase.
But just as importantly, a typical deductible of $3,250, will be reduced to about $1,000, resulting in a substantial savings. Highmark, Keystone, Ambetter, and UPMC offer excellent Silver-tier plans. Depending on household income and ages of applicants, deductibles as low as $250-$500 are available. Gold-tier and Platinum-tier policies are the least popular choices because of their higher cost.
There is an additional level of benefits available for young adults and older persons that may not be able to afford premiums. It is a “catastrophic” level that excludes several of the comprehensive copay coverages contained in the four Metal plans. Although an annual routine physical is fully covered, many other expenses fall under the deductible.
Often, three primary-care physician (pcp) office visits are covered with a simple copay. Several plans waive the deductible AND the copay. Prescriptions typically are subject to a deductible and/or coinsurance. The deductible for catastrophic plans is generally $8,200, which is the highest allowed deductible.
However, prices are inexpensive and often the savings easily offsets the benefits that are missing. This option may be ideal for healthy students that don’t want to spend a significant amount of money. If you are under age 30 or are over age 30 and meet one of the 12 hardship exemptions, you can purchase this plan. Otherwise, a comprehensive option may only slightly increase the premium.
The Obamacare Subsidy
Depending on your household income, a tax-credit could lower your premiums. A family of two adults (age 50) and two children with income of more than $98,000 may not receive any tax relief. However, an increasing amount of financial will be provided for lower incomes. The assistance is based on the Federal Poverty Level is be adjusted each year.
The estimated credit per family is often as much as $10,000-$15,000. The credit favors lower-income households, resulting in higher premiums for high-income households. However, if the total income is too low, the instant tax credit may not be available since Medicaid may be offered. CHIP benefits may also be available to children.
The more family members you have, the higher the subsidy. For example, a married couple (age 42) with no children living in Allegheny County with a $40,000 household income will receive approximately $960 in annual federal subsidies. However, if two children are included, the subsidy increases to more than $4,500, a whopping 400% increase!
It Is Not The Law!
Previously, the most controversial aspect of the all of the ACA changes was the law forcing consumers to buy medical insurance. For the first year, the tax was $95 per adult (half of that amount per child) and up to $285 per family. However, if 1% of your income was higher than the tax, you were required to pay the higher of the two. For example, if you made $75,000 per year, you were taxed $750 if you did not buy coverage.
Last year, the tax substantially increased to $695 for adults and $2,085 per family. If 2.5% of your income was higher, then you payed that amount. Thus, you paid $2,500 if you made $100,000 and did not want to purchase a policy. This “mandate” had been strongly debated by US politicians for years. However, the Internal Revenue Service accepted tax returns, regardless if the “prior compliant insurance” question was answered.
The mandate has now been repealed, and Pa residents can now purchase a Marketplace plan, or cheaper alternatives. Although remaining uninsured is not a wise decision, it will not result in a non-compliant tax or penalty. Any person treated for a serious illness or injury should enroll in a guaranteed plan before the December 15th deadline.
Choices IN 2021
As the ACA Legislation undergoes changes, additional impact may be felt in 2021. It is possible that more companies will offer plans, cheaper options will become available (without maternity and other optional benefits), and the state governments may be responsible for more critical decisions, rather than the federal government.
“High-risk pools” may also return to some states, allowing all applicants, regardless of medical conditions, to qualify for coverage at a discounted rate. Prior to the ACA Legislation, these “pools” provided guaranteed benefits for qualified applicants. Pa prices were approximately $350 per month, regardless of age or medical history.
Through our website and with the help of experienced brokers, you can select affordable policies from hundreds of options. Whether you prefer no deductible, or the $8,200 deductible, or no office visits covered, vs. unlimited office visit coverage, many options are offered. UPMC, Highmark Blue Cross, Keystone and Independence Blue Cross are large carriers with experienced staffs and extensive provider networks. Additional companies offer dental, vision, and additional Senior products.
Ambetter began offering plans in the Philadelphia area last year. Although Independent Blue Cross (IBX) continues to dominate the under-65 market in that area, Ambetter offers several low-cost alternatives. Copays are generally available for both pcp and specialist office visits. Most prescriptions and Urgent Care visits do not have to meet the policy deductible. This carrier also offers coverage in nearby Ohio and Indiana.
Oscar is a new carrier for 2020 in the Philadelphia area. Recently, Oscar began offering plans in Ohio (Columbus and Cleveland areas). They also underwrite coverage in seven additional states.
In most areas, UHC (UnitedHealthcare) offered very competitive rates, especially for Bronze and Silver plans. However, UHC (and Aetna) ceased offering Marketplace plans in the Keystone State. In many states, these two companies, along with Cigna and Kaiser, have determined it is not profitable or financially prudent to continue to offer private options.
UPMC continues to offer many low-cost policies in many counties, including Allegheny, Westmoreland, and Washington. However, since many physicians and facilities in their Network do not accept Highmark providers, when switching companies, it’s very important to verify your doctors and specialists are “in-Network.” Senior supplement plans offered by Highmark allow you to utilize any provider that accepts Medicare.