pennsylvania guide to health insurance

Or call toll-free

Pennsylvania health insurance exchange / marketplace

Nearly 473k enrollees in PA exchange for 2015; 115% of the target that HHS set for the state

Share this:
  • By
  • contributor
  • March 22, 2015

2015 enrollment data

472,697 people enrolled in private plans through the Pennsylvania exchange during the 2015 open enrollment period (through February 22, including the week-long extension).  HHS had projected 410,000 enrollees, so the exchange ended up with 115 percent of the projected total.

Of the people who selected a plan during the 2015 open enrollment period, 41 percent are new to the exchange for 2015, and 81 percent are receiving premium subsidies.

An additional 126,853 people enrolleed in Medicaid or CHIP through the exchange between November 15 and February 22.  Pennsylvania expanded Medicaid (under the Healthy PA program) in 2014, and newly-eligible resident were able to begin enrolling on December 1 (prior to December 1, people could still enroll if they were eligible under the old guidelines).

Enrollment in Medicaid continues year-round, and the state reports that as of early January, more than 101,000 households had applied for Healthy PA coverage, including those who are enrolling directly through the Healthy PA program instead of  At that point, just over 31,000 people had enrolled in Medicaid through, so the majority had enrolled directly through Health PA.

Open enrollment for 2015 is over, but there’s a special enrollment period (March 15 to April 30) for people who didn’t know they would owe a penalty for being uninsured in 2014.  Enrolling during the special enrollment period means those people can avoid paying another – steeper – penalty for all of 2015 as well.  Otherwise, you can only purchase a plan for 2015 – on or off the exchange – if you have a qualifying event.  The next open enrollment period begins on November 1, but coverage won’t be effective until January 1, 2016.

More choices for enrollees in 2015

Pennsylvania’s federally-run exchange has 15 carriers offering plans for 2015.  Three carriers that participated last year left the exchange, but four more – including giants Assurant and United Healthcare – have joined the exchange, making Pennsylvania among the many states where consumer choice is increasing for 2015.

15 insurers puts Pennsylvania’s exchange near the top in terms of the total number of participating carriers, but in some cases the total represents multiple affiliates of a single parent company.  And most of the carriers focus on a single region rather than the whole state, so local competition will vary from one area to another.  Nearly all regions of the state had at least three carriers available in 2014, and the overall trend is towards more consumer choice in 2015.

No penalty for families who had CHIP Buy-in

After it was determined that Pennsylvania’s CHIP Buy-in plan did not meet the ACA’s minimum essential coverage requirements, Governor Tom Wolf and Insurance Commissioner Teresa Miller worked with federal officials to ensure that families whose children had been covered under the CHIP Buy-in plan would not face a tax penalty for 2014, and would have an extended special enrollment period during which they can find new coverage for their children.  The special enrollment period runs through April 15.

Consumers win when carriers compete

UPMC lowered its rates in Western Pennsylvania by a whopping 41 percent for 2015, meaning they are the lowest priced carrier in the western part of the state.  UPMC is expected to retain most of their 2014 enrollees and also gain market share in 2015 because of their competitive premiums.

Highmark Blue Cross Blue Shield garnered a third of the market share during the first open enrollment period (Highmark had 104,324 exchange enrollees, plus an additional 43,679 enrollees outside the exchange) and were priced significantly lower than other carriers in 2014.  But Highmark has increased premiums by about 10 percent for 2015, and their network will be narrower.

In 2014, rates for coverage in the Pennsylvania exchange were lower than the national average.  As of early November, across 13 carriers, PricewaterhouseCooper was reporting an average premium increase of 10.4 percent in Pennsylvania for 2015.  And a Commonwealth Fund analysis published in December found an average rate increase of 12 percent in the Pennsylvania exchange, across all plans and metal levels, for a 40 year-old non-smoker.

But enrollees should be aware that they may be able to find a better value by shopping around than by simply defaulting to keeping their 2014 plan.

The NY Times put together an analysis of how enrollees in the 2014 benchmark plan (second lowest cost silver plan) will fare for 2015, depending on whether they opt to renew their coverage or switch to the new benchmark plan.  In Pennsylvania, there’s a range of results, with enrollees in some areas eligible for rate decreases if they shop around.  Letting the benchmark plan automatically renew will result in a rate increase in all areas of the state though, so it’s definitely in your best interest to shop around.

In a similar, but more specific analysis, the Kaiser Family Foundation looked at the average cost of the benchmark plan for a 40 year old enrollee in a major metropolitan area in each state.  In the Philadelphia area, the average premium was decreasing by 10.7 percent.

Andrew Sprung, writing at Xpostfactoid, is predicting that Pennsylvania will have a lot more people selecting Bronze plans in 2015 compared with 2014, and his explanation makes a lot of sense.  While the difference between the cheapest Silver plan and the cheapest Bronze plan in most areas of the county was usually at least $50 to $100 per month, in southeast Pennsylvania – the Philadelphia area – the difference was only $20 in 2014.

So people who were eligible for cost-sharing subsidies if they purchased Silver plans were more able to do so than in other parts of the country where there were Bronze plans that were very attractive because of their premiums, despite the fact that they didn’t include any cost-sharing subsidies.  But for 2015, the difference in price from Bronze to Silver is much greater in the Philadelphia region, because there’s no longer a Silver plan priced well below the benchmark (second-lowest-cost) Silver plan.

2014 enrollment numbers

By April 19, 318,077 Pennsylvania residents had completed their private plan selections in the exchange, nearly double the number who had enrolled by March 1.  By the end of the 2014 open enrollment period, private plan Obamacare enrollment in Pennsylvania was the fourth highest out of the 36 states where HHS is running the exchange (trailing Texas, Florida, and North Carolina).

Enrollment has continued throughout the summer due to qualifying events that trigger special enrollment periods;  HHS will release an updated enrollment total in November, which is when the 2015 open enrollment period will begin.

In contrast with the national trend, Pennsylvania had more uninsured residents in 2012 than in 2011 – an increase of  156,000 people.  But thanks to the ACA, the uninsured rate declined – albeit only slightly – during the first half of 2014.  A recent Gallup poll found that the uninsured rate in the state was 11 percent in 2013, and had declined to 10.1 percent by mid-2014.

Prior to the first open enrollment period, Families USA estimated that almost 900,000 Pennsylvania residents would be eligible for tax credits to help them pay for coverage purchased through the health insurance exchange.  During the 2014 open enrollment period, more than 257,000 people received tax credits (81 percent of the total exchange enrollment) in Pennsylvania.

Although expanded coverage didn’t take effect until 2015, 42,335 exchange applicants had been found to be eligible for Medicaid or CHIP under the state’s existing 2014 guidelines by mid-April 2014.  There is no open enrollment window for Medicaid; enrollment continues year-round.

PA 28th state to expand Medicaid

On August 28, 2014, Pennsylvania became the 28th state (including DC) to expand Medicaid under the ACA in an agreement reached with HHS after many months of discussion.  Eligible enrollees were able to begin enrolling on December 1, for coverage effective January 1.  Interest in the program is very high in the early days of enrollment.  In the first two days alone, 41,500 people enrolled (30,000 of them did so through  And in the first week, 27,000 households (probably at least 49,000 people) enrolled.

Governor Tom Corbett’s office announced the details of the approved Healthy Pennsylvania program, and HHS released an extensive explanation of how the state’s Medicaid waiver will work (a waiver is required if a state is doing anything other than straight Medicaid expansion as laid out in the ACA).  There are three plan options under Healthy PA, although one of them is still pending approval from HHS.

But then on November 4, Democrat Tom Wolf defeated Corbett in the election, and took over as Governor in January 2015.  Wolf has long been an advocate of fully expanding Medicaid under the ACA, without any state-specific waiver or modifications.  It’s unclear for now how the transition will play out, but Wolf has said he will abandon Healthy Pennsylvania in favor of straight Medicaid expansion, and Democratic state lawmakers are urging him to move quickly in doing away with Healthy PA and replacing it with straight Medicaid expansion under the ACA.

For now, advocates are concerned that the confusion surrounding the transition could cause some eligible residents to stay on the sidelines, and they’re encouraging people to enroll now rather than waiting to see what happens with the program (people who are eligible now would still be eligible if the program transitioned to straight Medicaid expansion).

Corbett originally announced that the state would not move forward with Medicaid expansion, but reversed his course in late summer 2013, saying that the state was negotiating with the federal government to create its own version of Medicaid expansion (Healthy Pennsylvania), using the federal funds to subsidize private health insurance for low-income residents instead of enrolling them in Medicaid, and adding restrictions that would remove some people from Medicaid or charge them a “modest monthly premium” (which he initially proposed to mean mean that people with incomes above 50% of poverty level would end up paying for their coverage).

Corbett’s plan has been very controversial in Pennsylvania, among lawmakers and residents alike.  On March 5, a letter from Corbett to Sec. Sebelius outlined his loosening of requirement that Medicaid recipients be actively searching for work, but his proposal did still include a work requirement.  Ultimately, the work requirement was dropped from the Healthy Pennsylvania program, but the state is running a voluntary job training and career coaching program that could let participating enrollees have lower cost sharing.

There will be no premiums charged for Healthy Pennsylvania in 2015, but starting in 2016 the program can charge up to two percent of income for enrollees with incomes between 100 percent and 138 percent of poverty level.

In late June the Corbett Administration had received a strong response from insurance carriers interested in participating in his Healthy PA program:  for some regions of the state, as many as six insurers had placed bids, while the Administration had been hoping for at least two per region.  In all, nine insurers have been approved by the state to participate in the Healthy PA program that was approved by HHS in late August.

Through these private insurers, newly-eligible Healthy Pennsylvania enrollees will be covered under a private, managed care Medicaid program – very similar to what Pennsylvania and many other states already use for existing Medicaid coverage.  Although by early October, there were some indications that the carriers providing the managed care Medicaid coverage were having difficulty getting enough providers to participate in their networks because of the relatively low reimbursement rates compared with commercial plans.

Grandmothered plans

Pennsylvania allowed insurers to extend existing 2013 policies into 2014 following the policy cancellation compromise that President Obama offered in mid-November.  Prior to the President’s announcement, a quarter of a million Pennsylvania residents – about one third of the individual market in the state – had received cancellation notices.  By the end of November, two Pennsylvania carriers had agreed to extend some existing policies – including one guaranteed-issue, limited benefit plan for low-income residents – for at least the first few months of 2014.

Despite the fact that policies slated for cancellation were allowed to be extended, and the fact that nearly 160,000 people had enrolled through the exchange by March 1 – and another 42,500 off-exchange through just one carrier – Gov. Tom Corbett continued to criticize Obamacare, focusing on the fact that supposedly, 250,000 people “are losing their health coverage due to the ACA.”  Corbett has been opposed to the ACA from the get-go, and continues to rely on his Obamacare opposition as he works to win reelection in PN.

Pennsylvania is among the states allowing pre-2014 plans to be renewed again this fall and remain in force in 2015.

Community Blue, UPMC network controversy

During the 2014 open enrollment period, Highmark BCBS enrolled a total of 148,003 members in Pennsylvania, and 80 percent of them – about 120,000 people – chose a Community Blue plan.  33 percent of the total private plan enrollment within the exchange in Pennsylvania was with Highmark, and the majority of them selected a Community Blue plan.

There was some confusion surrounding the Community Blue network, as the new plans do not include UPMC providers.  Community Blue offered insureds a transition period to have one final visit with a UPMC provider, or to complete (out-of-network) appointments that were scheduled before the end of December 2013.

In early March, the transition period ended, and Community Blue plans no longer provide coverage for UPMC facilities or providers.  If you have a UPMC provider and a new Community Blue policy, be sure to check with your carrier and your provider to make sure that you know what providers are in your network.

This issue has caused considerable consternation in Pennsylvania this year.  The state Senate decided in late June to allow senators, staff and retirees in 29 western Pennsylvania counties to opt for either a UPMC policy or a Highmark plan so that they can continue to receive care at a UPMC facility if that’s their choice.

Exchange history

In December 2012, Gov. Corbett announced Pennsylvania would use the federal health insurance exchange rather than implementing a state-run exchange. Corbett said the U.S. Department of Health & Human Services had failed to provide adequate information, making it irresponsible for the state to proceed on its own.  Thus HHS is running the exchange in Pennsylvania.  You can use to get quotes, compare plans, determine subsidy eligibility and enroll in coverage.

Leading up to the December announcement, Corbett had repeatedly indicated his administration preferred a state-run exchange, and feedback gathered by a consultant showed broad-based public agreement.  Corbett’s administration proposed establishing several, regional exchanges. However, consumer groups and legislators did not support the concept.

Although the state government has not involved itself in promoting the exchange, $7 million in federal funds went to various organizations around the state that served as navigators to assist people during open enrollment, which ended on March 31.  The 2015 open enrollment period begins on November 15, 2014.

Pennsylvania health insurance exchange links

State Exchange Profile: Pennsylvania
The Henry J. Kaiser Family Foundation overview of Pennsylvania’s progress toward creating a state health insurance exchange.

Operated by the Pennsylvania Health Department

Health Care Section, Office of the Attorney General
Serves Pennsylvania consumers with health-related problems.
(717) 705-6938 / Toll-free: 1-877-888-4877 (only in Pennsylvania)

Pennsylvania Consumer Assistance Program
Assists people with private insurance, Medicaid, or other insurance with resolving problems pertaining to their health coverage; assists uninsured residents with access to care.
(877) 881-6388 /