Frequently asked questions about health insurance
coverage options in Pennsylvania
Pennsylvania initially opted not to establish its own health insurance marketplace, so the state used the federally run exchange at HealthCare.gov for several years. But that changed in the fall of 2020, with the debut of Pennsylvania’s new state-run exchange, called Pennie.
The state enacted legislation in 2019 to authorize the transition away from HealthCare.gov. By switching to its own exchange, Pennsylvania expects to save up to $50 million per year, which is being used to cover the state’s portion of the cost of a reinsurance program.
The state also gained numerous other benefits in terms of flexibility and control over the marketplace. Among the most significant from consumers’ perspective is the flexibility to extend open enrollment – which Pennsylvania opted to do right out of the gates: Open enrollment for 2021 coverage lasted an additional month, compared with what it would have been if the state had continued to use HealthCare.gov. (As of the following year, HealthCare.gov also extended the standard enrollment window through January 15, which is the schedule being used now in most states.)
The marketplace (Pennie) is used by people who purchase their own health insurance. This includes people who are self-employed, people who are employed by a small business that doesn’t provide health insurance benefits, and early retirees who aren’t yet eligible for Medicare. The marketplace is also the only place where people can receive financial assistance (premium subsidies and cost-sharing reductions) that makes health insurance premiums and out-of-pocket medical expenses less costly.
Pennsylvania’s reinsurance proposal was approved by the federal government in July 2020. The federal government is providing pass-through funding that covers the majority of the cost of the reinsurance program (because reinsurance keeps premiums lower than they would otherwise have been, premium subsidies are also smaller, resulting in savings for the federal government; pass-through funding refers to the process of using a 1332 waiver to allow the state to use the savings).
Pennsylvania estimated that the transition to a state-based exchange and the implementation of a reinsurance program would result in individual market premiums about 5 to 10% lower in 2021 than they would otherwise have been. Insurers that offer health plan options in Pennsylvania’s marketplace ultimately reduced their average premiums by 3.3% (versus an overall average rate increase that would have been necessary without the reinsurance program).
The open enrollment period for individual/family health insurance runs from November 1 to January 15 in Pennsylvania. Outside of open enrollment, a qualifying event is necessary to enroll or make changes to your coverage.
Learn more about your enrollment opportunities in our comprehensive guides:
For both 2022 and 2023, 13 insurers offer individual market plans through Pennsylvania’s health insurance exchange (Pennie), although several share parent companies. The following insurers will offer individual/family plans in Pennsylvania’s exchange for 2023 coverage, with enrollment beginning November 1, 2022:
- Capital Advantage Assurance
- Geisinger Health Plan
- Geisinger Quality Options
- Highmark, Inc. (EPO and PPO)
- 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
For 2023 coverage, overall average premiums in Pennsylvania’s individual insurance market are increasing by 5.5%. Overall rates stayed nearly flat in 2022, so the average rates are less than 6% higher for 2023 than they were in 2021.
Pennsylvania’s reinsurance program has played a role in keeping premiums lower than they would otherwise have been, starting in 2021.
It’s important to remember that average rate changes refer to full-price premiums, and very few enrollees pay full price for their coverage. Most enrollees get premium subsidies, and the subsidies fluctuate from year to year to keep pace with changes in the benchmark plan’s premium (second-lowest-cost Silver plan).
Enrollment in the Pennsylvania health insurance marketplace grew from 2014 through 2016, but it decreased each year from 2017 through 2020, mirroring a national trend towards lower enrollment under the Trump administration in states that use HealthCare.gov.
It increased in 2021, and 2022, however, with 374,776 people enrolling during the open enrollment period for 2022 coverage. This was the highest Pennsylvania’s enrollment had been since 2018. The enrollment growth in 202 was driven in large part by the subsidy enhancements created by the American Rescue Plan (these have been extended through 2025 by the Inflation Reduction Act).
In 2013, before the bulk of the ACA’s regulations were implemented, the uninsured rate in Pennsylvania was 9.6% — well below the 14.5% national average uninsured rate at that point.
Initially, the state did not expand Medicaid, which resulted in a small decline in its uninsured rate during 2014, the year the ACA took effect. About 360,000 people obtained coverage, including Medicaid/CHIP and private plans, through the Pennsylvania exchange during the first open enrollment.
Pennsylvania expanded Medicaid in 2015 (initially with a waiver, but then as straight expansion once Gov Wolf took office), and saw even more residents gain coverage. By 2017, Pennsylvania’s uninsured rate dropped to 5.5%. It remained at that level in 2018, but grew to 5.8% in 2019. Nationwide, 9.2% of the population was uninsured as of 2019.
During the open enrollment period for 2022 coverage, nearly 375,000 enrolled in health plans through the Pennsylvania exchange. All of them had coverage for the ACA’s essential health benefits, and nearly 90% of them were receiving premium subsidies that make their monthly premium costs much more affordable than they would otherwise be.
There are no longer small business health plans available through the exchange in Pennsylvania, but all new small group health plans (up to 50 employees) are fully compliant with the ACA, which means that small businesses that have purchased health coverage since 2014 have coverage for the essential health benefits as well, without any lifetime or annual limits on the benefits.
In 2010, both of Pennsylvania’s U.S. Senators, Democrats Robert Casey and Arlen Specter, voted in favor of the ACA. In the U.S. House, eleven Democrat representatives voted yes, while seven Republicans voted no.
Specter has since been replaced in the Senate by Republican Pat Toomey, and the U.S. House delegation from Pennsylvania is evenly split, with nine Democrats and nine Republicans.
At the state level, the overall population in Pennsylvania has a Democratic majority, but the Republicans hold a majority in the state’s House and Senate. Former Gov. Tom Corbett was also a Republican and not an ACA supporter. As such, the state defaulted to a federally-facilitated health insurance exchange, although it’s transitioning to a state-run exchange under the Wolf administration.
But unlike many Republican governors, Corbett pursued the possibility of Medicaid expansion under the ACA. Corbett submitted his proposal for a modified version of Medicaid expansion – dubbed Healthy Pennsylvania – to HHS in February 2014. It took half a year of negotiations, but on August 28, 2014, Corbett and HHS reached an agreement, and Pennsylvania became the 28th state, including DC, to accept federal funding to expand Medicaid and thereby cover residents with incomes up to 138 percent of poverty.
Corbett lost the 2014 gubernatorial election to Tom Wolf, a Democrat. Gov. Wolf was sworn into office on January 20, 2015. Shortly after he assumed office, Wolf began to do away with Healthy PA in favor of traditional Medicaid expansion, which had been a campaign promise. Pennsylvania has had Medicaid expansion as called for in the ACA ever since, as opposed to the modified version of expansion that Corbett had overseen.
And under Wolf’s administration, the state transitioned to a fully state-run exchange and implemented a reinsurance program. These changes are working in tandem to reduce individual market health insurance premiums in the state.
Although Pennsylvania was a year behind many other states, the state accepted ACA’s Medicaid expansion and it took effect on January 1, 2015. As of mid-2021, enrollment under Pennsylvania’s Medicaid expansion stood at more than a million people.
This was a dramatic increase from early 2020, due in large part to the widespread job and income losses caused by the coronavirus pandemic, and the Families First Coronavirus Response Act that prevents states from disenrolling people from Medicaid until the end of the COVID public health emergency.
Read more about Medicaid expansion in Pennsylvania.
Pennsylvania does not have state regulations pertaining to the duration of short-term health insurance plans, so the state defaults to the federal regulations.
That means insurers in Pennsylvania short-term health insurance plans can have initial terms up to 364 days and the option to renew for a total duration of up to 36 months.
Read more about short-term health insurance in Pennsylvania.
As of mid-2022, there were more than 2.8 million Pennsylvania residents enrolled in Medicare. Most are eligible due to their age, but nearly 13% of the people covered by Medicare in Pennsylvania are under the age of 65 and eligible for Medicare due to a disability.
You can read more about Medicare in Pennsylvania, including residents’ choice of Original Medicare or Medicare Advantage, as well as the state’s requirements for Medigap plans.
- Pennie — The marketplace in Pennsylvania (residents now use Pennie instead of HealthCare.gov to enroll in individual market coverage). Offers private plans and Medicaid enrollment for individuals and families in Pennsylvania.
- Pennsylvania Insurance Department — Oversees, licenses, and regulates the health insurance companies that offer plans in the state, and the brokers and agents that sell the plans.
- Pennsylvania Department of Aging — Can provide a variety of helpful assistance for people with Medicare and their caregivers.
- Medicare Rights Center — A nationwide service (a website and call center) that can provide Medicare-related assistance and information.