Pennsylvania health insurance Marketplace guide

To be eligible to enroll in Pennsylvania Health Insurance Marketplace coverage, you must:

• Live in Pennsylvania
• Be lawfully present in the United States
• Not be incarcerated
• Not be enrolled in Medicare

Eligibility for financial assistance in the form of premium subsidies and cost-sharing reductions depends on your income and how it compares with the cost of the second-lowest-cost Silver plan in your area – which depends on your age and location. In addition, to qualify for financial assistance with your Marketplace plan you must:

• Not have access to affordable health coverage through your employer. If your employer offers coverage but you feel it’s too expensive, you can use our Employer Health Plan Affordability Calculator to see if you might qualify for premium subsidies in the Marketplace. 
• Not be eligible for Medicaid or CHIP, or premium-free Medicare Part A.⁶
• File a joint tax return, if married.⁷ (with very limited exceptions)⁸
• Not be able to be claimed by someone else as a tax dependent.⁹

In Pennsylvania the open enrollment period for individual and family coverage runs from November 1 to January 15.¹⁰

Your coverage starts on January 1 if you enroll before December 15. But if you apply between December 16 and January 15, your coverage will begin on February 1.¹¹

New federal rules finalized in 2025 will shorten the open enrollment period, starting in the fall of 2026. At that point, for enrollment in coverage for 2027 and future years, state-run exchanges will have to end their open enrollment periods no later than December 31. And all plans selected during open enrollment will take effect January 1.

Outside of open enrollment, you’ll need a special enrollment period (SEP) to enroll or make changes to your coverage. In most cases, a SEP requires a qualifying life event, but Native Americans can enroll year-round without a qualifying live event.

Pennsylvania also has an “easy enrollment” program that allows uninsured residents to begin the process of accessing health insurance via their state tax returns.⁴ Pennie confirmed by phone that about 900 people used Path to Pennie to obtain coverage in 2023, including Medicaid and private plans.

To enroll in an ACA Marketplace plan in Pennsylvania, you can: 

• Visit Pennie to enroll in Pennsylvania’s Marketplace. Here you will find an online platform to shop, compare plans and determine your subsidy eligibility. 
• Purchase individual and family health coverage with the help of an insurance agent or broker, a Navigator or certified application counselor.

You may find affordable health insurance options in Pennsylvania by utilizing the state’s health insurance exchange – Pennie. Here, residents can enroll in health coverage as well as determine their eligibility for financial assistance. 

During the open enrollment period for 2025 coverage, about 86% of Pennie enrollees were receiving premium tax credits (premium subsidies). These tax credits amounted to an average savings of $541/month. With subsidies, enrollees paid an average of $187 per month for health coverage (including those who paid full price).¹²

In addition to premium tax credits, Marketplace enrollees with household incomes up to 250% of the federal poverty level also qualify for cost-sharing reductions (CSR) that result in lower out-of-pocket costs (deductible, coinsurance, copays) on Silver plans. As of early 2025, three out of ten Pennie enrollees were receiving CSR benefits.¹³

Source: CMS.gov¹⁴

Between the premium subsidies and cost-sharing reductions, you’ll likely find that a plan obtained via Pennie provides you with the best overall value.

At some point, if state funding is allocated, Pennsylvania may start to offer additional subsidies, beyond the federal subsidies that are already available.¹⁵ But as of August 2025, state funding had not yet been allocated for this purpose,¹⁶ so Pennsylvania is not among the states that offer additional state-funded subsidies.

Governor Shapiro’s proposed 2024-25 budget calls for the state to create “an additional subsidy wrap” to make Pennie coverage more affordable for low-income and middle-income applicants.¹⁷

Legislation to create an “affordability assistance program” passed the Pennsylvania House in June 2024 and was sent to the Senate for consideration, but ultimately did not advance during the 2024 session.¹⁸ As a result, Pennie’s board of directors noted that funding for the state subsidy program was not available for plan year 2025.¹⁹ Funding still had not been secured by August 2025, making it unlikely that the subsidy program would be available for 2026 either.

The 2024 legislation did not contain any specific parameters for how the subsidies would have worked (premium subsidies or cost-sharing reductions) or who would have been eligible for them. It only noted that the program should be designed “to incentivize enrollment in on-exchange policies based on income or other eligibility criteria.”²⁰

As of May 2024, the Pennie Board of Directors was recommending a sliding scale premium subsidy for gold and silver plans, for households earning between 151% and 300% of the federal poverty level.²¹

That structure was still the assumption as of August 2024, but the program had been delayed until at least plan year 2026 by that point (as noted above, funding still had not been allocated as of August 2025, making it unlikely that this program could become available for 2026). So board members noted that if the American Rescue Plan’s federal subsidy enhancements aren’t extended past 2025, the lower income bound for Pennie’s additional premium subsidies could be reduced.¹⁹ (As of August 2025, the federal subsidy enhancements have not been extended, and are scheduled to expire at the end of 2025.)

The state will only be able to proceed with the subsidy program if the legislation is enacted and if the state can secure alternate funding for its reinsurance program, so that some of the funds currently being used for reinsurance can be diverted to the affordability assistance program.²²

As of mid-2025, Pennie’s board of directors noted that the state’s existing reinsurance funding was about $2 million short of what was needed, and was recommending the approval of the additional funds. But the additional state subsidy program was not discussed at that meeting.²³

There will continue to be 14 Marketplace insurers in Pennsylvania in 2026,²⁴ although Pennsylvania Health & Wellness will be Ambetter in 2026, and UPMC will be UPMC Health Plan.³ Enrollees in the 2025 versions of those plans will be transitioned to the new plans unless they select different coverage during open enrollment.

The following average rate changes have been approved for 2026 for the insurers that offer Marketplace coverage in Pennsylvania, amounting to a weighted average proposed increase of 21.5%²⁴ (calculated before subsidies; the after-subsidy rate increase will be much larger for most enrollees unless Congress extends the subsidy enhancements that are scheduled to expire at the end of 2025; see examples below to illustrate the scope of these net premium increases).

Source: Commonwealth of Pennsylvania³²⁴

Average rate changes apply to full-price health plans, but the majority of Pennsylvania health insurance marketplace enrollees receive premium subsidies, and thus do not pay full price.²⁵ However, if Congress doesn’t extend the federal subsidy enhancements that have been in effect since 2021, subsidies will be smaller than they would otherwise have been, and available to fewer enrollees in 2026. This will result in significant increases in after-subsidy premiums, and the expected enrollment decline (due to the larger net premiums) was a driving factor in pushing overall premiums higher for 2026.³

As of the start of the open enrollment period for 2026 coverage, Congress had not taken action to extend the subsidy enhancements. As a result, here are some examples of the sort of net premium increases that people are seeing in Philadelphia for 2026:²⁶

• 40-year-old earning $40,000:
  • Lowest-cost plan in 2025 is $41/month
  • Lowest-cost plan in 2026 is $116/month
• 60-year-old earning $63,000:
  • Lowest-cost plan in 2025 is $205/month
  • Lowest-cost plan in 2026 is $631/month

For perspective, here’s a summary of how average full-price premiums for Pennsylvania health insurance have changed over time:

• 2015: Average increase of 12%²⁷
• 2016: Average increase of 12%²⁸
• 2017: Average increase of 32.5%²⁹
• 2018: Average increase of 30.6%
• 2019: Average decrease of 2.3%³⁰
• 2020: Average increase of 3.8%³¹
• 2021: Average decrease of 3.3%³²
• 2022: Average increase of 0.2%³³
• 2023: Average increase of 5.5%³⁴
• 2024: Average increase of 3.9%³⁵
• 2025: Average increase of 6%³⁶

During the open enrollment period for 2025 coverage, 496,661 people signed up for private plans through the Pennsylvania Marketplace.³⁷ This was a record high, as shown in the chart below.

But Pennie’s board of directors has noted that if the federal subsidy enhancements are allowed to expire at the end of 2025, it could result in an enrollment drop of more than 30% in 2026.²³

Source: 2014,³⁸ 2015,³⁹ 2016,⁴⁰ 2017,⁴¹ 2018,⁴² 2019,⁴³ 2020,⁴⁴ 2021,⁴⁵ 2022,⁴⁶ 2023,⁴⁷ 2024,⁴⁸ 2025⁴⁹

Pennie
The official Pennsylvania health coverage Marketplace.

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

Health Care Matters, Pennsylvania 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 / [email protected]