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Health Insurance in Pennsylvania

Having comprehensive health insurance in Pennsylvania is one of the best decisions you can make to help protect your and your loved one's health and well-being. Pennsylvania health insurance is a type of insurance that covers medical expenses (like hospitalization costs, doctor visits, and prescription drugs) that may arise due to an illness. Pennsylvania uses a state-run health insurance exchange called Pennie, which has 14 participating health and dental insurers. Nearly 375 thousand Pennsylvania residents enrolled in private individual market plans through Pennie during the open enrollment period for 2022 coverage. Two types of health insurance policies are common in Pennsylvania:

  • Private insurance

  • Public insurance

While the government sells public insurance through Medicare, Medicaid, and Children's Health Insurance Programs (CHIP), private insurance policies are sold by private health insurance companies. Pennsylvanians can purchase health insurance plans on Pennie, directly from health insurance companies, or as a group policy through their employers. In addition, individuals over the age of 65, people with disabilities, and low-income earners can benefit from state-funded programs and alternative health plans like Pennsylvania Medicaid, CHIP, limited benefit, and short-term limited duration health insurance.

The best way to get health insurance in Pennsylvania is through a licensed health insurance agent. A knowledgeable agent can help you shop for a health insurance quote and by comparing various competitors - find you a comprehensive health insurance policy at an affordable rate.

How Does Health Insurance Work in Pennsylvania?

The Pennsylvania Insurance Department (PID) regulates all health insurance activities in the Commonwealth according to the Pennsylvania Insurance Code. The Pennsylvanian's insurance marketplace is called Pennie. Approximately 1.3 million Pennsylvanians enrolled in coverage made available by the Affordable Care Act (ACA) in 2021. Health insurance is not mandatory in Pennsylvania, but you must still report your coverage status on your federal tax return, and there is no penalty if you are not covered. Health insurance policies in Pennsylvania are categorized into two, namely:

  • Individual health plans

  • Group health plans

In Pennsylvania, an insured person pays health insurance premiums on a monthly basis. The average cost of health insurance in the Commonwealth is between $470 and $650 per month (premiums can be lower if the insured is in good health). Pennsylvania health insurers calculate premiums based on several factors like age, type of plan, location, lifestyle, and whether the policy covers only the individual or their family. In addition to premiums, insureds must also cover part of the health care cost through cost-sharing. They would have to pay deductibles, copayments, and coinsurance. However, when a set limit has been reached, they would not need to pay copayments or coinsurance. On the other hand, premiums must be paid monthly throughout the policy tenure. This is why you should talk to a Pennsylvania-licensed health insurance agent to get affordable coverage that will suit your health needs. They will help you compare prices from multiple health insurers and recommend an affordable health plan with comprehensive coverage.

There are different ways to obtain health insurance coverage in Pennsylvania, depending on the market and the type of insurance you need. Health insurance in the Commonwealth can be obtained through any of the following means:

  • Your employer

  • A membership association, union, or church

  • A Pennsylvania-licensed health insurance agent

  • A health insurance company

  • The Pennsylvanian's health insurance marketplace

  • The health insurance plan of your parents if you are under 26 years

  • Your spouse’s plan

  • Student plans offered by colleges or universities

  • Pennsylvania’s Children's Health Insurance Program

  • Pennsylvania's Medical Assistance (Medicaid) program website for other individuals or the Commonwealth's COMPASS tool

Speak to a licensed insurance professional to get answers tailored for your specific health insurance needs.

How Does Group Insurance Work in Pennsylvania?

A group insurance health plan is an employer-sponsored health plan that covers the medical care of employees or members of an organization. Coverage can also extend to dependents. Group health plans typically come at reduced costs because insurers’ risks are spread across a group of people. The two types of group health insurance in Pennsylvania are:

  • Small group health insurance: It covers employees of a small business (a company with 50 or fewer employees). Most small group health plans in Pennsylvania cover:

    • Mental/behavioral health outpatient and inpatient services

    • Substance use disorder outpatient and inpatient services

    • Some types of drugs, including antidepressants, mood stabilizers, and drug treatments for opioid dependence. However, small group health insurance plans do not have to cover every possible drug in each category

  • Large group health plan: This is a group health plan that covers employees of big corporations (companies with 51 or more employees). In Pennsylvania, large employers must provide health insurance coverage that covers certain serious mental illness, alcohol, and substance use treatment

All group insurance health plans in Pennsylvania must cover the following alcohol and substance use treatment:

  • A maximum of seven days of detoxification per admission and four admissions per lifetime (hospital or non-hospital inpatient detoxification)

  • 30 days of non-hospital residential treatment annually and 90 days per lifetime

  • 30 sessions of outpatient/partial hospitalization services annually and 120 sessions per lifetime (outpatient/partial hospitalization)

  • Family counseling and intervention services

  • 30 additional outpatient/partial hospitalization sessions may be exchanged on a two-to-one basis to provide 15 additional non-hospital residential treatment days

Group health plans are not available on Pennie. Hence, employers must get coverage on their own or with the help of Pennsylvania-licensed health insurance agents. Professional agents are better positioned to advise employers on the best group health plans that will be beneficial to their employees.

How Does Individual Health Insurance Work in Pennsylvania?

Individual health insurance is a type of health coverage purchased on an individual or family basis instead of through an employer or an organized group. Individual health plans are required by federal law to include ten types of healthcare services known as Essential Health Benefits (EHBs). Pennsylvania also mandates that individual health plans include specific health benefits. Pennsylvania law requires all individual health plans to cover mental illness and substance use disorder services, including behavioral health services. The minimum amount of services that must be covered by each of these categories are:

  • Mental/behavioral health inpatient and outpatient services

  • Substance use disorder inpatient and outpatient services

Additionally, individual health insurance plans must cover certain drugs like mood stabilizers, antidepressants, and medication-assisted treatment for substance use disorders. However, it is not mandatory for insurers to cover every drug in each of these categories. Your insurer can decide to limit Essential Health Benefits, like only covering services if they are medically necessary or only covering services performed by an in-network provider. However, it is important to know that your health insurer cannot place more limits on mental health and substance use benefits than on physical health benefits. This means your mental health and physical health benefits must be similar in terms of the following:

  • Which healthcare providers you can see

  • The use of management tools like prior authorization requirements

  • What you pay (co-insurance, co-pays, deductibles, and out-of-pocket maximums)

  • The process the insurer uses to determine what is considered medically necessary treatment

  • How much treatment you can get, like limits on the number of inpatient or outpatient visits that are covered

Pennsylvania health insurance marketplace sells individual health coverage through Pennie only during the open enrollment period, which typically runs from November 1 through January 15. However, if you experience certain qualifying life events like a change in marital status and loss of health coverage, you might qualify to sign up during the special enrollment periods. Purchasing individual health coverage through Pennie makes you eligible for premium subsidies (premium tax credits) and cost-sharing reductions. All U.S. nationals or qualified immigrants who reside in Pennsylvania can apply and enroll in individual health coverage through Pennie.

Although individual health insurance plans are available on Pennie, you can also purchase them outside the marketplace. Purchasing individual health plans outside the marketplace means you can benefit from premium subsidies (premium tax credits) and cost-sharing reductions. Individuals can also buy health insurance plans directly from health insurers or through licensed health insurance agents. Speak with a licensed Pennsylvania health insurance to assess your needs and to advise on the best plans to fit those needs.

What are Alternative Health Plans in Pennsylvania?

Alternative health plans in Pennsylvania are affordable plans that are suitable for people who are healthy, without pre-existing conditions, and are not in need of regular health services or prescriptions. Alternative health plans are good for people who do not require urgent coverage or need a health plan that would kick-in in case of an emergency.

Alternative health plans come with several setbacks that consumers should know. For instance, they do not meet the minimum requirements for comprehensive coverage under the Affordable Care Act (ACA). Alternative health plans are not required to cover essential health benefits, prescription drugs, or preventive services and can deny coverage to applicants with pre-existing conditions. Unlike ACA plans, alternative health plans:

  • May pay less for services, have waiting periods to join, and limit their total yearly payments

  • May not cover all illnesses or injuries, including chronic and pre-existing conditions

  • Will not allow you to get federal help (like tax credits and cost-sharing reductions) that can help reduce your premiums and out-of-pocket costs

Pennsylvania alternative health plans include:

  • Short-term health insurance

  • Limited benefit plans

  • Subscription plans

  • Association plans

  • Direct primary care

If you plan to purchase alternative health insurance in PA, make sure to consult with a knowledgeable Pennsylvania-licensed health insurance agent who has access to multiple types of plans and insurers for comparison.


Short term plans, or short-term limited-duration health insurance (STLDI) is designed to fill temporary gaps in coverage that may occur when a person is transitioning from one health plan or coverage to another. Most short-term health insurance plans are usually issued for 12 months or less and can be renewed for up to 3 years. In Pennsylvania, short-term health plans are suitable for individuals who are:

  • Temporarily unemployed

  • Waiting for other health insurance coverage to begin

  • Waiting to qualify for Medicare coverage

  • Without health insurance

It is not mandatory for short-term plans to comply with the Affordable Care Act protections. This means that insurers can deny coverage due to pre-existing conditions and are not required to cover essential health benefits like outpatient care, hospitalization, prescription drugs, and laboratory services. Before purchasing a short-term plan, ensure you speak to a Pennsylvania-licensed insurance agent. Beware of purchasing health plans from insurers packaging certain health policies as ACA compliant plans when they are not. Short-term health plans are usually less expensive because they have limited coverages than ACA-compliant major medical plans.


Limited benefit health plans in Pennsylvania provide coverage for only specified healthcare services or treatments. They are designed to supplement comprehensive health insurance plans. Examples of limited benefit health plans are:

  • Fixed indemnity plan: It pays a set amount for a medical service, regardless of the service's total cost

  • Basic surgical expense: It covers the cost of a surgeon's services, whether the surgery is performed in or out of the hospital

  • Specified disease plan: Provides coverage and benefits for only particular illnesses like cancer, heart disease, heart attack, or stroke

  • Hospital indemnity plan: It provides a daily, weekly, or monthly payment of a specified amount for hospital admission

  • Critical illness plan: It pays a set amount if an insured is diagnosed with any severe illness covered in the policy like stroke, heartache, coronary bypass, or organ transplant

  • Accident-only plan: It pays for losses incurred during an accident, not illnesses

  • Basic hospital expense: It covers the cost of hospital confinement for a specific time. Basic hospital policies specifically cover costs associated with daily room and board and other miscellaneous expenses like drugs, X-rays, anesthesia, lab fees, dressings, use of the operating room, and supplies


Telehealth is the use of digital information and communication technologies like tablets, smartphones, and computers to remotely access healthcare services and manage your health. In Pennsylvania, telehealth can take place from your home, or a health professional can provide it from a medical office. Using technology to deliver health care is very convenient, affordable, and accessible, especially for people living in rural areas with no medical facilities and doctors. Telehealth can be delivered in any of the following ways:

  • Synchronous: This is when the doctor uses a computer or telephone to communicate with a patient in real-time

  • Asynchronous: This is when data, images, or messages are recorded to share with the doctor at a later time

  • Remote patient monitoring: This is when measurements like weight or blood pressure are sent to the doctor

Although telehealth is very convenient and cost-effective, it still has its downsides. One of such downsides is that not every type of medical check can be done remotely. For instance, you will have to visit the hospital in person for blood work and imaging tests. Also, the security of personal data transmitted electronically is not guaranteed.

Note that telehealth is different from telemedicine. Telehealth offers a broader scope of remote medical services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth covers clinical and non-clinical services like continuing medical education, administrative meetings, and provider training.


Direct primary care (DPC) is where patients pay their physicians a flat fee monthly or annually for some primary care services. Such services may include:

  • Extended visits

  • Home-based medical visits

  • Telemedicine consultations via voice, video conferencing, and SMS

  • Highly personalized, coordinated, and comprehensive care administration

  • Free on-site tests and procedures

  • Discounted off-site tests and procedures

DPC only provides primary health care services. Therefore, DPC members should consider getting other health insurance policies to cover the costs of life-threatening emergencies, hospitalizations, and specialist care for severe illnesses and injuries. If you are confused about how this works, you can talk to a Pennsylvania-licensed health insurance agent who can advise you on the best insurance policy to combine with your DPC plan. They will also ensure that your health policy meets your current and future health needs.


Discount health plans are designed so that members can pay a monthly fee in exchange for discounts on some medical services. It is like using a coupon at a supermarket to reduce the price of a product. Discount health plans in Pennsylvania are usually very affordable, and they cover vision, hearing, or pharmaceutical services.


A subscription health plan is a type of plan that allows members to pay a flat fee in installments on a fixed basis (monthly, quarterly, or annually). This fee covers the visits and procedures provided by healthcare providers within the plan. Sometimes, there may be a limit on the number of visits that a member can schedule. The most common types of subscription plans available in Pennsylvania are concierge medicine and direct primary care (DPC).


Association health plans are plans designed for people with common interests, such as a similar industry or profession. Association health plans in Pennsylvania allow self-employed workers and small businesses to join and form a large group to take advantage of affordable health plans. Under association health plans, employers can negotiate better rates with their health insurers. Association health plans work like traditional major health insurance, and premiums are calculated based on age, gender, and industry type.

Commercial Health Insurance

Pennsylvania is home to around 1.1 million small businesses, employing 2.5 million individuals. Small businesses account for 99.6% of businesses in the Commonwealth. In 2020, there were about 302,018 employer establishments in Pennsylvania with approximately 5.6 million jobs. Pennsylvania law does not mandate these employers to provide health coverage for employees but opting for one reduces absenteeism due to health issues, boosts employee satisfaction, and increases retention.

Commercial health insurance is an insurance policy obtained from non-governmental entities, implying individuals cannot get commercial health coverage from Medicare, Medicaid, or CHIP. It can be privately purchased or employer-sponsored and may be provided on a fee-for-service basis or through a managed care plan. Commercial health insurance covers the insured’s disability income and medical expenses. It also includes group health insurance, disability income insurance, and workers’ compensation insurance.

Group Employer-Sponsored Health Insurance

Group employer-sponsored health insurance is a policy purchased by the employer of an organization for eligible employees, and it can be extended to their dependents (spouses and children). It allows employers to share health insurance premiums with their employees. In Pennsylvania, there are two types of group employer-sponsored health insurance:

  • Small group employer-sponsored health insurance

  • Large group employer-sponsored health insurance

Small group employer-sponsored health insurance is designed for employers with 50 or fewer employees. In contrast, employers with 51 or more employees must purchase large group employer-sponsored health insurance. These two types of group employer-sponsored health insurance have different inclusions and exclusions. This is why employers should talk with a knowledgeable Pennsylvania-licensed health insurance agent who can guide them in purchasing the right health insurance policies for their companies.

Pennsylvania Disability Income Insurance

Disability income insurance in Pennsylvania provides income to individuals unfit to work because of a disability. Disability income insurance comes in two different types:

  • Short-term disability coverage (STD): It provides coverage when you cannot work for a short period (a few weeks, months, or a year) due to illnesses, accidents, or injuries. Most short-term disability policies have a waiting period of zero to 14 days before coverage kicks in, and payments may only be made for a maximum of two years

  • Long-term disability coverage (LTD): It provides coverage for individuals who cannot work for a long period because of a disability. Normally, LTD plans work in conjunction with STD plans so that individuals begin receiving STD benefits before any long-term benefits kick in. The waiting period for LTD benefits can range anywhere from a few weeks to several months, and payments can last until the insured dies

Pennsylvania Workers’ Compensation Insurance

Workers' compensation insurance is usually purchased by employers to provide medical and wage benefits to employees who experience work-related injuries and illnesses. The Pennsylvania Department of Labor and Industry administers the workers’ compensation law. Workers’ compensation is mandatory for all employers with one or more employees, whether part-time or full-time. Uninsured employers may face severe penalties like imprisonment and fines. In Pennsylvania, employers can obtain workers’ compensation insurance through the following ways:

  • A licensed insurance agent or broker

  • The State Workers’ Insurance Fund (SWIF)

  • Purchase the coverage directly from any private insurance company that writes workers' compensation policies

Workers’ compensation insurance covers replacement of lost wages, payment of medical expenses, disfigurement benefits, and death benefits. It also covers specific loss benefits like when work-related injury leads to loss of vision, hearing, and/or the use of limbs (including fingers and toes). Workers’ compensation insurance does not cover employees when they:

  • Get injured while commuting to or from work

  • Sustain injuries due to intoxication

  • The cause of the work-related injury or illness is due to negligence

  • Sustain injuries due to illegal activities at the workplace

How Does Health Insurance for Seniors Work in Pennsylvania ?

Original Medicare 51%
Medicare Advantage 49%
Original Medicare Part A and Part B 57%
Medicare Advantage and Other Health Plan Part A and Part B Beneficiaries 43%
Medicare Part D (Medigap) 74%
Medicare Advantage Prescription Drug Plan 88%
Source: Data.CMS.gov, 2022

As of July 2021, Pennsylvania had a population of 12,964,056, with more than 2.4 million seniors (65 years or older). In 2020, almost 155,551 Pennsylvanians died, and about 121,288 of the deceased were seniors. The major causes of deaths were health issues like heart diseases, chronic lower respiratory disease, malignant neoplasms, cerebrovascular disease, and diabetes mellitus. Hence, the need for seniors in Pennsylvania to purchase health insurance cannot be overemphasized. Health insurance covers medical expenses like hospitalization costs, the cost of medicines, and doctor consultation fees. All seniors in Pennsylvania should consider the following health insurance policies:

  • Medicare

  • Medicaid

  • Medigap

  • Long-term care insurance


Medicare is a federal health insurance program created for people aged 65 or older. People with end-stage renal disease (ESRD) and individuals younger than 65 years but with certain disabilities in Pennsylvania also qualify for Medicare. Only legal citizens and residents of the United States who have resided there for at least 5 years qualify for Medicare. The primary purpose of medicare is to provide affordable access to health care and services to individuals who might not be able to afford healthcare due to their age or medical conditions.

The best time to enroll for Medicare is during the Medicare Initial Enrollment Period, which starts three months before you turn 65 and ends about three months after. Enrolling after your initial eligibility period may result in higher premiums. Individuals who could not sign up during the initial enrollment period can do so during the General Enrollment Period and Special Enrollment Period. Registering for Medicare during the general enrollment period comes with late enrollment penalties (Part A, Part B, Part D). Medicare coverage in Pennsylvania is divided into the following parts:

  • Original Medicare: This coverage allows the government to pay your healthcare providers directly and is divided into two parts:

    • Medicare Part A (hospital insurance): It covers inpatient hospital care, hospice care, skilled nursing facility care, home health care, and nursing home care. Most people in Pennsylvania get premium-free Part A. This means that they do not pay monthly premiums for Medicare Part A because they or their spouses paid Medicare taxes for a certain amount of time while working. People who do not qualify for premium-free Part A can get one and should expect to pay between $274 and $499 monthly premiums

    • Medicare Part B (medical insurance): It typically covers medically necessary services and preventive services like doctor’s visits, lab tests, clinical trials, mental illness health care, preventive care, and surgeries. The standard Part B premium amount is $170.10

    • Medicare Part A is funded through a part of the federal income tax called the Federal Insurance Contributions Act (FICA), while Part B is funded from monthly premiums paid by insureds and the federal government revenue

    • Medicare Part C (medicare advantage): A Medicare-approved health plan run by private insurance companies that combine original medicare and Part D coverages into one plan. Part C health plans cover all the services provided by Original Medicare, excluding hospice care and some care in eligible clinical research studies. It also covers some services that Original Medicare excludes, like vision, hearing, and dental services and prescription drugs. Medicare Advantage has network providers which insureds are expected to use when they need medical attention. Also, these insureds must use red, white, and blue Medicare cards from their Medicare Advantage Plans to get Medicare-covered services. Some common types of

Medicare Advantage Plans are:

Medicare does not cover long-term care, cosmetic surgery, acupuncture (except when needed for chronic low back pain), and most dental care. Additionally, it excludes eye exams related to prescribing glasses, dentures, hearing aids and exams for fitting them, and routine foot care


As of March 2022, approximately 3,524,494 Pennsylvania residents were enrolled in Medicaid and children’s health insurance programs (CHIP). Pennsylvania Medicaid is a program jointly funded by the federal and state government that covers medical costs for people with limited income and financial resources. The Pennsylvania Department of Human Services (DHS) runs the state’s Medicaid coverage program. To be eligible for Pennsylvania Medicaid, you must be a low-income earner who is either a United States citizen or a qualified non-citizen residing in the Commonwealth. Also, you must meet any of the following non-financial eligibility requirements:

  • A pregnant woman

  • A parent or caretaker

  • A former foster care youth

  • 18 years old or younger

  • 65 years of age or older

  • An adult between the age of 17 and 64

  • Under 65 years of age with a disability or visual impairment according to Social Security guidelines

Individuals can purchase Medicaid at any time during the year. Pennsylvania Medicaid covers the following services:

  • Inpatient and outpatient hospital services

  • Laboratory and x-ray services

  • Home health services

  • Transportation to medical care

  • Family planning services

  • Physician services

  • Nursing facility services and tobacco cessation counseling for pregnant women

  • Early and periodic screening, diagnostic, and treatment services (EPSDT)

  • Rural health clinic services

  • Federally qualified health center services

  • Nurse midwife services

  • Certified pediatric and family nurse practitioner services

  • Freestanding birth center services.

Pennsylvania Medicaid does not cover cosmetic surgery, acupuncture, organ transplants (which are not prior approved), custodial care, autopsies, procedures for implanting an embryo, and services to reverse sterilization.


Medigap, also known as medicare supplement insurance, is designed to cover some healthcare costs like co-payments, coinsurance, and deductibles not covered by Medicare. You must have Medicare Parts A and B to qualify for a Medigap policy in Pennsylvania. If you already have a Medicare Advantage Plan (Medicare Part C), you cannot buy a Medigap policy. Medigap policies exclude long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing. In 2022, over a million Medicare-eligible Pennsylvania residents used Medigap to supplement Original Medicare.

In Pennsylvania, Medigap policies are sold by private insurance companies who set Medigap premiums in the following ways:

  • Community-rated pricing: Premiums are not based on age; hence, everyone gets to pay the same premium.

  • Issue-age-rated (entry-age-rated) pricing: Premium is based on your age when you buy the policy. Younger insureds tend to pay lower premiums than their older counterparts.

  • Attained-age-rated pricing: Premiums are based on your current age and go up as you grow older. Hence, you might pay lower premiums at first but will pay higher premiums as you get older.

Medigap policies can be purchased during the open enrollment period starting on the first day of the month you enrolled in Medicare Part B. The open enrollment period lasts for about six months. No insurer in Pennsylvania can deny you Medigap coverage or increase your premiums due to past or present health conditions if you apply during the open enrollment period. Alternatively, if you purchase Medigap coverage after your open enrollment period, no insurer is under any compulsion to sell you a Medigap policy if you do not meet the medical underwriting requirements.


Long-term care (LTC) insurance in Pennsylvania provides financial protection for residents who can no longer perform the most basic functions of daily activity and require living assistance at home or a medical facility. Individuals must be unable to perform a minimum of two activities of daily living (ADLs) (bathing, continence, dressing, eating, toileting, and transferring) without assistance to be eligible for LTC insurance. LTC insurance covers nursing home care, home care, respite care, hospice care, personal care at home, services in assisted living facilities, and services in adult day care centers. Most long-term care insurance policies exclude:

  • Alcohol or drug addiction

  • Illness or injury resulting from an act of war

  • Attempted suicide or intentionally self-inflicted injuries

  • Treatment in a government facility or treatment already paid for by the government

  • A mental or nervous disorder or disease aside from Alzheimer’s disease or other dementia.

No Pennsylvania insurer will pay for long-term care the first day you go to a nursing home or start using home care. Coverage will go into effect based on the waiting period you select when you purchase your policy. This waiting period can be 20, 30, 60, 90, or 100 days and you might have to pay for your own care out-of-pocket until coverage begins. For example, a 60-day waiting period means the insurer will not cover long-term care costs incurred during the first 60 days.

What are Additional or Stand-Alone Health Insurance Options in Pennsylvania?

Additional or stand-alone health options are also called supplemental health plans. They cover healthcare costs like copayments, coinsurance, and deductibles that are not covered by traditional health plans. Some examples of additional or stand-alone health insurance options in Pennsylvania are:

  • Dental insurance

  • Vision insurance

  • Hearing (and hearing-aid) insurance

  • Critical illness plans

  • Short Term Health

  • Medigap (Part D)

  • Hospital indemnity

  • Disability income

  • Accidental death and dismemberment insurance

  • Long-term care insurance.

Note that supplemental health plans are not a substitute for comprehensive health coverage. This is because most supplemental plans do not meet minimum essential coverage (MEC). Still, they are suitable for individuals who want limited benefits for specific preventive treatments, critical illnesses, or health conditions.

What Health Insurance Rights Do I Have in Pennsylvania?

You should be aware of certain rights when shopping for a Marketplace (Affordable Care Act-compliant) insurance plan in Pennsylvania. These rights include:

  • The right to appeal an insurer's decision

  • No insurer can deny you coverage because you made a mistake on your application

  • No insurer can deny you coverage or increase your premiums due to pre-existing conditions

  • The right to receive free preventive care like blood pressure screening, colorectal screening, and immunizations

  • The right to remain on your parent's health plan if you are under 26 years old, even if you are married or working

  • An insurer must provide you with easy-to-understand information about your health benefits. They must give you documents like a Summary of Benefits and Coverage (SBC) written in simple terms and a glossary of medical care and health coverage terms to help you compare plans.

If your insurer makes it more difficult for you to access behavioral health services than physical health services or have questions about this requirement, contact the Pennsylvania Insurance Department at (877) 881-6388. You can also file complaints through the Consumer Services Bureau page. In addition, you can lodge a complaint via the Pennsylvania insurance complaint page if you have health insurance-related complaints.