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Pennsylvania Health Insurance

Pennsylvania Medical Insurance Overview

Many of Pennsylvania’s residents have a variety of health insurance options to choose from to ensure that they are able to stay healthy.  Residents can obtain plans through either private insurance providers, group insurance providers, or through one of the many public programs that are available.
Every plan is different and can be made to fit the needs and preferences of the individual applying for coverage.  Over the next few years, many rules and regulations regarding health insurance coverage will change, meaning that providers will have to adapt to the new healthcare legislation that was recently passed.

Health Care Issues
While Pennsylvania has a rather active population, it’s not a state that ranks high on the list of states that are very healthy.  Currently, the state ranks in 29th place in terms of overall health, dropping three points since 2011.  Additionally, thanks to the rising costs of health care, public funding costs throughout the state decreased, dropping from $73 per person in 2007 to $52 in 2012.

  • Here are some of the strengths that Pennsylvania currently offers:
  • Low infectious disease incidence
  • High adolescent immunization coverage
  • High child immunization coverage

Of course, there are also a few challenges as well, which include the following:

  • High air pollution levels
  • Low per capita public health funding
  • High percentage of drug related deaths

Understanding the State’s Uninsured Population
In 2014, eight percent of Pennsylvania’s population was reported to be without any kind of health insurance.  This is a slight drop from the 10.9% that was initially reported in 2012.  Thanks to the Affordable Care Act, this number is expected to continue to drop all the way until the year 2020.

Group Health Plans
Pennsylvania’s Department of Insurance regulates both private insurance providers and HMOs. Group health plans are essentially plans that can be purchased from a provider at a discounted rate by members of a particular group.  This discount can be offered because the provider is essentially spreading their risk over a pool of those who are insured.  These types of plans are also probably the most important benefits that employers can offer to their employees; however, there are some businesses that still struggle with this because of the high costs that are typically involved.
Employees are typically required to contribute a portion of their paychecks to pay for premiums; however, this share of their insurance cost is never taxed.  On the other hand, this insurance premium is still often too high in cost and most people sometimes cannot afford it.  Despite this, approximately 53% of Pennsylvania’s population still enjoys coverage through some form of group insurance plan that is sponsored by a business.

Signing Up
There are many businesses that have some sort of an open enrollment program once or twice per year, which is when employees can register for a group insurance plan. Typically, more than one plan is offered with many different benefits, costs, and co-pay amounts.
Before making any kind of a final decision on what kind of plan of which to register, there are a few factors that you should take into consideration, which include the following:

  • Available plans: How many are offered under the group plan?  Think about your future medical needs so that they can be met with a policy that is comprehensive enough.
  • Premium costs: Group insurance can be expensive and the premiums are taken from your paycheck automatically.  Can you afford to pay the premiums?
  • Dependents: Should you cover your dependents and/or spouse under your group health plan?
  • Health conditions: Are you suffering from a pre-existing medical condition?  If so, will any of the plan’s options afford you the ability to have your medical needs handled?

Pre-Existing Condition Exclusion Periods
In the state of Pennsylvania, pre-existing conditions are defined as physical diseases or conditions that you’ve received treatment or advice for within 90 days before being covered under any kind of group health insurance plan.  Exclusion periods will apply if you suffer from a pre-existing condition.  This means that you will have to wait a specific amount of time, usually up to one year, before your insurance benefits will go into effect.  On the other hand, you will be able to receive benefits that are not related to your pre-existing condition during this period. Premium costs for this period currently have no discounts.

There are also factors that need to be taken into consideration involving this as well, which include the following:

  • Dependents under age 19 who have any kind of a pre-existing condition are not subject to this waiting period
  • Health insurance providers can look back through your medical record by six months to determine whether or not you actually have a pre-existing condition
  • Predispositions to developing genetic conditions are not considered to be pre-existing conditions without any kind of an actual diagnosis

Waiting/Affiliation Periods
If you have an HMO as your group health plan provider, you will likely have to wait approximately two or three months before your benefits take effect.  During this period, you will not have to pay any kind of a premium; however, you will also receive no benefits.

Continuation Coverage
If, for any reason, you find yourself lacking sufficient health coverage for a number of different reasons, you may likely be able to take advantage of coverage through COBRA, or the Consolidated Omnibus Budget Reconciliation Act.  This enables you to receive additional coverage for up to 18 months, with eligibility determined by the overall size of the company that you previously worked for.  The only downside is that you must pay for the portion that your employer had previously paid on your behalf on top of what you had to pay as an employee.

Individual Health Plans
Currently, 6% of Pennsylvania’s population is covered under some form of individual health insurance plan.  These are best for those who do not qualify for some kind of group plan or government-run health program.  These plans are considered to be more complex in nature, as most of them require you to go through a physical exam and even one or more questionnaires.

There are a few different factors to keep in mind when considering one of these plans, including the following:

  • Identify services you may need in the near future
  • Don’t pay for coverage that you won’t end up using
  • Make sure your doctors are in your particular network
  • Know what your share of your costs associated with coverage are
  • Make sure your prescriptions are completely covered
  • Think about annual limits for both coverage and medical services
  • Consider several plan options and their associated costs

Pennsylvania Health Benefits Exchange
Although Pennsylvania was one of 25 states that challenged the legality of the Affordable Care Act, the state has since agreed that they will comply with the law.  The former governor also stated that while a state-run health exchange would be preferable, a federal exchange would be better to help manage things.  Two federal grants were provided in return to assist with this, but the state has defaulted to an exchange that is still managed by the federal government.  In order to research options, compare plans, buy coverage and apply for state-funded insurance programs, residents in Pennsylvania must use

State Insurance Programs
There are many different state insurance programs in Pennsylvania that are designed to help residents obtain the health coverage that they need in order to remain as healthy as possible.
These programs include the following:

PA Fair Care
This program is open to all United States citizens.  Those who wish to apply must have been uninsured for six months and must also have difficulty obtaining insurance due to a pre-existing condition.  This program covers the following:

  • Primary care
  • Specialty care
  • Prescription drugs
  • Hospital care

Costs can average approximately $283 per month, in addition to other copays and co-insurance.

Medical Assistance (Medicaid)
This is Pennsylvania’s version of Medicaid that offers assistance to lower-income individuals and families.  Many different types of services are covered, and eligibility for this plan is mostly determined by overall income level, with monthly premiums ranging from no cost to a very small fee.

Children’s Health Insurance Plan (CHIP)
This comprehensive program covers both children and teenagers throughout Pennsylvania up to age 19 who are ineligible for and not enrolled in Medicaid.  Coverage is provided for the following services:

  • Routine doctor visits
  • Dental
  • Eye care
  • Prescriptions

For many families, no cost is associated with this program; however, those families who have incomes above the posted guidelines to receive free care must pay a low monthly premium and co-pays.

Healthy Baby Helpline PA – Love ’em with a Check-up
This is an outreach program that benefits both pregnant and potentially pregnant women throughout the entire state by encouraging them to obtain the right medical care to ensure that their babies are born as healthy as possible.  This special helpline will provide referrals and other types of important information.

Healthy Woman Program
This is a program designed to assist women over 30 years of age, provided they are uninsured and meet specific income standards.  Cervical and breast cancer screenings are covered through this program.

Medicare, Medicare Prescription Drug Program, and APPRISE
Medicare is a program that provides coverage to both seniors and individuals who suffer from disabilities.  Eligibility is determined by the following:
You or your spouse must have worked in a job covered by Medicare for at least 10 years
Suffer from end-stage renal disease or other disability
In terms of APPRISE, this is a special Medicare counseling service.

Women, Infants, and Children (WIC)
Pennsylvania’s WIC program provides both new mothers and children under five years old with nutritional supplies and advice and also covers various types of health care services.  Factors such as income level determine eligibility.

Health Coverage Tax Credit
Those who receive TAA, or Trade Adjustment Assistance can obtain coverage through this particular credit. Services covered by this program include the following:

  • Inpatient/outpatient care
  • Doctor visits
  • Preventative care
  • Prescription drugs
  • Mental health care

VA Medical Benefits Package
Veterans of the United States armed forces must have served at least 24 consecutive months or completed their entire tour of service in order to qualify for this benefits package.  Additionally, no veteran must have been dishonorably discharged from service.  Standard benefits include the following:

  • Physical exams
  • Immunizations
  • Ambulatory services
  • Hospital services
  • Prescription drugs

The Health Insurance Portability and Accountability Act (HIPAA)
Initially passed in 1996, HIPAA allows workers to transfer and continue health insurance coverage whenever they change or lose their jobs.  Additionally, health care fraud and abuse is greatly reduced, and all private health information must be confidentially handled.  Another provision states that group health insurance providers are now expressly prohibited from denying coverage to a new enrollee just because they suffer from a pre-existing condition.