The Keystone State is home to a cross-section of culture and activity, from large cities like Philadelphia and Pittsburgh, to a more quaint population in Amish country and the Poconos. Many industries thrive in Pennsylvania, and its inhabitants are as diverse as the varying terrain. Health insurance companies in Pennsylvania include Aetna, HealthAmerica (a subsidiary of Coventry), and UnitedHealth. For an accurate list of availability and pricing in your area, enter your zip code in the quote engine below.
Pennsylvania residents have a fairly average ranking when it comes to health status, coming in at #29 on UnitedHealth Foundation’s list in 2011. Some of the positives are a high number of insured individuals, availability of primary care physicians, and a significant decrease in the smoking population over the past decade. Unfortunately, there are some other areas where Pennsylvanians can improve in health, including the increasing number of obese and overweight adults, as well as adults with diabetes. The state also has high levels of air pollution, which is an obvious detriment to health.
Only 35.5% of the adult population consumes fruit two or more times per day, and 25.1% consumes vegetables three or more times per day. Though 50.4% of the population of Pennsylvanians participates in moderate to vigorous physical activity, the level of health needs an increase, and this still leaves another 50% of all adults. By utilizing the health care system and the wellness programs provided by health insurance companies and the state, more Pennsylvanians could be in good health in the future. Luckily, the overall health of the state seems to be on an incline.
Health Insurance Plans
- Preventive and Hospital Care plans are HSA compatible high deductible plans, with the option of seeking in or out-of-network care. Preventive care is covered immediately from the day your plans begins, and after your deductible has been met, you can receive benefits on select forms of medical care, such as inpatient hospitalization, outpatient services, and emergency room services. Funds from your health savings account can be used to meet your deductible or pay for other qualified medical expenses. These are basic plans for people who want a safety net, yet do not expect to need an extensive amount of care.
- PPO plans from Aetna in Pennsylvania are available in several types: Value, Unlimited Primary Care Visits, Individual PPO, and High Deductible. Each of these plans gives members access to a preferred network of providers for a discounted rate of service, as well as 100% coverage on preventive care. High deductible plans have a more comprehensive level of benefits, and can be used with a health savings account. Value plans are more simplified and affordable, with a good amount of coverage. Some of these plans have dental and/or prescription drug coverage.
- HMO plans are much like an employer-sponsored health plan, and are easy and convenient to use. There is a predictable copay for many services, such as doctor’s office visits, prescription drugs, outpatient surgery, maternity care, and more. These plans give you access to Aetna’s HMO network of providers, and you will have a primary care doctor facilitating your overall care, referring you to specialists and other facilities. All services are available from the time your plan starts, including preventive care which is covered completely by the HMO.
- Rewards plans are PPOs with varying deductible and coinsurance options, as well as a rewards program (as the name suggests) for smokers who decide to quit, completing an online health risk assessment, and taking part in a fitness program. These plans provide preventive services in-network at no cost, and office visits for a copay after deductible. Other services, such as lab work, X-rays, allergy testing, and hospitalization are covered for a percentage of coinsurance after you meet your deductible. You can choose in-network providers for a lower rate, or still receive coverage on a lesser scale for out-of-network care.
- QHDHP plans are PPOs available with or without a health savings account (HSA). These plans have a variety of high deductibles and coinsurance options of either 90 or 100% coverage. Once your deductible has been met, you can receive medical care including outpatient surgery, home health care, X-rays, and inpatient hospital treatment for either no cost or 10% coinsurance, depending which plan you choose. Primary care doctor and specialist visits are available for a predictable copay after deductible, and preventive care is covered in full immediately.
- Copay plans are easy to use, with a flat rate assigned by your plan from day one. These plans offer a broad range of coverage with coinsurance choices of either 80, 90, or 100%. Immediately when your plan starts, you can pay for doctor’s office visits and prescription drugs with a set copay, and receive preventive care such as immunizations, child care, physicals, and GYN exams for no cost.
- Choice1 plans provide great discounts and 100% coverage after you meet your deductible when using in-network services. You also have the option of using out-of-network providers for a higher cost. These plans have maternity benefits available for a copay, in addition to doctor’s office visits. Hospital care including inpatient care, lab work, surgery, consultations, and therapy services are covered at 100% after meeting your annual deductible. These are available with either $2,000 or $4,000 in-network deductibles.
- Copay plans from UnitedHealthOne are PPOs, with either 70, 80, or 100% coverage after deductible, and a wide range of deductibles to choose from. All copay plans have prescription coverage, and convenient, predictable rates for regular services such as doctor’s office visits. Since these are PPO plans, you have the ability to use an out-of-network doctor or facility, though it will cost a bit more. The PPO network is very large and has many options if you are looking to save on health care. Preventive care is covered at 100% immediately when your plan starts, as long as you use an in-network provider.
- High Deductible plans have low monthly premiums, and give you access to the UnitedHealth PPO network. Preventive care services such as immunizations, child care, GYN and physical exams are covered at 100% from the day your plan starts. With a range of deductibles to choose from in each type you can find a high deductible plan to fit your budget. These plans come in three types: Plan 100, Plan 80, and Saver 80. Plan 100 provides you with 100% in-network coverage on most medical services including hospital care, surgeries, and emergency care after you meet your deductible. You will have to pay 20% coinsurance for major medical care with Plan 80 and Saver 80, but your monthly payments will be less.
- HSA plans have the ability to open a health savings account to use tax-advantaged money towards future medical expenses or meeting your deductible. These are high deductible plans that give you the choice of in-network or out-of-network care, though there are discounts when you use in-network providers. Preventive care is covered at 100% when your plan becomes effective, and after you meet your deductible you can either pay 30% coinsurance or have your expenses covered in full. There is also a vision care coverage option available with HSA plans.
Public Health Options
In the state of Pennsylvania, there are a variety of public health programs to accommodate people in need. The Medical Assistance program helps individuals, children, and families by providing them with health care through a network of providers funded by the state. Other programs are available for women, children, people with physical and intellectual disabilities, those with HIV/AIDS, homeless and more groups of people in need. These programs are available state-wide, as they are funded by the state government. For a detailed list of services, please refer to the Pennsylvania Department of Public Welfare site.
Medicaid: health care coverage for individuals, families, pregnant women and children with low-income, as well as persons who are disabled, blind or elderly
CHIP: the children’s health insurance program in Pennsylvania, providing medical assistance to any child under age 19, regardless of family income level
SelectPlan for Women: a state-run program for women’s health including free birth control, routine breast exams and pap smears, STD testing and more
Long Term Living in PA: provides long term care to individuals with medical needs, typically those who are elderly or cannot perform normal daily tasks
Health Insurance Laws
As with most other states, Pennsylvania health insurance companies are required to abide by the guaranteed renewability provision of HIPAA. This law ensures that once an individual has insurance, their insurer must offer to renew their same plan at the end of a term. It also secures an individual’s health insurance policy by preventing the insurer from terminating benefits on the grounds of becoming ill. As long as the policy-holder has paid all of their premiums in a timely manner and met their claims and other necessary payments, they are eligible for guaranteed renewal. HIPAA also provides protection in the process of transferring personal medical information between providers and insurers, requiring that the patient is informed and consents to giving their information.
Pre-existing conditions are defined in Pennsylvania as a medical condition or health issue for which an individual sought treatment or medical consultation, prior to applying for a health plan. This is called the objective standard, and is a more concrete way of describing and determining a pre-existing condition, as opposed to other states. If an insurer in Pennsylvania decides that an applicant has a pre-existing condition, they can reject them altogether for a plan. They may also accept the individual, but charge them a higher premium, and they can exempt themselves from covering costs related to treating the condition for up to 12 months. Insurance companies are currently also allowed to issue elimination riders, which permanently removes responsibility from the insurer for paying for the care of a specific condition.
Pennsylvania has a temporary solution to the pre-existing condition problem. Those who get turned down for a private health insurance plan have the option of a state-run, high-risk pool alternative called the Pre-Existing Condition Insurance Plan. PCIP offers health care coverage at an affordable rate to those who are unable to receive approval in the private market. If you are a Pennsylvania resident who has been rejected for a health insurance policy and want a basic health plan, compare rates in your area by getting a quote and selecting PCIP from the companies section.
As a result of the Affordable Care Act, all children with pre-existing conditions must be accepted for a health plan by private insurance companies. This has been in effect since 2010, and as of 2014, will be true for adults (if everything stays the same according to the Supreme Court). Insurance companies will not be able to deny nor issue elimination riders or exclusion periods to adults with pre-existing conditions. In the meantime, there is the PCIP option.