Obamacare in Pennsylvania

Health Insurance Marketplace in Pennsylvania

If you live in Pennsylvania, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Spanish language speakers can contact cuidadodesalud.gov.

Choosing the Right Health Insurance Plan

There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.

Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Expanded Medicaid

Pennsylvania has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under Pennsylvania’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Who you can contact for more help

Who can help you (the Navigators)

Get local help

Resources for Human Development, Inc.

Resources for Human Development, Inc. (RHD), a non-profit organization based in Philadelphia, Pennsylvania, will provide enrollment assistance in the ten counties in Pennsylvania with the highest rates of uninsured people. RHD will target specific groups and individuals who traditionally have poor access to healthcare insurance coverage.

Pennsylvania Association of Community Health Centers

Pennsylvania Association of Community Health Centers (PACHC) represents and supports the largest network of primary health care providers in the Pennsylvania. PACHC will coordinate enrollment assistance efforts in underserved areas throughout the Commonwealth using a connected and networked approach.

Pennsylvania Mental Health Consumers’ Association

Pennsylvania Mental Health Consumers Association (PMHCA) will work in a consortium with Mental Health Association in PA (MHAPA) and Mental Health America Westmoreland County (MHAWC) to provide enrollment assistance to people who use or need behavioral health services in their insurance plans, particularly those who experience serious mental illness or serious psychological distress.

Mental Health America

The Mental Health America Navigator Initiative will target underserved individuals with behavioral health disorders who are uninsured or underinsured. The National Office of Mental Health America (MHA) will serve as the lead agency in the Initiative. The Mental Health Association of Southeastern Pennsylvania (MHASP) will serve Bucks, Chester, Delaware, Montgomery, and Philadelphia counties in Pennsylvania.

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.

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Accountable Care Organizations in Pennsylvania

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

Rutgers, The State University Of New Jersey (The Center For State Health Policy) PA – Health Care Innovation Award
Joslin Diabetes Center, Inc. PA – Health Care Innovation Award
Finity Communications, Inc. PA – Health Care Innovation Award
The Trustees Of The University Of Pennsylvania PA- Health Care Innovation Award
George Washington University PA- Health Care Innovation Award
Innovative Oncology Business Solutions, Inc. PA – Health Care Innovation Award
The Trustees Of The University Of Pennsylvania PA – Health Care Innovation Award
Pittsburg Regional Health Initiative PA – Health Care Innovation Award
Institute For Clinical Systems Improvement PA – Health Care Innovation Award
University Of North Texas Health Science Center PA – Health Care Innovation Award
State of Pennsylvania PA – Multi-payer Advanced Primary Care Program
State of Pennsylvania PA – State Innovation Models Initiative: Model Design Awards

Health care facilities where Innovation Models are being tested

Einstein Medical Center Montgomery E Norriton, PA – BPCI Initiative: Model 2
Doylestown Hospital Doylestown, PA – BPCI Initiative: Model 2
Einstein Medical Center Montgomery E Norriton, PA – BPCI Initiative: Model 2
Lankenau Medical Center Wynnewood , PA – BPCI Initiative: Model 2
St. Luke’s Hospital-Anderson Campus Easton, PA – BPCI Initiative: Model 2
St. Luke’s Hospital Quakertown Hospital Quakertown, PA – BPCI Initiative: Model 2
Paoli Hospital Paoli, PA – BPCI Initiative: Model 2
St. Mary Medical Center Langhorne PA Langhorne , PA – BPCI Initiative: Model 2
Penn Presbyterian Medical Center Philadelphia, PA – BPCI Initiative: Model 2
Allegheny Valley Hospital Natrona Heights, PA – BPCI Initiative: Model 2
Pennsylvania Hospital Philadelphia, PA – BPCI Initiative: Model 2
Pocono Medical Center East Stroudsburg, PA – BPCI Initiative: Model 2
St. Luke’s Hospital Miners Memorial Hospital Coaldale, PA – BPCI Initiative: Model 2
Indiana Regional Medical Center Indiana, PA – BPCI Initiative: Model 2
Hospital of the University of Pennsylvania Philadelphia, P – BPCI Initiative: Model 2
Holy Redeemer Meadowbrook, PA – BPCI Initiative: Model 2
Riddle Media, PA – BPCI Initiative: Model 2
Thomas Jefferson Philadelphia, PA – BPCI Initiative: Model 2
Bryn Mawr Hospital Bryn Mawr, PA – BPCI Initiative: Model 2
The Western Pennsylvania Hospital Pittsburgh, PA – BPCI Initiative: Model 2
Canonsburg General Hospital Canonsburg, PA – BPCI Initiative: Model 2
The Reading Hospital and Medical Center West Reading, PA – BPCI Initiative: Model 2
Harrisburg Hospital Harrisburg, PA – BPCI Initiative: Model 2
Geisinger Wyoming Valley Wilkes-Barre, PA – BPCI Initiative: Model 2
Forbes Regional Hospital Monroeville, PA – BPCI Initiative: Model 2
St. Luke’s Hospital Bethlehem, PA- BPCI Initiative: Model 2
Einstein Medical Center Philadelphia and Einstein Medical Center Elkins Park Philadelphia, PA – BPCI Initiative: Model 2
Milton S. Hershey Medical Center Hershey, PA – BPCI Initiative: Model 2
Allegheny General Hospital Pittsburgh, PA – BPCI Initiative: Model 2
Golden LivingCenter West Shore Camp Hill, PA – BCPI Initiative: Model 3
Bayada Home Health Care, Inc. Newtown Square, PA – BCPI Initiative: Model 3
ManorCare Health Services-Huntingdon Valley Huntingdon Valley, PA
Bayada Home Health Care, Inc. Willow Grove, PA – BCPI Initiative: Model 3
Bayada Home Health Care, Inc. Hatboro, PA – BCPI Initiative: Model 3
Bayada Home Health Care, Inc. Philadelphia, PA – BCPI Initiative: Model 3
Bayada Home Health Care, Inc. Bethlehem, PA- BCPI Initiative: Model 3
Bayada Home Health Care, Inc. Wyomissing, PA- BCPI Initiative: Model 3
Bayada Home Health Care, Inc. East Stroudsburg, PA – BCPI Initiative: Model 3
Bayada Home Health Care, Inc. Harrisburg, PA – BCPI Initiative: Model 3
PennCare at Home Bala Cynwyd, PA – BCPI Initiative: Model 3
Bayada Home Health Care, Inc. Williamsport, PA – BCPI Initiative: Model 3
Bayada Home Health Care, Inc. Pittston, PA – BCPI Initiative: Model 3
Bayada Home Health Care, Inc. Lewisburg, PA – BCPI Initiative: Model 3
ManorCare Health Services-Pottstown Pottstown, PA – BCPI Initiative: Model 3
Wallingford Nursing & Rehabilitation Center Wallingford, PA – BCPI Initiative: Model 3
ManorCare Health Services-Yardley Yardley, PA – BCPI Initiative: Model 3
Tucker House Nursing and Rehabilitation Center of Pennsylvania Philadelphia, PA – BCPI Initiative: Model 3
Care Pavilion Nursing and Rehabilitation Center of Pennsylvania Philadelphia, PA – BCPI Initiative: Model 3
ManorCare Health Services-Yeadon Yeadon, PA – BCPI Initiative: Model 3
Maplewood Nursing and Rehabilitation Center of Pennsylvania Philadelphia, PA – BCPI Initiative: Model 3
Cheltenham Nursing and Rehabilitation Center of Pennsylvania Philadelphia, PA – BCPI Initiative: Model 3
Cliveden Nursing and Rehabilitation Center of Pennsylvania Philadelphia, PA – BCPI Initiative: Model 3
ManorCare Health Services-Lansdale Montgomeryville, PA – BCPI Initiative: Model 3
Good Shepherd Rehabilitation Hospital Allentown, PA – BCPI Initiative: Model 3
Golden LivingCenter Blue Ridge Mountain Harrisburg, PA – BCPI Initiative: Model 3
ManorCare Health Services-King of Prussia King of Prussia, PA – BCPI Initiative: Model 3
ManorCare Health Services at Mercy Fitzgerald Yeadon, PA – BCPI Initiative: Model 3
Delaware County Memorial Hospital Drexel Hill , PA – BPCI Initiative: Model 4
Lancaster General Hospital Lancaster, PA – BPCI Initiative: Model 4
Rothman Specialty Hospital Bensalem, PA – BPCI Initiative: Model 4
Crozer-Chester Medical Center Upland, PA – BPCI Initiative: Model 4
York County Area Agency on Aging York, PA – Community-based Care Transition Program
Delaware County Office of Services for the Aging PA – Community-based Care Transition Program – Community-based Care Transition Program
North Philadelphia Safety Net Partnership PA – Community-based Care Transition Program
Western Pennsylvania Community Care Transition Program PA – Community-based Care Transition Program
The Allegheny County Department of Human Services Area Agency on Aging PA – Community-based Care Transition Program
Black Creek Health Center Nuremberg, PA- Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Carmichaels Clinic Carmichaels, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Cornerstone Care Rogersville, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Cornerstone Care Greensboro, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
East Liberty Family Health Care Center, Inc. Pittsburgh, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Esperanza Health Center Philadelphia, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Family First Health Corporation- Hanover Center Hanover, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Freeland Health Center Freeland, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Hyndman Area Health Center, Inc. Hyndman, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Monroe Noxen Health Center Monroe Township, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Shickshinny Medical Center Shickshinny, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Uniontown Family Doctors Uniontown, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Wayne Memorial Community Health Centers Honesdale, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Wayne Memorial Community Health Centers Lake Como, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Wayne Memorial Community Health Centers Honesdale, PA – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
Hospital of the University of Pennsylvania Philadelphia, PA – Graduate Nurse Education Demonstration
Schnabel In-Home Care Program, Division of Geriatric Medicine, University of Pennsylvania Health System Philadelphia, PA – Independence at Home Demonstration
Neil Resnick MD Pittsburgh, PA – Innovation Advisors Program
Janice Pringle PhD Pittsburgh, PA – Innovation Advisors Program
Tonya Moody Philadelphia, PA – Innovation Advisors Program
Anna Marie Butrie MS Newtown, PA – Innovation Advisors Program
Renaissance Medical Management Company Wayne, PA – Pioneer ACO
Birth Care & Family Health Services Bart, PA – Strong Start for Mothers and Newborns Initiative
Einstein Medical Center Philadelphia Philadelphia, PA – Strong Start for Mothers and Newborns Initiative
Reading Birth and Women’s Center Reading, PA – Strong Start for Mothers and Newborns Initiative
Midwife Center for Birth & Women’s Health Pittsburgh, PA – Strong Start for Mothers and Newborns Initiative
Montgomery Hospital Medical Center Philadelphia, PA – Strong Start for Mothers and Newborns Initiativee

The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in Pennsylvania

On December 12, 2012, Governor Tom Corbett (R) notified federal officials that Pennsylvania would default to a federally-facilitated health insurance exchange.¹

Prior to the announcement, the Pennsylvania Insurance Department had taken the lead with exchange planning. The Insurance Department, released an extensive report in November 2011 that suggested broad support for a state-run exchange.² In January 2012, the Department released a conceptual draft for proposed legislation which would establish multiple private exchanges overseen by the Department.³ Consumer representatives expressed concern over the proposed model, citing such an approach would be inconsistent with the exchange requirements under the Affordable Care Act (ACA).⁴ In May 2012, the Department had begun soliciting for a subcontractor to provide guidance and consultation on exchange planning.⁵

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since Pennsylvania has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Aetna POS.

Exchange Funding

In September 2010, the Pennsylvania Insurance Department was awarded a $1 million federal Exchange Planning grant. In February 2012, the Department was awarded a $33.8 million federal Level One Establishment grant to continue with exchange planning and the procurement of technical expertise.⁶

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

Pennsylvania is participating in Medicaid expansion by reforming Medicaid.

Next Steps

The federal government will assume full responsibility for running a health insurance exchange in Pennsylvania beginning in 2014.

1. Press Release PA Insurance Department. Governor Corbett Announces State-based Insurance Exchange Decision. December 12, 2012.
2. Commonwealth of Pennsylvania, Pennsylvania Insurance Department. Insurance Exchange Planning. November 21, 2011. KPMG.http://www.portal.state.pa.us/portal/server.pt/community/health_insurance/9189/health_insurance_exchange_-_archived_exchange_information/1075404
3. Commonwealth Health Insurance Marketplace and Exchange Access Act. Conceptual Draft. January 30, 2012. http://www.phlp.org/wp-content/uploads/2012/03/Draft-exchange-bill-1-31-12.pdf
4. Comments on the Conceptual Draft of the Commonwealth Health Insurance Marketplace and Exchange Access Act. Community Legal Services and Pennsylvania Health Law Project. February 14, 2012. http://www.phlp.org/wp-content/uploads/2012/03/CLS-PHLP-Comments-to-PID-Exchange-Legislation-Conceptual-Draft.pdf
5. Pennsylvania Insurance Department. Request for Quotations for Pennsylvania Insurance Exchange Planning. May 2, 2012. http://www.emarketplace.state.pa.us/FileDownload.aspx?file=6100022192/Solicitation_0.pdf
6. Level One Exchange Establishment Grant application. Submitted December 28, 2011.http://www.portal.state.pa.us/portal/server.pt/community/health_insurance/9189/health_insurance_exchange/1064758

Also of interest

Provided by the Henry J. Kaiser Family Foundation