Finding the comprehensive and affordable healthcare you and your family need is easier than you think if you live in Pennsylvania – but you have to know your options before you can make the right choice. Whether you’re shopping around for major medical, short-term health insurance, a Christian health plan, or more, we can help you find out more information about local options near you. It’s only with this information that you can make the best choice for the health care coverage you and your family need.
Major Medical Insurance in Pennsylvania
The vast majority of Americans these days – at least, those who aren’t getting health insurance through their employer – are trying to get major medical health insurance coverage through the federal Health Insurance Marketplace. Pennsylvania has been relying upon the federally facilitated Marketplace at HealthCare.gov since its Inception, but there will be some interesting changes to this soon. For upcoming 2021 health insurance plans, Pennsylvania plans to run its own state exchange and to start a reinsurance program in order to get more residents covered.
Until then, however, you will have to rely on HealthCare.gov in order to apply for, shop for, and purchase major medical coverage. Open Enrollment starts on November 1st each year, and usually goes until December 15th unless unprecedented high demand changes the deadline. If you are outside of the Open Enrollment period but need major medical coverage, you should still check HealthCare.gov to see if you qualify for a Special Enrollment Period. Sometimes these enrollment periods can be something as simple as moving to a new zip code or something as important as having a child. If you’re confused about Special Enrollment Periods, it’s best to contact someone directly at HealthCare.gov to figure out if your life circumstances make you eligible.
The ACA legislation has mandated that all major medical policies be guaranteed issue, provide a certain set of guaranteed essential health benefits, and has tried to make these policies more affordable for more Americans with certain subsidies. The guaranteed issue part of the law helps people with pre-existing conditions get a health insurance policy without being rejected for coverage or having to pay an obscenely higher monthly premium because of their pre-existing conditions. As a matter of fact, the only reasons an insurance company selling major medical coverage can justify charging more for your premiums include the following:
- Your age
- Your location
- Your use of tobacco products
- Whether you are applying for an individual policy or a family policy
The guaranteed Essential Health Benefits are an important part of major medical coverage because they help you get the best possible medical care. This isn’t just good for meeting yourshort-term needs, but also for the preventative care you need to keep your medical costs lower over the long run. And those guaranteed benefits are:
- Ambulatory/outpatient services
- Emergency services
- maternity/newborn care
- Mental health and substance abuse
- Prescription drugs
- hab/rehab services and devices
- Lab tests
- Preventive and wellness services and chronic disease management
- Pediatrics (including oral and vision)
The reason that the ACA had to make these health benefits and the guaranteed issue status a requirement is because, before the ACA, it was almost unheard of to find major medical coverage with these options. Or if you did find it, it was prohibitively expensive. But that isn’t the case necessarily if you qualify for a premium tax credit. In the state of Pennsylvania, you need to make at least 138% of the federal poverty limit to qualify for the tax credit. If you qualify, the government pays a portion of your monthly premium directly to your insurance company, leaving you with a deeply discounted monthly premium. These tax credits can make the difference between whether or not major medical coverage is affordable for you and your family. You can use the chart below to see whether or not you are eligible for one of these subsidies:
|Household Size||Annual Income (138% of FPL)|
For anyone who doesn’t quite meet the 138% income requirement, there is the Medicaid expansion available for Pennsylvania residents. The state has accepted federal funding to allow people making 138% or less of the federal poverty limit to apply for Medicaid instead of major medical coverage. For more information on whether or not you qualify for Medicaid in Pennsylvania – because it may depend on more than just your income alone – you should visit the Compass website in order to apply online or contact your nearest Compass office to apply in person.
Short Term Health Insurance in Pennsylvania
The state of Pennsylvania has not yet passed any laws or regulations with regard to short-term health insurance. This means that you have the option to purchase a short-term health insurance plan lasting up to 364 days, with the option to renew for two additional years. If you don’t qualify for a federal subsidy or for Medicaid benefits in the state of Pennsylvania, your next best option is most likely short-term health insurance. These plans are good because not only do they come with consumer protections and afford you the opportunity to take your insurance company to court if they fail to honor their contract with you, but you might be able to save some money. Some short-term health insurance can cost up to 33% less than an unsubsidized major medical plan sold through the Health Insurance Marketplace. Lastly, you might be able to negotiate with your short-term health plan provider and get more of the Essential Health Benefits that people need to be optimally healthy and happy – but you might not be able to purchase all 10 of them.
But there are some reasons why you might want to think your decision over thoroughly before choosing short-term health insurance. These Insurance products require medical underwriting, which is why they cannot be sold through the Health Insurance Marketplace – because that is the exact opposite of guaranteed issue. Any pre-existing conditions you have could disqualify you for coverage or will result in extraordinarily high monthly premiums. You also have to pay a high deductible, sometimes as high as $5,000 or more, out-of-pocket before your medical benefits will kick in. There are no limits set on your total out-of-pocket costs; however, if you do require more than an average amount of medical care, you will likely run into caps on your annual or lifetime benefits. The healthier you are and the less medical care you require, the more affordable short-term health insurance can be. But if you require lots of care, if you require specialized care, or if you don’t have the resources to cover out-of-pocket costs up front, short-term health insurance can be tricky.
Christian Health Plans/Health-Sharing Plans in Pennsylvania
Then you have health share plans, also referred to as Christian health plans. Now that the individual mandate is no longer a legal requirement, most people might glance over health share plans as an option. But they actually have many things in common with short-term health insurance, which can make them a viable contender for the same reasons that short-term health insurance is for some people. As a matter of fact, here are all the things that short-term health insurance and Christian health plans have in common:
- These plans are NOT guaranteed issue
- They have unlimited out-of-pocket costs
- They have lifetime and annual benefit caps
- They likely won’t have all of the guaranteed essential health benefits
- They can cost up to 1/3 less than an unsubsidized ACA plan
Christian health plans are unique in that they require you to follow participation guidelines in order to be eligible for health benefits. Sometimes, these guidelines may be as simple as declaring a specific (and usually Christian) faith, or attending church regularly. Sometimes you may have to do more, like change your tobacco usage to improve your health or adopt other biblical lifestyle practices. You’ll also be paying your expenses a little differently. Christian health plans charge you a monthly share amount instead of a monthly premium that a regular insurance company does. And they don’t charge you co-pays, coinsurance, or deductibles; but they do charge you in similar ways, they just refer to them as “unshared amounts” or “personal responsibility amounts”. If you identify with a particular religious faith, if you don’t need a whole lot of medical care but want something just in case, and if you want to take advantage of the savings, then a Christian health plan might be a good option for you and your family.
Fixed Indemnity Plans in Pennsylvania
Are you thinking about an indemnity plan? They can be a great way to help cover your costs if you purchase one for the right reasons. But if you try to get one in order to replace your major medical coverage, that might not be the wisest decision. With a fixed indemnity plan, you get a fixed payout when it comes time for your insurance company to pay out your claims. Major medical, on the other hand, usually pays out a fixed percentage of your total costs – not a fixed amount. Fixed indemnity plans also put you through medical underwriting, put caps on your annual and lifetime benefits, and won’t have any limits to your total out-of-pocket costs. That’s why most people use them as a supplement to major medical, short-term health insurance, or even a health share plan as opposed to a replacement for major medical.
One of the good things about fixed indemnity plans is that you aren’t restricted to a specific medical network. Major medical plans usually require you to stick to an HMO or PPO network of doctors in facilities and could limit you from getting the care you need from the professionals you want. Fixed indemnity plans are almost universally accepted, but it’s still a good idea to call ahead and make sure that they will accept it when you go to get care outside of whatever medical network you are working with (if you are working with one). When you file a claim with a fixed indemnity plan, you will likely get your payouts on a daily, weekly, monthly per visit, or per event basis. These quick cash payouts can be a great way to stay afloat if you require more care than average and have a lot of frequent medical expenses. They can also help in the event of an unexpected medical emergency, but won’t be quite as helpful as more comprehensive forms of coverage.
Discount Cards in Pennsylvania
Then there are medical discount cards. But these can be hit or miss depending on where you live and who you sign up with. It’s not uncommon to find either bad deals or outright scams with medical discount cards. The problem is that lots of companies unscrupulously advertise them as a replacement for major medical coverage, even though they are absolutely not. Other companies may claim that you can get bigger discounts then you are actually eligible for, or that they participate with providers they don’t actually participate with. If they charge an expensive monthly or annual membership fee and make claims that sound too good to be true, it might be a scam in disguise. It’s a good idea to do your homework and double-check the claims they make are true before you buy one of these cards.
But not all medical discount cards are a scam. Some are actually quite helpful at helping you take a little bit of the edge off of your out-of-pocket costs. They work like any other membership club: you pay a fee for your membership, you receive a card in the mail, and you present that card at qualifying retailers and medical providers for a modest discount. Sometimes, the membership fee can be less expensive than the amount of money you save taking advantage of the discounts. Other signs of a worthwhile medical discount card program are cards that offer you discounts on prescription drugs or other, specific medical services. There are no claims to file and no reimbursements to wait for with a medical discount card; you get your discount right at the register and see your savings immediately.