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Small Business Employee Benefits and HR Blog

Pennsylvania Health Insurance Exchange Guide

This guide provides an overview of the Pennsylvania Health Insurance Exchange including the history of the exchange, how the exchange will operate, and exchange information for Pennsylvania residents and small businesses.

Pennsylvania Health Insurance Exchange Introduction

Pennsylvania Health Insurance Exchange

Beginning in 2014, as part of the Affordable Care Act (ACA), health insurance coverage for individuals and small businesses will become available through new state health insurance exchanges (also called health insurance marketplaces).

Most importantly, the key tax credits (e.g. the small business healthcare tax credits) and tax subsidies (e.g. individual health insurance tax subsidies) will only be available for coverage purchased through a state health insurance exchanges.

All states have three options for setting up a state health insurance exchange for 2014:

  1. Build a state-based exchange
  2. Enter into a state-federal partnership exchange
  3. Default to a federally-facilitated exchange

Pennsylvania will default to a federally-facilitated health insurance exchange.

Pennsylvania Health Insurance Exchange - History

Originally, the Pennsylvania Insurance Department took the lead on planning for the health exchange. In November 2011, the Insurance Department released a report suggesting the state would support a state-based exchange. In January 2012 the Insurance Department released draft legislation to establish multiple private exchanges. However, there was concern that this type of model would not meet the ACA exchange requirements. In December 2012, Governor Tom Corbett announced that Pennsylvania would default to the federally-run exchange, citing uncertain federal guidance and cost.

Pennsylvania Health Insurance Exchange - What is It?

The Pennsylvania Health Insurance Exchange will be operated through a federally-run health insurance exchange, also referred to as the Health Insurance Marketplace. Starting in October 2013, Pennsylvania residents will be able to access information about all the plans available through the Exchange. The SHOP Exchange will also be available to small businesses with 100 or fewer employers. Coverage from the Exchange starts in January 2014.

According to an estimate by healthcare.gov, 1,242,351 or 12% of Pennsylvania’s non-elderly residents are uninsured, of whom 1,141,718 (92%) may qualify for either tax credits to purchase coverage in the Marketplace or for Medicaid if Pennsylvania participates in the Medicaid expansion. 

More information on the Pennsylvania Health Insurance Exchange can be found here.

Pennsylvania Health Insurance Exchange - What Plans will be Available?

All plans offered through the Pennsylvania Health Insurance Exchange will meet the ACA definition of a Qualified Health Plan (QHP). The plans will be offered by level of coverage for essential health benefits (EHB), to allow consumers to compare plans on an "apples to apples" basis. The four "metal" levels are: Bronze (plan pays 60%), Silver (plan pays 70%), Gold (plan pays 80%) and Platinum (plan pays 90%). More information on the types of plans that will be available, and the carriers offering plans in Pennsylvania, is expected by late summer 2013.

Pennsylvania Health Insurance Exchange - Role of Insurance Professionals & Navigators

The Pennsylvania Health Insurance Exchange will follow federal guidelines for insurance professionals selling policies through the Exchange and for navigators assisting consumers and small businesses.

Insurance professionals will be able to register with the Pennsylvania Health Insurance Exchange and receive any commissions directly from the carriers (using their Exchange ID number and NPN). 

The Pennsylvania Health Insurance Exchange navigator program will assist consumers in making choices about their health care options and accessing their new health care coverage, including access to premium tax credits for some consumers. The federal government will run the navigator program in Pennsylvania.