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Pennsylvania Health Insurance

While Pennsylvania is not a guarantee issue state, Blue Cross and Blue Shield is required to offer plans all individuals, regardless of medical history. Other insurance providers employ medical underwriting, but cannot deny a renewal to currently insured persons, wrongly cancel existing coverage, or base premiums on health. Individuals without previous coverage are subject to a maximum 3 year exclusion period for conditions diagnosed in the last 5 years. Elimination riders that permanently refuse coverage for certain conditions are also permitted.

Small group employers are sold insurance on a guarantee issue basis, as long as they provide the appropriate census and tax information for the employees. Employees without previous continuous coverage must satisfy the 12 month exclusion period for medical conditions diagnosed in the last 6 months. Premiums are influenced by medical underwriting and can vary up to 300% from the standard rate.

Understanding Health Insurance Options in Your State

The mounting cost of medical care has forced many individuals and families to struggle without necessary coverage in times of poor health. Whether you’re looking for insurance independently or enrolling as a member of a group, the list of affordable options is steadily decreasing as premiums soar to unfathomable heights and benefits packages dwindle to nothing.

Finding affordable health insurance plans may seem impossible, but the key to obtaining great coverage lies in your knowledge of the laws and regulations that affect the services you receive. Health insurance is regulated to varying degrees on both federal and state levels, and the state you reside in determines the number of choices and protections afforded to consumers. Instead of braving another year uninsured, choose to invest in your health and learn about low cost health insurance options in your state.

Private Insurance Providers

Private health insurance is available in the form of an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization). With a prepaid HMO plan, patients have access to a contracted network of medical professionals and are generally charged a small co-pay for visits and prescriptions. HMOs focus on providing benefits for preventative care, such as immunizations and mammograms, in order to limit the development of serious medical conditions.

Similar to an HMO, a PPO program works with a network of doctors and specialists, but patients are allowed to visit doctors outside of the network at an increased cost. In a PPO, a fee is issued for each service, and a claim for reimbursement is presented to the insurance agents. Most PPOs also cover preventative care, but will likely charge a higher out-of-pocket fee.

HMOs are intended to be more cost-effective for the consumer and are more closely regulated in many states. Some insurance companies are required to offer HMO options to encourage an equal market for buyers to compare health insurance. For a list of local and nationwide licensed providers, such as Aetna and Humana, visit the Pennsylvania Department of Insurance.

The Availability of Insurance

Choosing the best major medical insurance is essential, as it can affect your entire family and the long-term maintenance of your health. While the purpose of health care insurance is to provide patients with quality medical treatment, insurance coverage is a business and it is in the interests of the insurance company to make, rather than lose, money. Insurance agents are not interested in insuring individuals who will require a lot of costly treatment over time, or paying for medical conditions that are guaranteed to be recurrent. If you fail to understand the conditions upon which coverage is offered, you may buy health insurance that doesn’t supply adequate coverage.

All private health insurance is not offered equally to all individuals. In most cases, insurance carriers are permitted to review your medical history to determine whether or not you are eligible for one of their health plans. If you are considered high-risk, you can be denied insurance or charged much higher monthly premiums. The insurance company may also opt to include contract clauses that force you to pay out-of-pocket for certain medical conditions that were diagnosed before your enrollment. Oftentimes, women are charged higher rates for insurance, without receiving benefits for major female-related conditions, such as pregnancy, that require significant medical attention.

There are various laws that regulate the freedom of Pennsylvania health insurance providers to place restrictions on insurance programs. The type of plan you choose (HMO or PPO), your health status, gender, age, and income bracket are all factors that influence how much protection you receive under these laws. Under the Federal Health Insurance Portability and Accountability Act (HIPAA), some buyers can avoid certain insurance restrictions and gain equal access. For individuals who have difficulty attaining private coverage through traditional routes, there are opportunities to receive public state-sponsored insurance.

Group and Individual Insurance

Group Insurance

Standard private insurance is sold in two forms, group or individual coverage. Basic group coverage is sponsored by an employer and is usually more affordable than buying directly on your own. It is easier to purchase personal and family medical insurance this way because all applicants under a group plan must be accepted as long as they meet any attached criteria, including weekly hour totals and duration of employment. The employer may institute a waiting period before an employee is eligible to join the group plan.

Insurance obtained through a group can usually be extended to cover dependents, full-time, students, and spouses. Group plans are also helpful in getting discount health insurance, as a portion of the premium is paid by the employer and the state of Pennsylvania may have specific regulations concerning the maximum amount you can be charged.

Individual Insurance

If you are self-employed or retired without public aid, individual health insurance might be your only option. Unlike group coverage, individual insurance policies don’t have to be granted to all applicants. If your health is poor, your chances of being rejected are extremely high. The insurance provider may also have more flexibility to determine benefits package and set rates. Since you are responsible for paying all of the premium, the cost can be significantly greater than group insurance.

Fortunately, many state insurance departments seek to remedy the practice of medical underwriting by mandating open enrollment periods, during which time a specified insurance carrier is required to offer insurance coverage to anyone who applies, regardless of their medical condition. Most commonly Anthem or Carefirst Blue Cross and Blue Shield are designated to host the enrollment period, depending on their availability in the area.

Self-Employed

A single person running a private business can often qualify for cheap medical insurance by applying as a group. If group health insurance for self employed individuals is not permitted in Pennsylvania, you can buy coverage individually or research unions and professional associations in your area that offer sponsorship. Most self employed people are eligible to claim insurance costs on their taxes, so it is possible to recoup some of your expenses later on.

Types of Alternative Insurance

Temporary Insurance

Temporary insurance is used to bridge short gaps between coverage, usually following discontinuation employment, divorce, the death of a spouse/parent, and any other event that causes you cancel enrollment in a group plan. Temporary insurance is very expensive, as all costs are covered by the individual, but it can help you to maintain your coverage during difficult times.

The most commonly used temporary insurance is state or federally regulated COBRA coverage, which allows a former employee to continuing receiving employer-sponsored coverage for a period ranging between 3 and 36 months, depending on state of residence. Other types of temporary insurance include conversion policies, which required that the individual’s current insurance provider offer different choices of plans with different costs.

Public Insurance

Government-sponsored insurance is intended to provide coverage to groups of people who don’t meet standard health criteria, are temporarily ineligible for insurance, or fall into low income brackets, such as the elderly and unemployed. Medicare and Medicaid are public insurance plans for the elderly and handicapped, respectively.

The state of Pennsylvania also offers public health insurance options for uninsured children whose parents are out of work or awaiting an opportunity to join a group plan. Many of these specialized programs offer cheap health insurance options, while making sure to include all basic benefits to keep children healthy and protected.

Pennsylvania may define a high-risk pool of individuals whose medical history bars them from buying private insurance. Under state laws, they are given annual opportunities to buy insurance with the guarantee of being accepted.

Catastrophic Insurance

Rather than abandoning health insurance altogether, individuals who rarely require medical attention may find it more beneficial to opt for catastrophic health insurance. With this plan, the consumer pays out of pocket until the monthly limited is reached, and the remaining expenses come from the deductible. By attaching a health savings accounts, you can save funds to pay health costs and eventually put the funds towards other expenses if the money is never needed for medical costs.

Supplemental Insurance

Supplemental health insurance helps to cover the costs that are not reimbursed by your primary insurance provider. The patient receives or can withdraw funds from the deductible to be applied as needed towards medical expenses.

Choosing Insurance

For every type of insurance, there are countless factors that must be considered before you make a purchase. Focus on getting affordable insurance, but don’t settle for a plan that will leave you paying your own expenses at every doctor’s visit. If you ask the right questions as you search for insurance, you will have a better chance of making a smart decision.

• Use online resources, including the Pennsylvania Insurance Department, to make comparisons between providers, plans, and rates.
• Pay attention to benefits packages to be sure that you are getting standard coverage.
• Try to find plans that can’t be altered after enrollment without your permission.
• Be sure that your policy is renewable, without regard to your health.
• Check to see how easily your policy can be adjusted to include dependents if necessary.
• Review the state regulations on exclusion periods, ratings caps, and premium increases.

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