Pennsylvania Individual Health Insurance Regulations

People seeking affordable health insurance plans in Pennsylvania should know that their applications will be medically underwritten to determine whether the insurer will accept or decline the application. The process is also utilized to determine premium rates. During underwriting, the insurer may review the applicant's medical history and current medical condition; the insurer may review up to 60 months prior to the application date. Once the process is complete, the health insurance provider has the right to either accept the application and provide medical coverage or decline the application.

The law in Pennsylvania states that insurers may impose a three year period excluding coverage for condition labeled as pre-existing during the underwriting process. Insurers are not required by law to credit prior coverage. However, the insurer reserves the right to place elimination riders on a plan, denying coverage for specific conditions that have been identified as pre-existing.

Pennsylvania Blue Cross Blue Shield health insurance provides a selection of health plans offering guaranteed issue to all consumers, regardless of current health or medical history. Guaranteed issue plans vary from city to city in Pennsylvania and often come with increased premiums as well as limited benefits.

Small Group Pennsylvania Health Insurance Regulations and Guarantee Issue

There are no specific regulations regarding the definition of a small group in Pennsylvania, therefore, insurers have the freedom to determine who qualifies for small group insurance in Pennsylvania. Typically, an insurance provider recognizes a small group based on the number of employees being between two and 50.

Insurers in Pennsylvania require certain information before being able to move forward with an application for coverage within a small group. Items such as tax return forms, a group census, and an unemployment compensation report are among the information requested.

Because Pennsylvania requires insurers to provide group health insurance on guaranteed issue, coverage cannot be declined to a group based on health issues or medical claims for an individual or for the entire group.

In the case of applicants without prior creditable coverage, insurance providers may impose a one-year exclusion period for any condition labeled pre-existing. Insurers have the right to review the medical history up to 6 months prior to application date.

It is during the process of medical underwriting that the premium rates for each group are determined; the premiums may not exceed 300% of the standard rate.

Understanding Pennsylvania COBRA and Continuation Coverage Issues

While some states have a mini-COBRA plan for groups with less than 20 employees, Pennsylvania only offers COBRA benefits to groups with 20 or more. The coverage gives employees the opportunity to stay with the group coverage for a period of 18 months as long as they pay premiums and a 2% admin fee. There are conversion products available to employees who do not choose COBRA or have exceeded the 18 months on the COBRA plan. Pennsylvania's Blue Cross Blue Shield provides plans with guarantee issue to people who are unable to obtain coverage through private insurers.

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