Pennsylvania Health Insurance Guide

Types of plans offered in Pennsylvania include major medical health insurance coverage such as Personal Health Quotes, Family Health, and Group Health. Start your search for low-cost health insurance today!

Health Insurance Resources for PA State Residents

As a resident of the Commonwealth of Pennsylvania you have access to a variety of health insurance programs including individual and group plans through private insurance carriers, as well as Pennsylvania-sponsored affordable health insurance for families and children, and federal programs including Medicare.

Pennsylvania is a guaranteed issue state giving all residents the right to individual health insurance purchased through either Blue Cross or Blue Shield, although the choice of plans may be limited and there may be an exclusion period of pre-existing conditions (except for HIPAA-eligible individuals). All other insurance carriers in Pennsylvania can medically underwrite individual applicants and deny coverage to anyone who applies, except as prohibited by federal law. Under the Pennsylvania Free Look provision, you have a minimum of 10 days to review any health insurance policy and return it for a full refund of any premium paid.

Pennsylvania regulations for group health insurance plans stipulate that qualified employees cannot be turned down or charged more because of a health problem, although an employer can require a waiting period before offering group coverage to a new hire. Group health insurance providers can also review your medical records for six months prior to coverage if you have a pre-existing condition, and they can designate an exclusion period for coverage of that condition not to exceed 12 months.

Pennsylvania currently has 60 mandated treatments and conditions that must be included in every health insurance sold in the commonwealth. These include a gamut of preventive care services, treatments and surgeries including treatment for autism, breast reconstruction, pap smears, mammography, colorectal screening, hospice care, newborn hearing screening, maternity minimum stays, general mental health, prostate cancer screening and well child care.

Major medical health care insurance options in Pennsylvania include:

• Fee-for Service Plans, also known as traditional or indemnity insurance
  Typically the most flexible and therefore highest priced choice, these plans allow you to select your health care providers without restriction. Depending on your plan, all or part of certain services will be paid by the carrier, although a deductible may have to satisfied first and co-payment may be required when you have a claim.
• Health Maintenance Organizations (HMOs)
  These are Managed Care plans that require you to select a primary care physician, who must make all referrals to specialists. You are also required to restrict your providers to the plan’s network. Your plan may not reimburse you for using an out-of-network provider except in stipulated emergency situations. HMOs typically offer a comprehensive range of services.
• Preferred Provider Organizations (PPOs)
  hese are groups of health care providers and facilities that contract with health insurance companies and agree to provide services at negotiated discount rates. You do not need a primary care physician to see a specialist. Although you can elect to go out of the preferred network, you will receive the highest level or coverage including lowest deductibles and co-insurance by using the preferred providers.
• Point of Service Plans (POS)
  POS plans are hybrid of an HMO or PPO and a fee-for-service plan. You can choose to receive a service from a preferred provider or a non-contracted provider. You’ll receive the plan’s maximum benefits by using a primary care physician for referrals to specialists.

 

 

Alternative Health Programs in Pennsylvania

• AdultBasic
  AdultBasic provides health insurance for adult residents of Pennsylvania ages 19 to 65 who have no health insurance and meet other eligibility requirements. It is administered by the Pennsylvania Insurance Department and services are provided by contracted insurance companies. Benefits include preventative care, office visits, diagnostic services, treatment for illness and injury, hospitalization, out-patient hospital services, and emergency accident and medical care. Recently, high demand has created a wait-list for the adultBasic program.
• CHIP
  Pennsylvania’s Children’s Health Insurance Program, provides health insurance to all uninsured children and teens up to 19 who are not eligible for Medical Assistance. There is no income limit for families to enroll a child in CHIP, although there is a sliding scale depending on income. Families whose incomes exceed the free CHIP coverage limit are charged below-market monthly premiums and co-pays for some services. CHIP coverage must be renewed every 12 months.
  
  Act 4 of 2009 expands health insurance coverage for children of insured parents, allowing adults up to age 30, under certain circumstances, to remain on a parent’s health insurance plan. Coverage expansion is at the sponsoring employer’s discretion and may include an increase in premium contribution.

 

Regulating Agencies
Health insurance in Pennsylvania is regulated by the Pennsylvania Department of Insurance and/or its Bureau of Managed Care, which hears appeals regarding complaints and grievances about health care coverage received under managed care plans.
Get access to Pennsylvania health insurance quotes based on your coverage needs and individual health circumstances.

Pennsylvania Insurance Department
1326 Strawberry Square Harrisburg, PA 17120 www.insurance.pa.gov http://www.ins.state.pa.us/ins/site/default.asp

Consumer Services
Philadelphia Regional Office
801 Market Street, Room 6062
Philadelphia, PA 19107
Phone: (215) 560-2630
Fax: (215) 560-2648
TTY/TDD: (215) 560-2471


Pennsylvania Department Of Health
Health and Welfare Building
7th & Forster Streets
Harrisburg, PA 17120
1-877-PA-HEALTH
www.dsf.health.state.pa.us

(NAIC) National Association of Insurance Commissioners
The National Association of Insurance Commissioners (NAIC) is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. The NAIC provides a forum for the development of uniform policy when uniformity is appropriate. NAIC members are the elected or appointed state government officials who along with their departments and staff regulate the conduct of insurance companies and agents in their respective state or territory.
www.naic.org