Jeffrey Wade
Pennsylvania offers several options for health insurance coverage for its residents. The state has a fully state-run health insurance marketplace called Pennie, which provides individuals and families with the ability to shop for health plans and apply for financial assistance. The state also has an easy enrollment program that allows uninsured residents to access health insurance via their state tax returns. Additionally, Pennsylvania mandates certain benefits that exceed ACA requirements, such as durable medical equipment, diabetes care management, reconstructive surgery following mastectomy, and infusion therapy for chemotherapy.
| Characteristics | Values |
|---|---|
| Health Insurance Options | Private insurance companies, HealthCare.gov, Pennie (Pennsylvania's insurance marketplace), SHOP (Small Business Health Option Program) |
| Who Can Apply | Pennsylvania residents who are citizens, U.S. nationals, or have a qualified immigration status |
| Enrollment Period | Open enrollment: November 1 through January 15; Special Enrollment Periods after certain life changes (e.g., losing employer health insurance, change in marital status, birth of a baby, or moving) |
| Financial Assistance | Available through Pennie; tax credits for small businesses using SHOP |
| Additional Benefits | Durable Medical Equipment, Diabetes Care Management, Reconstructive Surgery following mastectomy, Infusion Therapy for chemotherapy |
| Essential Benefits | Preventive and wellness, chronic disease management, pediatric services |
| State and Federal Programs | Medicaid, COBRA, Medicare |
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What You'll Learn
Health insurance for small businesses
As a small business owner in Pennsylvania, you have several options for providing health insurance to your employees. Here is some information on health insurance for small businesses in Pennsylvania:
Pennsylvania's Health Insurance Requirements
Pennsylvania mandates certain benefits that exceed the requirements of the Affordable Care Act (ACA). These benefits, which must be provided or offered by private providers authorized to sell health insurance in the state, include:
- Durable Medical Equipment, such as scalp prosthesis.
- Diabetes Care Management, including supplies and education.
- Reconstructive Surgery following a mastectomy.
- Infusion Therapy, such as chemotherapy (excluding HMOs).
Options for Small Businesses:
If you own a small business in Pennsylvania with 50 or fewer full-time-equivalent employees (FTEs), you have a few options for purchasing health insurance for your employees:
- Small Business Health Option Program (SHOP) Marketplace: You can purchase qualifying coverage through SHOP or through a private broker or insurance agent. Using SHOP may qualify you for tax credits worth up to 50% of your premium costs. Beginning in 2016, SHOP will be available to employers with up to 100 FTEs.
- Private Insurance Companies: You can choose from various health insurance plans offered by private insurance companies, such as Independence Blue Cross (IBX) and Geisinger Health Plan. These companies offer ACA-compliant plans with benefits like prescription drugs, pediatric dental and vision care, and enhanced behavioral health services.
- Pennie: Pennie is Pennsylvania's official health insurance marketplace, where individuals and small businesses can shop for health plans and apply for financial assistance. It offers low-cost or no-cost quality health plan options and financial savings to help lower the cost of coverage and care.
Self-Funded Plans:
You may also consider self-funded health plans, where your organization takes on the responsibility and financial risk of providing health insurance benefits to your employees. Geisinger's Self-Funded Administrative Services Only (ASO) plans, for example, offer cost-effective and flexible solutions, including essential core services such as enrollment, claims processing, and customer service.
Compliance:
It is important to note that under the Employer Shared Responsibility provision of the ACA, employers with 50 or more FTEs must offer at least one ACA-compliant plan to their employees or face fines. All qualifying plans must offer 10 standardized essential benefits, including preventive care, chronic disease management, and pediatric services.
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Additional benefits
Pennsylvania offers its residents several options to get themselves and their families covered with health insurance. Pennie, Pennsylvania's insurance marketplace, provides individuals and families with the ability to shop for high-quality health plans and easily apply for financial assistance. Pennie offers low-cost or no-cost health plans and nine out of ten Pennie customers qualify for financial savings.
Pennsylvania mandates that the following benefits, which exceed ACA requirements, must be provided or offered by private providers authorized to sell health insurance within the state:
- Durable Medical Equipment – scalp prosthesis – for individual, small and large group plans
- Diabetes Care Management – supplies and education – for individual, small and large group plans
- Reconstructive Surgery – following mastectomy – for individual, small and large group plans
- Infusion Therapy – chemotherapy – for individual, small and large group plans (excluding HMOs)
Additionally, if you are self-employed with no employees, you can use the federal exchange to purchase coverage. You may also be entitled to certain state and federal programs such as Medicaid and COBRA. If you own a small business in Pennsylvania (50 or fewer full-time-equivalent employees), you can purchase qualifying coverage for your employees through SHOP, the Small Business Health Option Program, or through a private broker or insurance agent.
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Essential health benefits
Pennsylvania offers several options for health insurance coverage for its residents. The state's official health insurance marketplace is called Pennie, which provides individuals and families with the ability to shop for health plans and apply for financial assistance. All Pennsylvania residents who are citizens, U.S. nationals, or have a qualified immigration status can apply and enroll in health coverage through Pennie during an eligible enrollment period.
Pennie offers quality health plan options at low or no cost. It is the only place to get financial savings to help lower the cost of coverage and care. Open enrollment for individual health coverage typically runs from November 1 through January 15. However, if you experience certain life changes, such as losing your employer health insurance, a change in marital status, the birth of a baby, or a move to a different area, you can sign up for health coverage during a Special Enrollment Period.
Pennsylvania also offers Medicaid and Medicare coverage for its residents. PA Health and Wellness is a local health insurance provider that offers Medicaid and health insurance plans in the state. They are committed to improving the health of Pennsylvania residents by providing access to quality healthcare coverage through local, regional, and community-based resources.
In addition to the options available through Pennie and PA Health and Wellness, Pennsylvania residents can choose from various health insurance plans offered by private insurance companies. These companies may offer additional benefits beyond the state's requirements. For small business owners in Pennsylvania, the Small Business Health Option Program (SHOP) allows employers with 50 or fewer full-time-equivalent employees (FTEs) to purchase qualifying coverage for their staff. Beginning in 2016, SHOP will be expanded to include employers with up to 100 FTEs.
Regardless of the source of health insurance coverage, all plans in Pennsylvania must include certain essential health benefits. These benefits are standardized and mandated by the state, exceeding the requirements set by the Affordable Care Act (ACA). The essential health benefits include:
- Preventive and wellness services for adults and children, including chronic disease management.
- Pediatric services, including oral care.
- Emergency services.
- Outpatient or ambulatory services.
- Maternity and newborn care.
- Mental health and substance abuse services.
- Laboratory services.
- Prescription drugs.
- Therapy services, such as physical therapy, and devices.
- Hospitalization.
- Durable medical equipment, such as a scalp prosthesis.
- Diabetes care management, including supplies and education.
- Reconstructive surgery following mastectomy.
- Infusion therapy, including chemotherapy (excluding HMOs).
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Short-term health insurance
As of September 1, 2024, short-term health plans in Pennsylvania are limited to a total duration of no more than four months, including renewals. This change was implemented by the Biden administration, reducing the previous limit of 364 days with the option to renew for up to 36 months. To be eligible for short-term health insurance in Pennsylvania, applicants generally need to be under 65 and not have any pre-existing medical conditions that would cause their application to be declined.
It is important for consumers to carefully review the terms and conditions of short-term health insurance plans before purchasing. These plans may not cover all essential health benefits, and termination of a short-term plan does not grant a special enrollment period for ACA-compliant coverage. Pennsylvania residents have several options for obtaining health insurance, including purchasing plans from private insurance companies, enrolling through Pennie (Pennsylvania's official health insurance marketplace), or exploring state and federal programs such as Medicaid and COBRA.
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Financial assistance
Pennsylvania offers its residents several options to get covered for health insurance. Pennie, Pennsylvania's official health insurance marketplace, is the only place to get financial savings to help lower the cost of coverage and care. Pennie offers quality health plan options for low or no cost. Nine out of ten Pennie customers qualify for financial savings, which can help lower monthly premiums and/or out-of-pocket costs.
If you are low-income, you may be eligible for a $0 premium plan through Pennie. You can apply at any time if you are applying for free health coverage benefits through Medical Assistance. You can also enrol in health coverage when it is not Open Enrollment if you are low-income or have had a "qualifying life event" in the last 60 days. This is called a "Special Enrollment Period." Losing existing health coverage of any kind, including Medicaid or CHIP, is considered a qualifying life event.
If you are self-employed with no employees, you can purchase coverage through the federal exchange. You may also be entitled to certain state and federal programs such as Medicaid and COBRA. If you own a small business in Pennsylvania (50 or fewer full-time-equivalent employees), you can purchase qualifying coverage for your employees through SHOP, the Small Business Health Option Program. Beginning in 2016, SHOP will be open to employers with up to 100 full-time-equivalent employees. Under the Employer Shared Responsibility provision of the ACA, employers with 50 or more full-time-equivalent employees must offer at least one ACA-compliant plan or face fines of $2,000 per employee.
If you have low income and limited resources, you may be able to receive cash assistance through Temporary Assistance for Needy Families (TANF) or General Assistance. Many immigrants may also qualify for coverage and financial assistance. Persons who have had permanent residence for at least five years, asylum, refugees, and children with documented statuses may qualify for Medicaid coverage. Persons with other immigration statuses, such as permanent residents for less than five years, persons with work visas, student visas, and others may qualify for coverage through Pennie with financial aid.
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Frequently asked questions
Yes, Pennsylvania requires its citizens to have medical benefits insurance.
Pennie is Pennsylvania's insurance marketplace. It provides individuals and families with the ability to shop for health plans and apply for financial assistance.
Pennie is the only place to get financial savings to help lower the cost of coverage and care. It also has an "easy enrollment" program that allows uninsured residents to access health insurance via their state tax returns.
If you own a small business in Pennsylvania with 50 or fewer full-time employees, you can purchase qualifying coverage for your employees through the Small Business Health Option Program (SHOP) or through a private broker or insurance agent.
You may qualify for tax credits worth up to 50% of your premium costs if you use SHOP.
