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Pennsylvania Health Insurance

Health insurance is an important precaution when it comes to insuring your financial future as well as your family’s overall health. Protecting your family against the occurrence of illness or injury is indeed tough; however a suitable health policy can relieve your financial worries caused by these situations. When shopping for health coverage, you should evaluate all potential risks and its effect on your finances. In the U.S., approximately 47 million people are uninsured, majority of whom are working families. These families, especially children, become the victims of the lack of proper health coverage. For those families who are not covered by their employers’ group plan, there are low-cost state sponsored health insurance programs that provide insurance to these individuals.

Pennsylvania is the 27th healthiest state to live in and obtain health coverage, according to the United Health Foundation’s 2008 Health Rankings. The state fell from its 24th position in 2007; it was on 28th position in 2006. The major strengths of Pennsylvania include low number of uninsured residents, deceasing percentage of children under 18 in poverty, ready access to primary care and low geographical disparity within the state. However, the state of Pennsylvania, with more than twelve million people, offers both private-market and public health insurance alternatives. The private-market health insurance consists of various types of health plans including family, Medicare supplemental, short-term, student, group and dental. Additionally, the state and federal government sponsored programs provide low-priced coverage to the uninsurable residents of Pennsylvania who meet specific eligibility requirements of age and income.

The Pennsylvania Insurance Department manages and supervises all kinds of insurance sold through private-market health insurers as well as public health coverage programs. However, as the state deals with issues concerning high levels of pollution, approximately 9.8% of the state population remains still uninsured. According to the Censor Bureau’s 2007 and 2008 Current Population Survey, roughly 36.5% of Pennsylvania’s uninsured residents come under the above 200% FPL category.

Buying health coverage is easier said than done, however, with the help of a licensed health insurance agent/broker, you can choose a proper health insurance plan with benefits suiting you and your family.

Individual/Family Health Insurance

Below is the guidelines for applying for and obtaining individual health insurance in the state of Pennsylvania. These regulations apply to all insurance companies offering individual or family health insurance in Pennsylvania:

Medical Underwriting


Pre-Existing Condition Exclusion Period

12 months

Look Back Period

60 months

Look Back Standard


Mandatory Benefits

Cancer screening for women including breast cancer screening and cervical cancer screening, IP mastectomy stay as determined by the physician, reconstructive surgery after mastectomy, direct access to OB/GYNs

Market Rate Restrictions


Guaranteed Issue Options


Small Group Health Insurance

Below is the guidelines for small group health insurance in the state of Pennsylvania. These regulations apply to all insurance companies offering small group health insurance in Pennsylvania:

Small Group Size


Employee Qualifications

Two employees must work for at least 6 months out of the year, and work 20 hours per week

Guaranteed Issue


Premium Rating Factors

No Rating Restrictions

Rate Adjustment Factors

Rate variations allowed up to 300% of the base rate

Look-Back Period

6 months

Pre-existing condition exclusionary period

12 months

Mandatory Benefits

Same as Individual

State Cobra Variations for Small Groups

Below are the COBRA guidelines for small groups in the state of Pennsylvania. For employer groups of more than 20 employees, refer to the federal COBRA guidelines:

Mini-Cobra Option


Eligible Group Sizes


Extension of Benefits Period - Standard


Extension of Benefits Period - Disabled


Maximum Premium Increase


State Legislation Reference


Additional Notes


State Sponsored Health Insurance Programs

There are several state sponsored health insurance programs in the State of Pennsylvania to assist those without insurance in obtaining adequate coverage.

High-Risk Pools

ome states offer special state sponsored health insurance plans for qualified persons that are not eligible for individual health insurance due to pre-existing medical conditions. However, Pennsylvania does not have a high risk pool for its residents who are unable to obtain private health insurance due to high-risk health status.

Children’s Health Insurance Program

Through shared funding from the federal government, the State of Pennsylvania provides health insurance for uninsured children that meet certain eligibility guidelines. A summary of this program is outlined in the chart below:

Program Name

Pennsylvania’s Children’s Health Insurance Program (CHIP)


Phone Number


Apply Online


Age Limits

Under 19

Insurance Carrier

Aetna, AmeriChoice, Capital BlueCross, First Priority Health (BCNEPA), Highmark Blue Shield (Central PA), Highmark Blue Cross / Blue Shield (Western PA), Keystone Health Plan East (IBC), Unison Kids, UPMC for Kids

Length of Coverage

12 months

Residency Requirements

Pennsylvania resident, U.S. citizen, Qualified Alien

Other Eligibility Requirements

The child must be uninsured for six months and not be eligible for Medical Assistance

Pre-Existing Condition Exclusions



Cost depends on whether your child qualifies for free, low cost, or full cost health coverage. Average Premiums range from $0 to $195, with co-payments of $0-$50.


Medicaid is a state program partially funded through the federal government. Qualification guidelines, as well as the types of people that are eligible, will vary by state. The chart below provides a summary of the Medicaid programs in the State of Pennsylvania:

Governing Agency

Pennsylvania Department of Public Welfare


Phone Number


Residency Requirements

Pennsylvania resident and U.S. citizen

Federal Poverty Line Income Limits

Pregnant women and infants age 0-1: 185% FPL
Children (ages 1-5): 133% FPL
Ages 6-19: 100% FPL (also aged, blind and disabled)
Parents with incomes up to 200% FPL can also apply for the Adult Basic program (which currently has a waiting list for coverage)
SSI recipients: 74% FPL
Medically Needy Individual: 59% FPL
Medically Needy Couple: 46% FPL

Additional Resources

Pennsylvania Health Care Options Matrix™ Guide

Provided by the Foundation for Health Coverage Education, the guide is a quick reference guide prepared by the non-profit Foundation for Health Coverage Education that outlines Pennsylvania’s public and private health care choices for individuals and groups with various demographic profiles.

Family Health Insurance Guide by

The guide created by provides useful information regarding health insurance coverage such as individual/family health insurance, group health insurance, separate child health insurance and state-sponsored programs that are available for low to middle income families.

Pennsylvania: At-A-Glance

Provides exclusive health data of Pennsylvania. is a project of the Henry J. Kaiser Family Foundation and is designed to provide free, up-to-date, and easy-to-use health data on all 50 states.