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Pennsylvania Health Insurance

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Facts and Figures

  • Place in State
    Health Report Card
  • Insured 10,935,163
  • Uninsured 1,310,000
  • Insurance
  • Number of
    Primary Care Physicians
  • Number of
  • Average Cost of
    Health Insurance*

Breakdown of Insureds

  • Employer-sponsored health insurance 62%
  • Private plans 6%
  • Medicaid 16%
  • Medicare 16%

State Health Report Card

In the last ten years, smoking went down from 24.3 percent to 18.4 percent among adults in Pennsylvania. Today, there are more than 1.8 million adult smokers in Pennsylvania. Obesity went up from 21.2 percent to 29.2 percent among adults in the last ten years. There are nearly 2.9 million adults living with obesity in the state today. Diabetes went up from 9.0 percent to 10.3 percent among adults in the past year. Today, there are more than 1 million obese adults in Pennsylvania. Children living in poverty increased from 14.5 percent to 16.4 percent among those 18 years old and below in the past year.

Pennsylvania Health Insurance Laws and Regulations

Pennsylvania health insurance plans must be sold with a guaranteed renewability clause. This assures all customers the ability to renew coverage as many times as necessary provided they keep up with their premium payments and do not commit any type of fraud. In addition, health insurers are not allowed to terminate a policy due to an injury or sickness. Newborns and newly-adopted children are automatically covered under a parent’s health policy as long as that policy covers dependents. This coverage can last up to 31 days, giving enough time for parents to make necessary arrangements. Pennsylvania health insurance plans can exclude coverage for a pre-existing condition for up to 12 months after the policy is implemented. Thankfully, this waiting period will not reset should you decide to transfer from one plan to another as long as you maintain continuous coverage. Private insurance companies can deny an application for coverage based on factors like age, health, and family history of the applicant. However, premium rates cannot be raised based on your health condition alone. It’s still possible for insurers to consider factors like age and location, though. Blue Cross Blue Shield of Pennsylvania is required by the state to accept applications of all residents. In addition, premium rates cannot be based on the applicant’s health status. A probationary period of up to thirty days may be required by Pennsylvania health insurers before a policy sold becomes effective. Small businesses (with 2 to 50 employees) are qualified to purchase group health plans similar to other plans being offered to small groups in the state. However, certain conditions may be required in order to continue with the coverage like having a minimum number of participants and a minimum employer contribution. Health insurers cannot terminate coverage based on a member’s health condition. Pennsylvania health insurance quotes for group coverage can vary according to the risk factors of its members. Self-employed individuals living in the state are not qualified to purchase a group health plan unless they have one other employee. Instead, they can purchase an individual health insurance, with the advantage of having a portion of the premiums being tax deductible.

Heath Care Reform

With the new health care law, children under the age of 26 can choose to stay under their parent’s Pennsylvania health insurance as long as they are not offered an employer-based health insurance. This provision enabled 2.5 million young adults to have insurance nationwide. In Pennsylvania, 64,798 young adults have insurance coverage through this provision as of June 2011.

The new health care law allowed 247,686 Medicare policyholders in Pennsylvania to receive a $250 rebate check to help with prescription drug costs when they fell into the Medicare gap in 2010. In 2011, 235,820 Medicare plan holders were given a 50% discount on brand-name prescription drugs covered by their plans when they hit the donut hole. An average of $662 per person or a total of $156,108,903 was saved in Pennsylvania.

Previously uninsured individuals without health coverage because of a pre-existing condition can now apply for a Pre-Existing Condition Insurance Plan. This plan is available to U.S. citizens or legal residents with a pre-existing condition and have been uninsured for at least 6 months. In 2011, 4,567 individuals in Pennsylvania have benefited from this new law.

When looking at Pennsylvania health insurance quotes, applicants are assured that at least 80 percent of the price will go directly to health care services and other related improvements. A rebate or premium discount shall be provided if the minimum is not met. All private policyholders in Pennsylvania will get greater value for their premium payments because of this 80/20 rule.

Preventive care services like immunizations, colonoscopies, mammograms, or annual wellness doctor visits must be included in all Pennsylvania health insurance with no deductibles or co-pays. In 2011, 1,509,076 Medicare subscribers and more than 236,300 individuals with private policies received such services in Pennsylvania.

Under the new law, insurance companies are no longer allowed to impose an annual dollar limit-a cap on the yearly spending for your benefits, or a lifetime dollar limit-a lifetime cap for spending for your covered benefits. This law frees chronically ill individuals like cancer patients from worrying about getting further treatment because of such limitations. In 2011, 4,582,000 Pennsylvania residents have benefited from this law.

If insurance companies want to raise their premium rates by ten percent or more, they are required by federal law to publicly announce and justify their actions. To guard against such unreasonable increases, the state of Pennsylvania received a total of $5.3 million.

All fifty states receive increases in funding for community health centers under the Affordable Care Act. This will help construct new health centers, provide medical services to more patients, improve preventive and primary health care services, and fund infrastructure projects. In Pennsylvania, 236 community health centers received a total of $34.2 million to fund these improvements.

In 2010, the Affordable Care Act created the Prevention and Public Health Fund. This new fund was created for wellness promotion, disease prevention, and protection against public health emergencies. Pennsylvania has already received a total of $29.6 million to support its policies, programs, and communities to help its residents lead healthier lives.

State Government Insurance Programs Offered

Medicaid (Medical Assistance)


Medicaid is available for Pennsylvania residents who cannot pay for medical for medical care on their own. Benefits include office visits, emergency room care, laboratory and x-ray, vision and hearing, prescription drugs, immunizations, and mental and substance abuse treatment. Eligibility: 1. Must be a U.S. citizen or a legal resident living in Pennsylvania. 2. Must not exceed income limits: Pregnant women and infants aged 0-1 years: 185% of the federal poverty level (FPL). Children aged 1-5 years: 133% of the FPL. Children aged 6-18 years: 100% of the FPL. Parents and caretakers living with children aged 0-18 years: 36% of the FPL. Medically-needy: Singles: $425 monthly income with assets not exceeding $2,400. Couples: $442 monthly income with assets not exceeding $3,200. Aged, blind, and disabled: Singles: 100% of the FPL with assets not exceeding $2,000. Couples: 100% of the FPL with assets not exceeding $3,000.

Pennsylvania’s Children’s Health Insurance Program


Children’s Health Insurance Program (CHIP) in Pennsylvania provides health insurance to uninsured children under 19 years who are ineligible for Medical Assistance. CHIP offers comprehensive health insurance coverage for doctor visits; hospitalization; emergency care; prescription drugs; maternity care; dental, vision, and hearing services; mental health and substance abuse; durable medical equipment, and many more. Eligibility: 1. Must be U.S. citizen or qualified resident living in Pennsylvania. 2. Must be under 19 years of age. 3. Must be uninsured and ineligible for Medical Assistance.

The Healthy Women Project


HealthyWoman Program (HWP) of Pennsylvania offers free breast and cervical cancer screening services to qualified women living in Pennsylvania. The program is funded by the Department of Health and also receives grants from the Centers for Disease Control and Prevention. Services offered include clinical breast exams, mammograms, pelvic exams, Pap smears, education on breast self-exam, follow-up diagnostic care for abnormal results. Eligibility: 1. Must be women and U.S. citizens or qualified residents living in Pennsylvania. 2. Must be between 40 and 64 years old. 3. Must be uninsured or current insurance does not cover breast and cervical cancer screening services. 4. Income must not exceed 250% of the federal poverty level. Women enrolled in Medicare Part B, Medicaid, or HMOs are not eligible for coverage. Women aged 65 and above are qualified if they are not enrolled in Medicare. Women under 40 may qualify if they have breast cancer symptoms, have not been screened for cervical cancer in the past five years, or require follow-up for an abnormal Pap test.

Medicare Medicare Prescription Drug Program 800-633-4227 APPRISe (Medicare advice) 800-783-7067 (Click: Health & Wellness)


This health care system is administered by the federal government and provides health insurance coverage for Americans aged 65 and above or those younger than 65 but have a disability or end-stage renal disease. Coverage has four parts: Part A: provides inpatient care in hospitals and rehabilitative centers. Part B: provides doctor and some preventive services and outpatient care. Part C: provides Medicare benefits through Medicare Advantage. Part D: provides prescription drug coverage. Eligibility: 1. Must be a U.S. citizen or permanent U.S. resident. 2. Must be 65 years or older, with you or your spouse having worked in a Medicare-covered employment for at least ten years; or have a qualified disability or end-stage renal disease, regardless of age.

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