There are many types of Pennsylvania health insurance plans. “Catastrophic” and “HSA” plans will tend to be the least expensive options, but feature high out-of-pocket costs to the insured. “Comprehensive” plans offer lower out-of-pocket costs on the most common claims, but are the costliest type of coverage.
For families, typically, this is a very popular type of policy, and similar to employer-sponsored plans. Large unexpected medical bills can be easily covered, along with smaller day-to-day items such as physician visits for common colds, the flu, stomach viruses, and other non-serious conditions. HMO, PPO, EPO, and POS contracts are available for enrollment. Utilizing the provider network can easily save thousands of dollars of out-of-pocket medical expenses.
ER and Urgent Care claims are often covered by copays instead of a large deductible. Telemedicine visits have become very popular because of the 24/7 availability, ease of use, and low cost. Many carriers offer $0 copay for virtual and telemedicine visits. Medical advice can be received at your home, office, or another location. Prescription drugs can also be quickly prescribed. Often, after hours, Urgent Care facilities are not open and telemedicine visits are the best option. More serious diagnosis, such as COVID and other epidemics, typically require a face-to-face visit.
Pa comprehensive health insurance covers the standard inpatient major medical items such as room/board, intensive care, recovery and operating room, prescriptions, ambulance, and professional fees of doctors, surgeons and nurses. Outpatient expense benefits include facility/hospital fees for outpatient surgery, surgeon fees, emergency room fees, some mental and nervous disorders and X-ray and lab fees performed at network facilities. Service provided at non-network facilities is usually covered, but at a lower level.
Traditionally, office visits (primary care and specialist) and prescriptions (generic and non-generic) are included expenses although a copay is certain to apply. In Bronze-tier plans, a higher copay ($25-$50) is fairly customary, while Silver, Gold, and Platinum plans often feature copays of $10-$35. Specialist visit copays are much higher, and can reach $80-$150, depending on the policy and Metal-tier. Often, specialist visits may be subject to a deductible, coinsurance, or both. Limits to the number of covered non-deductible visits may also apply.
Mandated Preventative Expenses Have No Deductible Or Copay To Meet
Qualified wellness and preventive costs are covered at 100%, so there are no out-of-pocket expenses for those items. There are no waiting periods or co-payments, and benefits extend to children and teenagers. These enhancements were part of “The Affordable Care Act” legislation and are expected to remain, regardless of any potential Congressional change. Group plans through employers also provide free preventative benefits, with active wellness departments available to assist employees. Many employers provide financial incentives to their employees to take advantage of wellness perks.
Several specific Pennsylvania wellness/preventative coverages include mammograms, pap smears, PSA screenings, child immunizations and annual physicals. As you get older, additional treatments will be covered and the Department of Health and Human Services will periodically update and add new benefits. In recent years, many diagnostic tests and screenings have been added, and the list has become quite extensive.
Many covered women’s expenses have also been added. Some of the most utilized examples are anemia and cervical cancer screening, contraception, domestic violence counseling, breastfeeding information and counseling, sexually-transmitted disease counseling, and smoking-cessation interventions.
The Pa Insurance Exchange/ Marketplace (Pennie) may also make changes. One of the more controversial issues is the inclusion (or lack of inclusion) of federal/state funds paying for expenses related to abortion. Currently, the Exchange does not approve of those types of expenses. It is also not expected that any future legislation will attempt to challenge the status quo. Private plans also do not cover the cost of abortions or any related expenses. Note: Senior Pa HMO Medicare plans provide very extensive benefits. Many carriers offer Medigap plans in the Keystone State.
Companies That Offer Comprehensive Benefits
Many major Pennsylvania medical insurance companies offer policies that are benefit-rich and the list is quite extensive. Aetna, UnitedHealthcare (UHC), Independence Blue Cross, Keystone, Capital Blue Cross, Highmark, UPMC, Oscar, Ambetter, and Geisinger offer extremely competitive rates for their private or Group plans. This type of coverage is typically available in either a PPO (Preferred Provider Organization) or an HMO (Health Maintenance Organization). With a PPO, you can see any doctor or visit any hospital within the preferred network of providers. “Out of Network” providers will pay smaller benefits. Note: Financial subsidies are not offered on employer-provided plans.
Primary Care Physician Copays (PPC)
Listed below are the office visit (primary care physician) copays for Pa private non-Group plans. Specialist visits are also covered, although a higher copay and a deductible may apply. Plans not listed do not have a pcp office visit copay, or are HSA-eligible.
$10 – UPMC Advantage Gold $1,000/$10
$10 – Geisinger Marketplace Extra HMO 10/50/500
$10 – Geisinger Marketplace Extra HMO 10/50/4500
$15 – Ambetter Secure Care 5
$15 – Highmark my Direct Blue EPO Gold 800
$15 – Highmark my Blue Access EPO Gold 800
$15 – Keystone HMO Gold Proactive
$20 – Independence Blue Cross Personal Choice EPO Bronze Basic
$20 – Independence Blue Cross Personal Choice EPO Gold
$20 – Geisinger Marketplace All-Access HMO 20/40/1000
$20 – Highmark my Direct Blue EPO Gold 0
$20 – Capital Blue Cross Gold PPO 2150/10/20
$25 – UPMC Advantage Silver $3,500/$25
$25 – Capital Blue Cross Gold Simple PPO 0/0/25
$25 – Ambetter Secure Care 15
$25 – Ambetter Balanced Care 26
$25 – Oscar Silver Classic $0 Ded
$30 – Geisinger Marketplace All-Access HMO 30/60/4650
$30 – Geisinger Marketplace All-Access PPO 30/60/4650
$30 – Oscar Gold Classic
$30 – Oscar Silver Classic Next
$30 – Oscar Silver Classic Copay
$30 – Independence Blue Cross Personal Choice PPO Silver
$30 – Independence Blue Cross
$30 – Ambetter Balanced Care 11
$35 – Oscar Bronze Classic Next
$35 – Ambetter Balanced Care 12
$35 – Keystone HMO Gold
$40 – Capital Blue Cross Silver PPO 6000/20/40
$40 – Geisinger Marketplace All-Access HMO 40/80/8400
$40 – Geisinger Marketplace All-Access PPO 40/80/8400
$40 – Ambetter Balanced Care 24
$40 – Oscar Silver Saver 2
$40 – Keystone HMO Silver Proactive
$50 – Independence Blue Cross Personal Choice PPO Bronze
$50 – Keystone HMO Silver Proactive Lite
$50 – Capital Blue Cross Bronze PPO 8000/0/50
$50 – Highmark my Direct Blue EPO Silver 2900
$50 – Highmark my Blue Access EPO Silver 2900
$50 – Oscar Bronze Classic
$50 – Oscar Bronze Classic PCP Copay
$50 – Oscar Silver Classic
$50 – Ambetter Balanced Care 28
$60 – Highmark my Direct Blue EPO Bronze 3800
$60 – Highmark my Blue Access EPO Bronze 3800
Older Grandfathered Plans
An HMO may provide a broader coverage, but with smaller Network availability. HMOs also offer maternity protection on grandfathered plans, while older PPO plans often excluded that coverage. If you have an existing policy and are not happy with the network or provided benefits, you can sign up for a different plan during Open Enrollment (November and December). If maternity benefits are needed, all qualified policies offer immediate coverage, although out-of-pocket expenses will vary. Cesarean Sections and complications of delivery expenses are covered, subject to applicable deductibles, coinsurance, and copays.
Some of the most popular policies that are no longer available include HealthAmerica’s Copay 100% plan, Aetna’s HMO 20 and HMO 30 plans, UnitedHealthOne’s Copay Select plan, Capital Blue Cross’ Personal Blue plan and Blue Cross’ Keystone Health Plan East HMO. Of course, there are other comprehensive plans that may be your best option, depending on your specific situation. Pittsburgh health insurance is well represented by Highmark and UPMC, while Geisinger and Capital Blue Cross have several popular options in the middle of the state. Independence Blue Cross features many comprehensive plans for residents in the Philadelphia area.
Aetna, Celtic and UHC also offered discounted comprehensive coverage from 2009-2013 that covered a specific number of office visits. Premiums were reduced about 25% and these policies were always considered if they were available in your area. UHC and Aetna have developed updated compliant plans (not in Pa) while Celtic does not offer a viable option in the state. However, they continue to market plans through “Ambetter” in many other states.
We often compare the specifics of these types of plans to other types of coverage. The UHC “Copay Value” and Aetna “Value” plans were very popular options, but are also no longer offered. For persons that were uninsured, these types of policies were budget-oriented regardless of your age. You sacrificed some office visits, but your premium also reduced. Unitedhealthcare offers private short-term plans, while Aetna offers an extensive portfolio of Group and Senior products.
Which Types Of Coverage Are Not Comprehensive?
Temporary Plans – Short-term policies are very cheap, and are available at any time throughout the year, regardless of Open Enrollment periods. Approval often takes less than 24 hours and there is no waiting period of benefits to begin. However, preventative benefits are generally not included or must meet a deductible. Office visits and prescriptions, if included, may require a higher premium. An annual cap applies to the payout of medical expenses ($250,000-$2 million), and policies are not always guaranteed to be renewed, which can cause a large gap in coverage.
Limited Benefit Plans – Very limited and restrictive benefits with per-claim caps that result in large out-of-pocket expenses. For example, surgeries, length of hospital stay, and types of office visits may be subject to special guidelines, instead of unlimited coverage. Often, a stated number of dollars is paid for hospital stays or operations, although the amount will not cover all expenses. Depending on the policy, the amount may only cover 25%-50% of the expenses.
Accidental Plans – Although coverage for accidental injury to all family members is the primary benefit, additional benefits are limited or missing. This type of plan is often utilized as a supplement to other policies. Universities also frequently offer accidental coverage that is packaged with other contracts. However, benefits for sickness and chronic disease are not included. Many credit cards also offer free accidental death and dismemberment benefits.
Supplemental Plans – As the name suggests, this type of coverage is not designed to be your primary coverage, since benefits are very specific and limited. However, a supplemental plan can be very effective by filling in gaps of out-of-pocket costs, or providing extra income during a major hospital confinement. Plans can also be purchased without any other underlying coverage.
What About Low-Cost Policies Now?
Bronze-tier plans are the least-expensive options, but still provide all-inclusive benefits that you need, such as inpatient and outpatient hospital treatment. Maternity and mental illness are also covered, since they are a required mandated benefit. However, deductibles are higher, and large hospital bills are likely to result in the highest out-of-pocket expenses. Household that qualify for a larger federal subsidy, should strongly consider Silver-tier plan choices. When “cost-sharing” is applied, deductibles and out-of-pocket expenses can drastically reduce.
If you don’t have any dependents (or you have older dependents), and there are no existing medical issues, an HSA or a high-deductible policy may be worth your consideration. Each year, deductibles and maximum out-of-pocket expenses change, so during Open Enrollment, comparing all plan options is required. New carriers may enter the Marketplace with plans that feature lower rates in your area. Also, physicians and hospitals within proximity may become available with the introduction of new or expanded networks.
Monthly Rates For Selected Pa Comprehensive Medical Plans
Prices assume a family of five (45-year-old husband and wife with three children) with household income of $98,000
Sullivan, Wyoming, Susquehanna, and Bradford Counties
$352 – Ambetter Essential Care 1
$356 – Geisinger Marketplace All-Access HMO 40/80/8400
$379 – Ambetter Essential Care 10
$392 – Ambetter Essential Care 2
Philadelphia, Delaware, Bucks, and Montgomery Counties
$302 – Ambetter Essential Care 1
$331 – Ambetter Essential Care 10
$346 – Ambetter Essential Care 2
$397 – Independence Blue Cross Personal Choice EPO Bronze Basic
We take the time to review the advantages and disadvantages of that type of coverage, and what specific impact it has on your situation. We can also teach you what benefits are important when you are shopping for a new policy. To quickly request a free quote, please enter your zip code in the quote portion at the top of the page. Within minutes, you can review the best medical benefits available to residents of the Keystone State. Comprehensive healthcare plans in Pennsylvania are much easier to find compared to five years ago. And for many persons, they’re now also cheaper!