En español | Most Pennsylvanians are eligible to buy health insurance through Pennie, the state’s Affordable Care Act (ACA) marketplace. And you might be able to save money on premiums, thanks to expanded federal tax credits in the March coronavirus relief bill. Pennie’s open enrollment begins on Nov. 1, but you may be able to switch to a marketplace plan if you get married, have a baby or experience another qualifying life event.
Most people already enrolled in ACA marketplace plans will also see their premiums go down this year because the recently enacted American Rescue Plan increases tax credits for insurance premiums and expands the number of households who qualify for them. Every household that pays more than 8.5 percent of their household income now qualifies for federal tax credits to help them afford health insurance. Prior to the new law, such tax credits were only available to people making up to 400 percent of the federal poverty level (around $51,000 for one person).
The average American with a marketplace plan can save $50 per month with the new assistance, the federal government says. As of now, this additional federal financial assistance will only be available in 2021 and 2022.
Who is eligible?
- Most Pennsylvanians are eligible to buy health insurance through Pennie, regardless of whether they are currently insured. Some non-U.S. citizens may also be eligible.
- Low-income people and families may also qualify for free or low-cost health insurance through Medicaid. You can fill out a questionnaire through the state’s COMPASS benefits portal to see if you’re eligible for Medicaid. If you start a Pennie application and realize you’re eligible for Medicaid, you’ll be redirected to COMPASS and won’t need to reenter your information.
- The Children’s Health Insurance Program offers health insurance for children and teens in families with incomes too high to qualify for Medicaid but who still may struggle to find affordable coverage. You can apply for the program through the COMPASS benefits portal or by calling 800-986-5437. If you start a Pennie application and realize your children are eligible for the program, you’ll be redirected to COMPASS and won’t need to reenter your information.
When can I enroll?
- Pennie’s open enrollment runs from Nov. 1 through Jan. 15.
- You can enroll anytime if you experience a qualifying life event but you only have 60 days from that event to enroll. Qualifying events include certain moves, births and adoptions, loss of employer-provided coverage, marriage, divorce and other special circumstances.
- You can also enroll anytime if you qualify for Medicaid, if your children qualify for CHIP or if you’re a member of a recognized American Indian tribe.
How do I sign up?
First, use the Pennie Plan Comparison Tool or contact a certified enrollment assister to estimate costs and sort through various plan options. Once you’re ready to sign up, you can apply online, over the phone or through an assister or insurance broker, in person or by phone. Once you’re approved for a plan, you’ll need to pay your first monthly premium for your coverage to begin.
To apply and enroll:
- Online: Go to Pennie’s website and click “Get Covered.” You’ll need to create an account and, if you have them, to provide your Social Security number and proof of household income, such as recent pay stubs or federal or state tax returns.
- By phone: You can enroll over the phone by calling Pennie’s service center (844-844-8040)
- Through an assister or broker: Both offer free help with creating an account and selecting a plan, but only brokers can offer advice about what’s best for you. Pennie’s website lets you search for assisters and brokers by zip code. You may be able to meet with an expert in person or virtually.
You can also call Pennie’s service center (844-844-8040) to ask questions and to help determine if you qualify for financial assistance.
What is covered, and how much will it cost?
Coverage and cost depend on where you live, the type of plan you choose, your estimated household income, and the age and disability status of you and your family.
If you qualify for Medicaid, you will be able to get free or low-cost coverage and may not need to worry about premiums or copays, depending on your level of income.
All Pennie plans cover 10 “essential” benefits, including:
- Emergency services and hospitalization
- Pregnancy, maternity and newborn care
- Mental health services (including counseling)
- Chronic disease management and pediatric care
- Prescription drugs
Insurance companies cannot deny coverage because of preexisting conditions. When you apply, you can identify your medical needs and choose a plan that makes financial sense for you and your family.
All Pennie plans cover basic dental services for children, including cleanings and exams. But adults who want dental coverage must add it to their policy or get a separate plan. Deductibles and out-of-pocket costs vary between plans.
What about new federal assistance for premiums?
Every eligible household that pays insurance premiums that exceed 8.5 percent of annual income now qualifies for federal tax credits for insurance premiums.
For example, a single 64-year-old filer earning $51,000 per year could potentially save more than $8,000 with the new tax credits, according to the Kaiser Family Foundation.
Is there any other financial assistance available?
Yes. If you qualify for a premium tax credit, you may also qualify for a cost-sharing reduction that would help you pay for such out-of-pocket expenses as deductibles and copays. You must enroll in a Silver-level plan to get this assistance.
If you’ve collected unemployment benefits this year, even for just one week, you may qualify for an almost $0/month premium health coverage option, thanks to the American Rescue Plan. This extra financial help will expire at the end of 2021.
What plans are available?
Pennie’s plans are organized into four categories:
- Bronze plans have the lowest monthly premiums and the highest deductibles and copays, and cover roughly 60 percent of care costs. They’re designed to help you in case of serious illness or injury.
- Silver plans have moderate monthly premiums, deductibles and copays. They cover roughly 70 percent of costs. They’re the only plans eligible for cost-sharing subsidies.
- Gold plans have higher monthly premiums and lower deductibles and copays, and cover roughly 80 percent of care costs.
- Platinum plans have the highest monthly premiums and the lowest deductibles and copays, and cover roughly 90 percent of care costs. These are for people who have significant health care needs and are willing to pay the highest premiums.
The Pennie Plan Comparison Tool helps you estimate costs and benefits of various plans and check whether you might qualify for financial assistance. Pennsylvanians younger than 30 can also apply for a catastrophic plan offering low premiums but with high deductibles.
What if I already have health insurance?
If you already have coverage through your employer or directly through an insurance provider but are eligible for lower premiums, you can switch to Pennie. But you may not qualify for tax credits if you opt out of your employer’s plan — unless those premiums exceed a certain portion of your household income. The premiums would need to be more than 9.83 percent of your household income for individual coverage to qualify for the tax credits.
If you get coverage through the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) because you were terminated from a job or were put on reduced hours, you should be receiving a temporary COBRA premium subsidy that covers 100 percent of your monthly premium cost. This premium assistance, made possible through the American Rescue Plan, runs through the end of September or the end of your last month of COBRA eligibility, whichever comes first.
If you’re on COBRA, you may want to sign up for a marketplace plan that starts as soon as your COBRA coverage ends. If you’re not sure about whether making this switch makes sense for you, you can ask for free advice from a certified insurance broker or assister.
Will I need to get a new doctor?
That depends. Major insurance providers, including Capital Blue Cross, Highmark and UPMC, offer Pennie plans, but not all doctors accept them. You can talk to your primary care physician to see whether he or she accepts a particular marketplace plan.
Will my family members qualify for the same health plan that I do?
It depends. You can enroll as a family. But in some cases, some family members may also be eligible for subsidies or other programs such as Medicare, Medicaid or the state’s Children’s Health Insurance Program, depending on age, income and disability or caregiver status. Such families may choose to enroll separately. They may still be able to see the same doctor or go to the same medical practice, depending on the types of insurance plans accepted.
This guide was updated on Aug. 16 with more information about open enrollment.