Pennsylvania Health Insurance (PA)

Pennsylvania (PA)
Individual Health Insurance Regulations

Learn more about Pennsylvania Individual Health Insurance

Pennsylvania allows the practice of medical underwriting to be applied during the application process of individual health insurance polices. Under this process, the health insurance carrier is allowed an opportunity to examine the applicant's past and present medical conditions and, based upon their findings, do one of the following: (1) Approve the application and offer health insurance coverage under the terms of the health plan, (2) Approve the application offering modified coverage under the terms of the health plan, or (3) deny coverage to the applicant. Pennsylvania law permits health insurance carriers a 60 month look back, 36 month exclusionary period on pre-existing conditions and does not require that credit for prior coverage be given. Elimination riders permitting the exclusion of coverage on specific pre-existing conditions are permitted. In Pennsylvania, Blue Cross/Blue Shield does offer a variance of guarantee issue products. These products would allow the applicant to obtain health insurance coverage, despite his/her medical history and without the need of the medical underwriting process. These plans vary by region and may be limiting in the benefits that are offered.

Pennsylvania
Small Group Health Insurance Regulations

For purposes of obtaining group health insurance, the State of Pennsylvania does not provide definitive numbers on what they consider to be a small group employer. Most health insurers recognize a small group employer to be any employer with 2-50 employees. Health insurance carriers require that employers provide them with a group census, the name of their worker's compensation carrier, a copy of their federal income tax 1040 Schedule C form or a copy of the Unemployment Compensation Report. Group health insurance in Pennsylvania is offered on a guarantee issue basis and does not permit the declination of coverage based upon the health history of the group as a whole or any individual therein. On enrollees lacking prior creditable coverage, insurers are allowed a 12 month exclusionary period on all pre-existing health conditions and may look back 6 months prior to the date the insured enrolls in the health plan. Premiums are determined via a medical underwriting process and may vary up to 300 percent of the base rate.

Pennsylvania COBRA and Continuation Coverage

Because the State of Pennsylvania does not have a mini-COBRA plan in force for groups of 19 or less, COBRA benefits are only available to employees of a company with 20 or more employees. Federal COBRA guidelines provide for the continuation of health care coverage upon the happening of a qualifying event which causes an individual to lose their health insurance benefits under the employer-sponsored group health plan. COBRA coverage allows the individual to remain on the employer's group health plan and receive the same level of coverage for a period of 18 months. In addition to a 2 percent administration fee, monthly premiums for this continuation coverage will be at the sole expense of the COBRA recipient. If COBRA coverage is not available, not elected, or exhausted, conversion products are available. Blue Cross Blue Shield of Pennsylvania offers guaranteed issue individual health plans to persons that are uninsurable and have no other options for coverage.

Additional Pennsylvania Resources

• Pennsylvania Children's Health Insurance Program (CHIP)
  A state sponsored program providing free or low-cost health insurance for Pennsylvania's children whose families are not able to afford private health insurance but make too much to qualify for Medical Assistance.
• Pennsylvania Department of Health
  Pennsylvania's Department of Health provides a wealth of health related information concerning health planning, public health initiatives and health care providers.
• Pennsylvania Office of Medical Assistance
  Provides managed care solutions for qualified individuals and families in Pennsylvania.

PA Medical Insurance Statistics

Total Population: 12,281,000
With Health Insurance: 10,994,000 / 89.5%
Without Health Insurance: 1,287,000 / 10.5%
*According to 2005 CPS Reports / U.S. Census Bureau

Note: The percentage of Pennsylvania residents without health insurance has decreased by 1.4% since 2004. It is among the states with the highest perentage of insured residents.

Commonwealth of Pennsylvania Insurance Department
Phone: 877-881-6388
The goal of the Pennsylvania Insurance Department is to provide Pennsylvania consumers with an objective source of information when dealing with or attempting to understand the complexities of your health insurance coverage.

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