Pennsylvania Health Insurance

According to the Center for Disease Control, between 2001 and 2003, an annual average of 10.7% of Pennsylvanians went uninsured for Pennsylvania health insurance.

Pennsylvania Health Insurance Regulations

Individuals insured through an employer’s health insurance plan cannot be denied or limited coverage under that health insurance policy. Persons looking to obtain individual health insurance are guaranteed the right to purchase a policy through one of the Blue Cross and Blue Shield branches that operate in the state of Pennsylvania:

• Highmark Blue Cross Blue Shield (Western Pennsylvania)
• Blue Cross of Northeastern Pennsylvania (Northeastern Pennsylvania)
• Capital Blue Cross and Blue Shield (Central Pennsylvania)
• Independence Blue Cross and Blue Shield (Philadelphia area)

For individuals who are HIPAA eligible, Blue Cross and Blue Shield (BCBS) must offer standardized plans, otherwise plans can differ from person to person. There is usually a probationary period of up to six months with BCBS during which premiums must be paid but there is no coverage other than for accidents and emergencies. HIPAA eligible individuals are exempt from probationary periods and pre-existing condition exclusion periods.

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Pre-Existing Conditions

BCBS can impose a pre-existing exclusion period of up to 36 months. During this time, if an individual claims a condition, BCBS has the right research five years into patient history to determine if the condition was pre-existing. If so, then BCBS will not cover the claim.

Individual Pennsylvania health insurance companies that are not BCBS can impose both pre-existing exclusion periods as well as elimination riders. Elimination riders permanently or temporarily exclude specific conditions or body parts from coverage under the policy. Private health insurance companies can also deny applications for insurance based on age, health or other factors.

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Pregnancy

Pregnancy can be a pre-existing condition under any health insurance plan whether it is BCBS or a private insurer. Newborns are automatically insured during the first 31 days after birth but the parent must make policy adjustments after the initial coverage period.

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Charges

Guaranteed issue plans from BCBS have limits as to what they can charge. They cannot charge more for policies based on health, age, or other factors. Private individual Pennsylvania health insurance companies have no limits or restrictions to what they can charge for individual health insurance policies. Individual Pennsylvania health insurance rates under private insurers can depend on age, gender, health, status, family size, and other factors.

All Pennsylvania health insurance policies are guaranteed renewable. This means that any individual is guaranteed the right to renew an existing policy provided he or she has met all the regulations of the insurance company. Premiums, however, can be increased during the renewal.

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Temporary Insurance

Temporary health insurance is available through BCBS and private insurance companies. Temporary health insurance can be used to cover time between plans or employer health insurance.

Alternative Pennsylvania Health Insurance Options

For individuals who have difficulty affording Pennsylvania health insurance, there are state programs that may help:

• Pennsylvania Medicaid is available to any qualifying individual who meets the eligibility criteria.
• Pennsylvania Children’s Health Insurance Program is designed to provide health insurance to children up to 19 years of age whose families do not qualify for Medicaid and who may not be able to afford Pennsylvania medical insurance.
• COMPASS is the Adult Basic Health Insurance Program that is designed to help adults between ages 19 and 64 gain access to health insurance. There is a waiting list and eligibility requirements must be met.
• Pennsylvania Health Law Project helps individuals who are having difficulty accessing publicly funded health care services or coverage.

Pennsylvania Insurance Department

1326 Strawberry Square
Harrisburg, PA 17120

Automated Hotline: (877) 881-6388
Phone: (717) 783-0442
Fax: (717) 772-1969

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For other Pennsylvania Insurance Resources, See:

• Pennsylvania Auto Insurance
• Pennsylvania Home Insurance
• Pennsylvania Health Insurance

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