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Tips for Navigating the Health Insurance Marketplace in Pennsylvania

The Pennsylvania Health Insurance Marketplace can be divided into Medicaid or CHIP users, Medicare users, and those who are commercial fully-insured or commercial self-insured. Most individuals fall under commercial fully-insured and self-insured, meaning that they will have to pick their coverage level and plan type for themselves. For those looking to understand their options, here are some helpful tips for navigating the Health Insurance Marketplace in Pennsylvania.

Coverage levels

Your coverage level will need to be determined by your household’s specific medical needs and financial constraints. For minimum coverage, the Bronze level is recommended, and for maximum coverage, the Platinum level is a good option. There are also plenty of plans in between that may better suit your medical and financial needs.

  • Bronze – This coverage level has the lowest monthly premiums, but the highest deductibles. The Bronze level is suited for those who only want coverage for medical emergencies. You will also need to pay out of pocket for most of your routine care.
  • Silver – This level has moderate premiums and moderate deductibles, but is a great coverage level for those who qualify for “extra savings.” Silver coverage can save you money with “extra savings” and covers more of your routine expenses than Bronze.
  • Gold – Gold-level coverage has higher monthly premiums and lower deductibles. This level covers most of your medical expenses and is a good choice if you need frequent medical care.
  • Platinum – The most expensive coverage level is Platinum. This level has the highest premiums but the lowest deductibles, and covers almost all of your medical expenses. If you visit multiple specialists regularly, this is your best option.
  • Catastrophic – Catastrophic coverage is only available to individuals younger than 30 years of age who qualify for hardship exemption. This coverage level only covers the bare minimum and requires most expenses be paid out of pocket.
Plan Types

There are plan types for every level of coverage, which you will also need to decide on. Choosing a plan is usually determined by your preference in physician, hospital and your specific medical needs. It is important to consider all these factors before making a decision.

  • Exclusive Provider Organization (EPO) Plan – This plan only allows you to use physicians and hospitals within a plan’s network. The only exceptions to this rule are medical emergencies.
  • Health Maintenance Organization (HMO) Plan – HMOs usually require you to live within the network area. They may often only allow you to see doctors within the network and require you to use pre-approved hospitals, unless it is a medical emergency.
  • Point of Service (POS) Plan – With POS plans, you are allowed to see doctors outside of the network, but only with a referral. You will pay less for choosing a doctor within the network, but will be charged extra for choosing care outside the network.
  • Preferred Provider Organization (PPO) Plan – PPO plans do not require a referral if you wish to see a doctor outside of the plan’s network. However, you may have to pay extra for seeing a physician or visiting a hospital outside of the network, depending on the plan.