Pennsylvania health insurance marketplace guide 2023

Pennsylvania now operates its own fully state-run exchange, known as Pennie. But this was a transition after several years of using the federally-run exchange.

Pennsylvania enacted legislation (H.B.3/Act 42) in 2019 that called for the state to transition to running its own exchange platform and also create a reinsurance program to help to make coverage more affordable. Both took effect in 2021 (Pennie was operational as of the fall of 2020, for people to enroll in 2021 coverage).

Although Pennsylvania initially opted not to establish its own exchange, the state seriously considered establishing its own exchange in 2015, when the King v. Burwell lawsuit threatened premium subsidy access in states that didn’t run their own exchanges. But the Supreme Court ultimately upheld subsidies for people in states that used the federally-run exchange, so Pennsylvania continue to use HealthCare.gov for several more years. 

The open enrollment period for individual/family coverage runs from November 1 to January 15 in Pennsylvania. This includes plans sold through the exchange as well as plans obtained off-exchange.

Outside of open enrollment, a special enrollment period (SEP) is necessary to enroll or make changes to your coverage. In most cases, a special enrollment period requires a qualifying life event.

(For people who lose Medicaid in 2023 or early 2024 due to the end of the pandemic-era continuous coverage rules, Pennie will be an important source of coverage if the person isn’t eligible for an employer’s plan. Here’s more about how this.)

There are also some special enrollment periods, such as Pennie’s low-income SEP, enrollment opportunities for Native Americans, and the tax-time “Path to Pennie” (described in more detail below) that do not require specific qualifying events.

In addition, Medicaid enrollment is available year-round.

Pennsylvania’s state-run exchange, Pennie, has 13 participating insurers, although some share a parent company. But there are still eight distinct entities offering coverage, which was a record high for Pennsylvania’s exchange as of 2022. The following insurers offer plans through Pennie for 2023, with varying coverage areas:

• Capital Advantage Assurance
• Geisinger Health Plan
• Geisinger Quality Options
• Highmark, Inc.
• Highmark Benefits Group
• Highmark Coverage Advantage
• Keystone Health Plan East (Independence Blue Cross HMO)
• QCC Insurance Company (Independence Blue Cross PPO)
• UPMC Health Coverage
• UPMC Health Options
• PA Health and Wellness
• Oscar Health
• Cigna

Pennsylvania’s exchange is fairly robust in terms of overall insurer participation, but it’s gone from having four or more insurers offering plans in every county in 2015, to several areas of the state having only one insurer option in 2018 and 2019.

Three carriers that participated in 2014 left the exchange, but four more — including giants Assurant (Time) and UnitedHealthcare — joined the exchange, making Pennsylvania among the many states where consumer choice increased for 2015. But Assurant ceased sales of new policies nationwide on Jun 15, 2015, and UnitedHealthcare exited the exchanges in most states, including Pennsylvania, at the end of 2016. United’s total exchange enrollment in Pennsylvania was 65,159 in 2015.

Aetna also left the exchange in Pennsylvania (and ten other states) at the end of 2016. Aetna insured about 31,000 exchange enrollees in Pennsylvania in 2016, all of whom needed to switch to a new plan during open enrollment for 2017 coverage. Aetna then exited the off-exchange market at the end of 2017. Freedom Life/National Foundation Life also exited the off-exchange market at the end of 2017, but the Pennsylvania Insurance Department confirmed that Freedom Life/National Foundation Life never marketed their plans and didn’t have any enrollees in 2017.

Geisinger Quality Option (PPO) stopped being available on-exchange as of 2017, although Geisinger Health Plan (HMO) continued to be available on-exchange (nationwide, insurers have trended towards offering HMOs and/or EPOs in the individual market, especially in the exchange, instead of PPOs). But for 2019, Geisinger Quality Options has returned to Pennsylvania’s exchange.

Keystone Health Plan Central also stopped offering plans in the exchange in 2017, according to the rate approval notice published by the Pennsylvania Insurance Department. They were not offering silver plans at all in the individual market in 2017, which is a prerequisite of offering coverage in the exchanges under ACA rules. As of 2019, Keystone Health Plan Central is continuing to only offer plans outside the exchange, although they have over 2,000 enrollees.

All of the insurers that offered plans in Pennsylvania’s exchange in 2018 continued to do so for 2019 — and several expanded their coverage areas — and Ambetter (Centene) joined the exchange. Ambetter from PA Health & Wellness is offering plans in the Philadelphia area (Bucks, Montgomery, and Philadelphia counties). Residents in nearly half of Pennsylvania’s counties had additional plan options for 2019. In 31 of Pennsylvania’s 67 counties, there were more health insurers offering coverage in the individual market in 2019 than there were in 2018. And in addition to a new entrant into the market, four of the five insurers already in the individual market expanded their coverage areas for 2019. Further, the number of counties with just one health insurer offering coverage in the individual market decreased from 20 to eight.

For 2020, all of the existing insurers remained in the exchange, and Oscar joined in the Philadelphia area. Highmark also expanded into 14 additional counties for 2020.

In Pennsylvania, Highmark’s individual market plans are available through several affiliates. One of them — Highmark Choice Company — discontinued its 2020 plans (which were offered on- and off-exchange) at the end of 2020 and is instead only offering one bronze plan outside the exchange for 2021. Highmark Choice Company’s filing indicated that they expected to have very low enrollment (only two members) in 2021. Approximately 3,720 enrollees who had Highmark Choice Company plans in 2020 needed to switch to another plan for 2021.

For 2022, Cigna joined Pennsylvania’s exchange, with plans available in the Philadelphia area. The same 13 insurers continued to offer coverage in 2023. 

Thirteen insurers offer individual market plans through Pennsylvania’s health insurance marketplace/exchange (Pennie) in 2023, although several of them share parent companies.

The insurers that offer plans through Pennie implemented the following average rate changes for 2023, amounting to an overall average increase of 5.5%:

• Capital Advantage Assurance: 11.2% increase.
• Geisinger Health Plan: 15.5% increase.
• Geisinger Quality Options: 17% increase.
• Highmark, Inc. (EPO and PPO): 9.1% increase.
• Highmark Benefits Group: 13.2% increase.
• Highmark Coverage Advantage: 4.3% increase.
• Keystone Health Plan East (Independence Blue Cross HMO): 1.3% increase.
• QCC Insurance Company (Independence Blue Cross PPO): 0.9% increase.
• UPMC Health Coverage: 4.4% increase.
• UPMC Health Options: 4.2% increase.
• PA Health and Wellness: 4.9% increase.
• Oscar Health: 8.4% increase.
• Cigna: 4.8% increase.

Across the entire individual market, including the insurers that only offer plans outside the exchange, the average rate change amounted to an increase of 5.5% for 2023.

For perspective, here’s a look at how average premiums have changed in Pennsylvania’s exchange over the years:

• 2015: Average increase of 10-12%: In 2014, rates for coverage in the Pennsylvania exchange were lower than the national average. As of November 2014, across 13 carriers, PricewaterhouseCooper was reporting an average premium increase of 10.4% in Pennsylvania for 2015.  And a Commonwealth Fund analysis found an average rate increase of 12% in the Pennsylvania exchange, across all plans and metal levels, for a 40-year-old non-smoker.
• 2016: Average increase of 12%: The overall weighted average rate increase in the individual market amounted to 12%. The average subsidy in the Pennsylvania exchange in 2016 was $251/month (lower than the Healthcare.gov average of $290). But for people who qualified for premium subsidies in the Pennsylvania exchange, the average pre-subsidy premium was $396/month in 2016, which was exactly the average across the 38 states that use Healthcare.gov.
• 2017: Average increase of 32.5%: When the final rates were approved, the Pennsylvania Insurance Department noted that the average individual market rates (including off-exchange plans) would increase by 32.5% for 2017.
• 2018: Average increase of 30.6%: The initial rate filings for 2018 were based on the assumption that funding for cost-sharing reductions (CSR) would continue in 2018. Some of the insurers revised their filings after HHS finalized risk adjustment data in July 2017, and rates were again revised based on the assumption that CSR funding would not continue (the Trump administration terminated funding in October 2012). Insurers in Pennsylvania added the cost of CSR to the premiums for on-exchange silver plans. Insurers were also able to create new off-exchange-only silver plans that don’t have the cost of CSR added to their premiums. The final average rate increase was 30.6% for 2018; it would have been in the range of 7.6% if CSR funding had been committed for 2018. The Pennsylvania Insurance Department and the CEOs of the five individual market insurers had sent a letter in April 2017 to HHS, asking the federal government to take swift action to ensure stability in the individual insurance markets, including continued enforcement of the individual mandate and continued federal funding for CSR. Ultimately, however, the loss of federal CSR funding ended up being a boon for many consumers, as insurers added the cost to silver plan rates, and that, in turn, resulted in larger premium subsidies for all subsidy-eligible enrollees.
• 2019: Average decrease of 2.3%: Initially, in June 2018, Pennsylvania insurers filed plans with an overall rate increase of 4.9%. But they modified their rate filings in July, resulting in an overall average proposed rate increase of 0.7 percent, after the load to account for the cost of CSR was reduced somewhat. And when the rates were approved, some additional reductions resulted in rates decreasing by an average of 2.3%, although there was considerable variation from one insurer to another. But average benchmark premiums in Pennsylvania were an average of 15% lower for 2019 than they were for 2018. Premium subsidies are based on the cost of the benchmark plan, so average subsidies were smaller in 2019 than they were in 2018, for people whose income remained the same. For 2018, the average subsidy amount in Pennsylvania was $625/month, whereas it was $539/month in 2019. The Insurance Department’s summaries of the proposed and approved rates made it very clear that the federal government’s actions with regards to the ACA had been destabilizing, and highlighted the “Wolf Administration efforts to combat the effects of sabotage on health insurance markets by the federal government and specifically the Trump Administration to dismantle the Affordable Care Act (ACA).” Although overall average rates in Pennsylvania’s exchange declined slightly for 2019, they would have declined even more if the individual mandate penalty hadn’t been eliminated and if the Trump administration hadn’t expanded access to short-term plans and association health plans (AHPs). According to an analysis by the Urban Institute, the combined effect of those changes was expected to drive Pennsylvania premiums 19.2 percent higher in 2019 than they would otherwise have been.
• 2020: Average increase of 3.8%. In July 2019, the Pennsylvania Insurance Department published the proposed rate changes for 2020. Pennsylvania’s insurance commissioner also announced that Highmark would be expanding its coverage area into 14 additional counties for 2020, and Oscar would be joining the exchange in the Philadelphia area (Bucks, Chester, Delaware, Philadelphia, and Montgomery counties). Once rates were finalized, the average increase stood at 3.8%, down from 4.6% that insurers proposed initially. Final approved rates for some insurers were slightly higher than the insurers had proposed, but the overall impact of the rate review process was a somewhat smaller overall average rate changes across the whole market.
• 2021: Average decrease of 3.3%. Across the entire individual market in Pennsylvania, which includes five additional insurers that only offer plans outside the exchange, the overall average rate change was a decrease of about 3.3%. In the small group market, insurers implemented an average rate increase of 2.1%, down slightly from the proposed average rate increase of 2.3%.
• 2022: Average increase of 0.22%: Across the entire individual market, including the insurers that only offer plans outside the exchange, the average rate change amounts to an increase of 0.22% for 2022.

More than 371,000 people enrolled in private plans through Pennie during the open enrollment period for 2023 coverage. This was a little lower than the prior year’s enrollment total. Although nationwide exchange enrollment hit another record high in 2023, the state-based exchanges (of which Pennie is one) saw their 2023 enrollment dip slightly lower than the prior year’s numbers. 

Here’s a summary of enrollment numbers during each year’s open enrollment period:

• 2014: 318,077 people enrolled 
• 2015: 472,697 people enrolled (modified Medicaid expansion took effect)
• 2016: 439,238 people enrolled (transition to unmodified Medicaid expansion took effect)
• 2017: 426,059 people enrolled
• 2018: 389,081 people enrolled
• 2019: 365,888 people enrolled
• 2020: 331,825 people enrolled
• 2021: 337,722 people enrolled
• 2022: 374,776 people enrolled (The growth was due in large part to the American Rescue Plan’s subsidy enhancements, which made coverage more affordable for most enrollees.)
• 2023: 371,516 (preliminary)