The Pa Health Insurance Marketplace offers affordable Exchange medical plans and generous tax subsidies. Many Pennsylvania consumers now pay less for their coverage than before the Affordable Care Act (ACA) was created. But there are still a few surprises along the way. We highlighted most of the major examples, so you won't be caught off guard when you notice them, and can easily and quickly preview 2020 plans.
This Federally-Facilitated Marketplace (FFM) allows you to purchase low-cost plans at affordable prices through our website. Our assistance is always free, and advice is unbiased. For consumers that choose NOT to participate in the Exchange, there are many options for "Off-Marketplace" plans that have large networks and premiums that fit within your budget. Open Enrollment for non-Medicare applicants, begins on November 1st for coverage. However, the last day is December 15th, instead of January 31st, which was the last day for previous enrollments.
Previously, the penalty for not securing qualified coverage was $695 per adult ($2,085 maximum) or 2.5% of total household income, whichever was higher. However, applicants were exempt from the penalty if your household income was lower than the federal income tax return filing threshold. Generally, this was approximately $10,400 for a single return, and $20,800 for a joint return. You could also bypass the penalty if you were not a US citizen, were incarcerated, or gap in lapsed coverage is less than three months. The tax penalty was repealed in 2019.
Medicare sign-up is not affected since the Exchange offers plans to persons under the age of 65. Seniors that have reached age 65, have a different Open Enrollment period (October 15th-December 7th). Medicare Supplement and Advantage plans are popular Medigap options that can help pay for many expenses that are not covered. Part D prescription drug plans are also offered to Seniors. Long-term care, accident, life, dental, and vision coverage can be purchased separately from several carriers. Dual plans are also offered for applicants that are eligible for both Medicaid and Medicare.
Previously, UnitedHealthcare (UHC), one of the nation's largest providers, began offering plans in the Philadelphia and Pittsburgh areas, and several additional states. One of their cheapest policies was a Bronze-tier contract with a high deductible. However, UHC no longer offers private ACA-compliant plans, although their non-ACA portfolio is extensive, including popular temporary plan options. Ambetter, a national carrier, offers several plans in Philadelphia-area counties. Parent company Centene Corporation provides coverage in 32 states.
Aetna has exited the Keystone State for individual coverage but offers off-Exchange and Group plans. Other carriers offering either individual (on or off Marketplace) or Group plans include Capital Blue Cross, Independence Blue Cross, Geisinger, UPMC, Highmark, Ambetter, First Priority Life, Freedom Life, Keystone Health Plan Central, and National Foundation Life.
Are Rates Higher?
Yes, they are, but don't get a high temperature over it! Not all companies are raising premiums, and many plans saw moderate or no rate increases. Our website always offers the most recent prices, once each carrier has publicly released their new cost structure, so you'll be able to easily find the least expensive choices. Since rates can often substantially change, it is important to properly shop and review all available policies in your area. Names of plans often change each year, and it is common for deductibles and maximum out-of-pocket expenses to also change.
Important: Much of your premium may be determined by the amount of government subsidy that you are offered. If you had an increase (or decrease) of income of more than 10%, the most appropriate plan selection this year may not be the best option for next year. For example, you may gain (or lose) an important "cost-sharing" feature on a Silver-Tier plan that could make a difference of thousands of dollars in premiums and deductibles.
It's also possible that you may become Medicaid-eligible if there was a substantial pay reduction. If you reach age 65, a combination of Medicare and Medigap coverage should be properly discussed. Seniors should be aware of the enrollment periods for signing up for Parts A and B benefits, along with Part D prescription drug coverage. Although it is possible to change from an Advantage plan to Supplement coverage (and vice versa), specific restrictions and time-limits may apply.
I Missed Pa Open Enrollment! Now What?
Unless you qualify for a special "lifetime event," you will not be able to utilize federal subsidies or Exchange options until the next Open Enrollment. However, there are many qualifying events, such as having a baby, losing your employer-provided or private-provided coverage, moving to Pennsylvania from another state, reaching age 26 while covered in a parent's policy, and getting a divorce. There are also several additional situations that qualify for an exception. These are also referred to as "Special Enrollment Periods" (SEP).
For persons that forgot to apply for coverage or don't qualify for a special event, there are several low-cost policies that can be purchased, and often quickly approved. However, it is possible they will not contain all of the mandatory benefits that the new ACA legislation requires or cover a condition you are currently being treated for. Note: Senior Medigap (Advantage and Supplement) plans are not required to contain 10 "essential benefits" that are required for persons under age 65.
Short-term plans are very cheap and can be approved within 24 hours. These plans can be purchased any time of the year. UnitedHealthcare is one of many reputable companies that offer this type of plan. You can purchase a policy directly through our website at the lowest offered cost. However, they are not designed to cover a condition that you are presently being treated for. Also, since they are "non-compliant," unlimited benefits are not included. However, up to $2 million per person per year is offered, which is generally sufficient until guaranteed benefits are secured.
Young Healthy Persons Are Needed
Under the Affordable Care Act legislation (Obamacare), everybody is eligible for coverage, regardless if you are in impeccable health or have life-threatening medical conditions that cost hundreds of thousands of dollars per year. Since all plans are "guaranteed approval" with no underwriting (except for smoking), you can not be denied coverage, or charged a higher premium because of a medical condition.
However, since millions of additional claim dollars will be paid by Pennsylvania health insurance companies (compared to previous years), for the system to work, additional healthy persons, that file very few claims, will have to be added. Young adults, although their premiums are not high, are becoming a big target for carriers. If more persons under age 25 enroll, the lower prices will become for everyone else.
And why not? Typically, these groups of people (especially males) have very few claims and rarely utilize benefits, even if they are free. So, adding as many young people to the "pool" of persons now being insured is needed to avoid potentially large rate increases for other applicants in the upcoming years. It's also possible (depending upon legislation) that Medicare could be offered to eligible applicants that have reached age 62 (instead of 65).
During the first three months of the first Open Enrollment, approximately 24% of new applicants were from persons in the 18-34 age range. Although these figures were slightly lower than expected, young persons typically sign up later rather than earlier. 2019 enrollment of persons under age 30 is lower than originally expected. The larger the number, the more likely prices for everyone will remain stable or reduce.
No, You Can't Keep Your Doctor...Or Can You?
Maybe you can, and maybe you can't. But there is no guarantee that the doctors, specialists and hospitals you used in previous years will be considered a "network provider" this year. For example, if you were covered under a "grandfathered" plan, in many areas, they may not be participating in the Exchange. Therefore, your current physician may not accept your new company, forcing you to choose from a short list of insurers that are acceptable.
However, there are providers that are adding additional carriers, so it is possible that the opposite effect could occur for many Pa consumers. A specialist, for example, that was not "in network" in prior years, may now be acceptable to use. We will always provide a list of available physicians upon your request. Verification of network-participation can also be requested prior to your visit with a physician or specialist.
Anthem Blue Cross, for example, in Ohio (and other states) has previously utilized the "Pathway" and "Pathway X" networks. The "X" designates it as an Exchange provider list and it is different (and less inclusive) than the non-X network. Thus, it is possible that once you shift to a Marketplace policy, although the carrier stayed the same, the provider list didn't. Online provider lists are available from all carriers.
Also, it is expected that many doctors and specialists will choose to retire, sell their business, or limit the number of insurers they accept for their services. When the issue of malpractice was not seriously discussed by Congress, many physicians began looking at other opportunities in the medical profession. Many physicians decided to forgo their practice and become consultants or teachers/lecturers for local colleges and universities.
"Pay As You Go" practices are also starting to appear. Since third-party payments leave out insurance and the government, if you want to continue to use their services, you must pay for everything in cash (check or credit card, of course, is fine also). This is a major cost-saving feature for practices but many patients also like this method. Prices for procedures are published and satisfaction appears to be high for persons that are treated.
It's All About Metals
Often, you hear references to "Metals" in healthcare conversations. No, not sheet metal! The format for comparing qualified Pa Exchange plans names them after metals. Currently, there are four options and they are Bronze, Silver, Gold and Platinum. The differences in the four metals are their actuarial value, which is defined as the approximate percentage of medical expenses covered by the policy. Prices of each of the four options are different.
The Bronze plan (the least expensive) covers about 60% of anticipated expenses. The Silver, Gold and Platinum increase from 60% by 10% respectively. But it's still important to compare different companies since a Gold policy from one carrier could actually be more expensive than another carrier's Platinum policy. Also, Silver-tier plans are eligible for unique "cost-sharing," which can significantly lower your deductibles, copays, and out-of-pocket expenses.
There is also the cheapest contract - the "catastrophic" plan, that diminishes costs, but still maintains a solid framework of benefits. However, you must be under age 30 to qualify for this policy. The exception is if you can prove "financial hardship." We can review the specific requirements upon request. Since catastrophic plans are not eligible for financial aid, often this low-cost option is more expensive than a Bronze or Silver option. NOTE: Deductibles and maximum out-of-pocket expenses of catastrophic plans are typically $7,900.
Catastrophic plan options are: Independence Blue Cross Catastrophic, UPMC Advantage Catastrophic, Geisinger Marketplace Value, and Highmark my Direct Blue Major Events. Typically, several primary-care physician office visits are provided with low or no copays. However, most other benefits, including specialist visits, ER visits, and Urgent Care visits, are subject to a large deductible. Prescription drugs also must meet a deductible. Qualified preventative expenses are always covered with no out-of-pocket cost. Negotiated network agreements also help reduce the cost of expenses that are subject to a deductible.
The "SHOP" Exchange (Small Business Health Options Program) is designed to offer affordable medical and dental benefits to companies with less than 50 employees. "Dental only" plan options can also be offered. However, all workers with 30 or more hours (weekly) must be offered coverage. For companies with under 25 employees, a special tax credit that potentially pays up to half of the premiums.
If the company you work for has more than 50 employees, your benefits are likely to not be impacted as much as individuals buying new coverage. Although there may be new and revamped coverage added to your group package, there will be no overhaul. If premiums rise, it may be a combination of higher local facility charges and your employer simply paying a smaller share of the group policy.
If your employer has less than 50 workers, there is a greater chance of major changes, including the elimination of healthcare benefits. Although the company would pay a fine, the cost may be far less than providing a group medical policy to all employees.
Companies Available On The Pa Health Insurance Exchange
A wide variety of carriers offer plans on AND off the Marketplace. Therefore, if you don't want an "Obamacare" plan, you can opt out and enroll without providing financial information for a subsidy calculation or having to visit the government website. Pennsylvania has several participating companies offering plans. We have listed them below: (UnitedHealthcare and Aetna no longer offer Pa Marketplace contracts)
Capital Blue Cross (Keystone Health Plan Central)
Keystone Health Plan East
Independence Blue Cross
But I Don't Want Maternity Coverage
Of course you don't want maternity benefits. You're a 60-year-old male that just had a vasectomy. There is no risk of pregnancy and you're not even married! Sorry. You have to buy the coverage. It's automatically included in all eligible policies and there's no way to delete it. However, it's possible that more customized options may be offered in 2021, with several plans omitting specific required benefits, such as maternity. These plans would cost less, and would be ideal for healthy applicants that prefer basic major medical benefits. Currently, one-year short-term plans are not available in the Keystone State.
Previously, you could pick plans with or without maternity benefits. For example, an Aetna HMO plan would include it while their PPO plans excluded it. And naturally, you saved money by eliminating the coverage. Many other carriers such as Geisinger, Highmark and Independence Blue Cross also offered the same cost-saving options. Several carriers included maternity benefits with a 270-day waiting period.
But times have changed. Due to "Essential Health Benefits" now becoming mandatory in all plans, you can't delete it from your policy. While it's a very necessary coverage for many families (both young and old), it is expensive, and an unneeded financial burden to others. Typically, applicants that have reached age 50 do not want maternity benefits and would choose a cost-saving plan that excluded this benefit.
However, the extra cost associated with adding maternity and prenatal care has been much less expensive than originally anticipated. Many Bronze-tier plans with higher deductibles don't pass on the full cost of maternity benefits. Rates for older ages are beginning to reflect the lower incidence of maternity claims.
Other "Essential Health Benefits" that you must accept are pediatric dental and vision, mental health, substance abuse, behavioral treatment, emergency room, baby well visits (even if you have no children), prescriptions and chronic condition coverage. If any of these benefits are not included in a policy, it will not be available for the Pennsylvania Health Insurance Exchange. A complete list of mandatory Pa State Required Benefits can be found here.
Since I'm Retired, Obamacare Does Not Matter To Me
Perhaps it should. If your employer plans on making no changes to your existing coverage that you have carried since retiring, then the impact from the healthcare changes will not have a big effect on you. But there are many large corporations that are going down a different path in future years. Contributions towards coverage are decreasing, and HSA offerings are becoming more popular. With many companies, up to $3,000 is deposited into the Group HSA.
For example, Time Warner, IBM and several additional Fortune 500 companies have eliminated retiree medical benefits, and instead, offer a specified amount of cash for purchasing coverage on the Pa Health Insurance Exchange. The amount of money received is often not enough to buy a policy that duplicates existing coverage. Also, actual benefits may be different than what was previously provided for many years.
The Health Insurance Marketplace in Pennsylvania will offer affordable medical coverage to many consumers. Are you one of those persons? We help you find out. Open Enrollment on the Exchange has already started. Since glitches and delays still occur, but we continue to offer free Obamacare quotes here. You can also easily enroll in a non-Obamacare plan with no deadlines to meet.
UPDATES From The Past:
The deadline for a January 1 effective date is December 15th. Although the enrollment process will not take long (working with an experienced broker helps quite a bit), there is an application to be completed. If you feel you will qualify for a federal subsidy, a few financial-related questions will be asked.
The enrollment deadline has been extended to December 23rd (this year only) for a January 1 effective date. We give you a choice of applying over the phone or online. Also, all plans allow you to send payments through the mail or by credit card or EFT. Previously, the direct mail method was only offered by a few companies (Aetna, Blue Cross and others).
More than 10,000 persons in the state signed up for Exchange coverage in November (We didn't write all of them!) as the December 23rd deadline approaches for January 1 effective dates. This is just a guess, but we estimate less than 1000 of those persons actually paid their first premium.
Paper applications appear to take the longest to process. Typically, we avoid that method of enrollment.
Children in low-income households can change to Medicaid. The government has granted the extra time at the request of Governor Tom Corbett. this change impacts children over the age of six in households with poverty-level incomes under 133%, but as high as 100%. Currently, many of these children are covered under CHIP.
Businesses with 51-99 employees were granted an extra year to provide mandatory healthcare for their workers. This applies to employees that work more than 30 hours weekly. Although part of the ACA legislation, this is the second consecutive year that the mandate has been postponed. About 2% of all companies and corporations have 51-99 workers.
Open Enrollment ends the end of this month. There is a possibility that the time period will be extended. No word yet from the White House (They have plenty to worry about from Mr. Putin!). But we would not be shocked if we saw a 30-90-day extension announced shortly.
Pa navigators may have to undergo background checks, get FBI clearance and carry clear identification if Senator John Eichelberger's ideas become law. His legislation will protect consumers from unscrupulous persons that attempt to take advantage of consumers. There is clear evidence that navigators are often poorly-prepared to provide the help needed by many persons. Brokers and agents are still the best resource for explaining Marketplace options.
Although Obamacare Open Enrollment in Pennsylvania has ended, residents can still apply for low-cost plans in two ways. Firstly, short term policies are offered by several carriers. They can effectively provide coverage until the next OE period. Also, "qualified events," such as losing your job, divorce, and moving, may allow you to enroll in a new plan. Pre-existing conditions would be covered and you can qualify for a subsidy.
Expanding Medicaid is close to becoming a reality. Republican Gene DiGirolamo's bill, which would provide more than 450,000 persons with subsidized coverage, was just approved by the House Human Services Committee.
The governor's "Healthy Pennsylvania" proposal to expand Medicaid has still not been approved by the federal government. It appears that January of 2015 may be the earliest that the legislation could become law. Meanwhile, DiGirolamo's could be implemented very quickly.
Are you one of the estimated 91,000 consumers that received an unexpected check from your insurer? More than $5 million was returned because of the 80/20 rule which requires companies to spend at least 80% of revenue on treatment of patients and other related costs. UnitedHealthcare, Aetna and Time are the three carriers that refunded the most money. This feature will continue for 2015 plans as well.
Plan prices have been released. As expected, rates have gone up for most plans, although several policies have lower costs for the upcoming year. The enrollment period is only three months, which is a few months less than last year. A last-minute change that adds extra time is not expected. However, when we get closer to February, we'll see what happens.
Although OE is over, an extension was provided to persons that did not previously obtain coverage and were unaware of the penalties imposed for not obtaining coverage. However, in order to take advantage of this special exception, you must have paid the non-compliance tax penalty with your 2014 tax return.
About 470,000 Pa consumers enrolled in an Exchange plan. Approximately two out of every five applicants did not previously have Marketplace coverage, and more than 80% of all policies issued were subsidized by the federal government. The average subsidy was between $220 and $230.
The Pennsylvania Medical Society concluded a report that indicates 75% of state residents can see a physician within a week of the first request. More than a third of the respondents to the survey said their out-of-pocket expenses are higher for their current policy compared to last year. The survey covered the entire state.
As the Supreme Court gets ready to rule on a key piece of the ACA (state subsidies) next month, Governor Tom Wolf is preparing for the worst, and hoping for the best. A contingency plan is ready to create a Pa State Exchange that would replace the federally-run Marketplace that is currently used. This would only be implemented if the Supreme Court agrees that federal tax-credit subsidies can only be used for state-based Exchanges.
Rate increase requests are slowly being received by the Pa Department of Insurance. As expected, some hefty price increases are being requested. Geisinger is seeking up to a 40% increase on some plans while Highmark and Keystone requests for selected plans are above 30%.
Several of the larger plan rate increases are listed below:
61.2% - Time Individual Medical
58.4% - Geisinger Choice Individual
40.6% - Geisinger HMO POS
39.7% - Highmark Comprehensive Care PPO
36.6% - Keystone Health Plan West Care Guide Blue HMO
36.2% - Highmark Comprehensive Care Blue PPO
35.0% - First Priority Life my Blue Cross Multi State
34.5% - First Priority Life myBlue Access LP
More news. Conditional approval has been granted to Pa's application for a state-based Exchange. Governor Tom Wolfe is rightfully concerned that the Supreme Court ruling this month could eliminate federal subsidies for more than 380,000 persons. King vs. Burwell is expected to decide if states that utilize the federal government for their Marketplace, are eligible for financial aid.
Open Enrollment begins in about 70 days and Pa insurers have submitted their requests for rates. Highmark and many other companies are requesting substantial increases. Aetna, like several other companies, will not be offering "on-Exchange" plans.
Although changes have been proposed and discussed by the Trump Administration, negotiations continue. It's possible that additional high-deductible options will be available.
Open Enrollment has ended, although "short-term" plans are offered by several carriers.