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 will be 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, described here by Jessica Altman, Pennsylvania’s Insurance Commissioner and the chairwoman of Pennie’s board of directors. 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.
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 make 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 will cover the majority of the cost of the reinsurance program (because reinsurance will result in lower premiums, premium subsidies will also decline, 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).
Open enrollment for 2021 health plans was extended in Pennsylvania through January 15, 2021, but Pennsylvania’s exchange is offering a COVID-related special enrollment period, which continues through August 15, 2021.
The annual open enrollment period is an opportunity for people to newly enroll in individual market coverage, and for current enrollees to renew or change their coverage for the coming year. It’s also an opportunity to update the income and household information that’s on file with the exchange, to ensure that premium subsidies for the coming year are accurate.
Outside of the open enrollment period, a qualifying event is normally necessary in order to enroll in a health plan or make a change to current coverage. This is true both in the exchange and outside the exchange (directly through a health insurer; the insurer will require proof of the qualifying event if the application is submitted outside of the open enrollment period).
Eleven insurers are offering 2021 individual market plans through Pennsylvania’s health insurance exchange (Pennie):
- 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 Options (PPO and EPO).
- PA Health and Wellness
- Oscar Health
Most of the insurers offering 2021 individual market plans through Pennsylvania’s health insurance exchange proposed average rate decreases for 2021, although a few proposed modest rate increases. And regulators approved overall average rates that were a little lower than insurers had proposed, thanks to adjustments to two insurers’ proposed rates.
Pennsylvania’s new reinsurance program is playing a role in keeping premiums down for 2021; the expectation is that insurers would have proposed a small overall average rate increase if the reinsurance program had not been created.
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, however, with 337,722 people signing up for coverage during the open enrollment period (up from 331,825 people the year before). There was a general uptick in enrollment numbers nationwide, but Pennsylvania also transitioned to a fully state-run exchange prior to the start of the open enrollment period for 2021, and extended the enrollment window an extra month, both of which likely helped to boost enrollment.
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.
As of early 2021, nearly 338,000 people had enrolled in health plans through the Pennsylvania exchange. All of them had coverage for the ACA’s essential health benefits, and 85% 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 January 2021, enrollment under Pennsylvania’s Medicaid expansion stood at 907,796 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.
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 February 2021, there were nearly 2.8 million Pennsylvania residents enrolled in Medicare. Most are eligible due to their age, but 15% 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.