What is Health Insurance, and How to Get One in Pennsylvania?

Health insurance is an important component of your whole well-being. It offers protection against unexpected medical expenses. Although not mandatory, the importance of having it can’t be over-emphasized.

Knowing how to get health insurance is crucial for Pennsylvania residents seeking comprehensive health coverage. This guide aims to clarify health insurance and offer insights on obtaining it. You will learn the health insurance basics and how to navigate your way in the insurance industry. Whether you’re new or have been here for a while, this information will help you understand the types of health insurance jargon and make informed healthcare decisions.

HealthCare.gov states it is “A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.”

It offers a way to reduce to a reasonable cost of your medical expenses since the company or insurer agrees to pay all or some of your healthcare costs in exchange for a premium.

The premium you pay to the health insurance company or insurer allows you to share risk with many other people (like you who enrolled for a policy) who are making similar payments. Insurance companies will profit from the excess premiums not paid out and from investing out of those premiums.

In the U.S., health insurance agreements generally come with coverage exceptions, including:

1. A deductible that requires you to pay certain “out-of-pocket” costs up to a maximum amount agreed before the insurance coverage kicks in.
2. Co-payments for certain services or procedures, where you pay a set share of the cost.

COVID-19 gave way to the most unprecedented payout in the insurance industry. Over $1,211 billion has been spent by private insurance companies on healthcare providers (the amount also includes nonmedical costs).

Governments worldwide scrambled for funds to treat and contain their people to stop the spread of the virus. Regulations and legislations were amended to ensure that their people could get the health care they need without giving them the burden of the costs.

Despite the best efforts of our political leaders, resources dwindle, and financial assistance is limited.

And this is where insurance companies enter. To the uninsured, the hospitalization cost for coronavirus can go as much as $42,486 to $74,310.

Health insurance gives you peace of mind and protects against unforeseen conditions like COVID-19.

The recent pandemic is just one example. Other than that, health insurance also covers you to fight lifestyle diseases and safeguards your family from medical costs. It also deals with medical inflation and protects your savings. One critical illness can wipe out your entire savings in just one snap. Insurance can help you and your family feel at ease and comfort that you’re covered and your hard-earned money is safe.

Insurance companies have ways to cover your health expenses. Even though the methods vary, the only thing they are similar to is that most of the medical costs are covered by your insurer. Before your insurance pays your medical expenses, there are “out-of-pocket” expenses that you’re responsible for paying.

• A deductible is the amount you pay before co-insurance takes effect. First, you must know about deductibles to understand the difference between co-insurance and copays. A deductible is the fixed amount you pay annually for healthcare before your plan covers the costs of services. If you have a $1,000 deductible, you must pay that before insurance takes effect. Dependents on your policy have individual deductibles and have different amounts for the family.
• A copay is a fixed amount you must pay for prescriptions, doctor visits, and various forms of healthcare. It’s a payment to your medical provider when you receive services. Copays start at $10 and vary based on the type of medical care. Various copays apply to different types of visits and prescriptions. Your copay is due regardless of whether or not you’ve met your deductible. For example, if you have a copay set at $50 to see a specialist, you pay that $50 regardless of meeting your deductible.
• Co-insurance is the cost percentage you pay once your deductible is met. Your insurer, depending on your plan, pays the rest. An “85/15” plan covers 85%, and you pay 15% until you reach the out-of-pocket limit. It’s worth noting that co-insurance only applies to covered services stipulated on your plan. To know more about the services available to your plan, check the copy of your policy or call your financial advisor.

Plans have separate costs for in-network and out-of-network providers. In-network providers have negotiated special rates with your plan. Everything else falls under out-of-network providers, which tend to be more costly.

Prioritize in-network providers for your healthcare needs. Verify that your plan’s network includes your preferred doctors and facilities. If not, switching health plans during the next open enrollment period could make financial sense.

To give you more clarity, here’s an example provided by Investopedia:

Say you have an individual plan (no dependents) with a $3,000 deductible, $50 specialist copays, 80/20 coinsurance, and a maximum out-of-pocket limit of $6,000.

You go for your annual checkup (which is free because it’s a preventive service) and mention that your shoulder has been hurting. Your doctor sends you to an orthopedic specialist (for a $50 copay) to take a closer look.

That specialist recommends an MRI to find out what’s going on. The MRI costs $1,500. You pay the entire amount because you haven’t met your deductible yet.

As it turns out, you have a torn rotator cuff and need surgery to fix it. The surgery costs $7,000. You’ve already paid $1,500 for the MRI, so you need to pay $1,500 of the surgery bills to meet your deductible and have the coinsurance kick in. After that, your share is 20%—which, in this example, is $1,100. All in, your torn rotator cuff costs you $4,100.

Pennsylvania is home to over 13 million residents, making it the fifth most populous state in the United States.

It has a diverse healthcare landscape with numerous hospitals, clinics, and medical practitioners’ offices spread across the state.

In recent years, the state has been grappling with rising healthcare costs, with healthcare representing one of the state’s most significant expenses. In 2020, healthcare spending in Pennsylvania was about $13, 557 per capita, making the total spending around $176.2 billion, the 14th highest healthcare spending per capita in the country.

Additionally, many Pennsylvanians remain uninsured despite the Affordable Care Act (ACA) and Pennsylvania’s adoption of Medicaid expansion. In 2021, the uninsured rate in Pennsylvania stood at 5.49%, with approximately 713,000 individuals without health insurance.

The impact of health insurance on overall health outcomes in Pennsylvania cannot be overstated. Uninsured individuals in the state are less likely to receive preventive care or access care for chronic conditions, leading to adverse health outcomes.

Furthermore, research indicates that the availability of health insurance can increase access to health care, improve outcomes, and reduce overall healthcare costs.

If you are looking to get health insurance in Pennsylvania, there are several options available to you. We’ll take you through the process of getting health insurance. These are the several ways to purchase health insurance in Pennsylvania; it could be through:

1. Your employer
   Check with them if they offer any health insurance coverage. Every employer with over 50 full-time employees is legally required to offer this.
2. Healthcare Marketplace
   If your employer offers no health insurance, visit your state’s healthcare marketplace. It’s a government-run website where people can buy health insurance plans. In Pennsylvania, the official marketplace for insurance, whether health or life, is Pennie. Here, you can browse a range of options and see which plans offer you the coverage you need.
3. Private Insurance Companies
   These insurance companies, like Simpson Benefits, offer customized insurance plans for individual healthcare needs. To find the right insurance provider, compare coverage, costs, and customer service from different companies. Reviewing the terms and conditions and understanding the costs involved is important.

Once you have selected the health insurance plan that best meets your needs, you must apply and provide information such as your personal details, employment, income, and any pre-existing medical conditions.

During the process of shopping for health insurance, it’s also worth noting that there are federal health insurance that offer free-of-charge services to those who qualify. For example, Medicare offers free medical services for 65-year-old and older citizens. For your kids or children, a free to low-cost government insurance called the Children’s Health Insurance Program (CHIP)or Medicaid. When you have been laid off, the COBRA program enables you to maintain the insurance coverage previously offered by your former employer. COBRA coverage offers a 60-day election window, that’s if you qualify. If you decide to keep your COBRA health insurance plan, you’ll be responsible for covering the employer’s portion of the premium.

Through Commonwealth’s COMPASS tool, you can access Pennsylvania’s health and human service programs.

When selecting a health insurance plan, it is crucial for you to assess your individual needs and set a budget.

Consider your medical conditions, lifestyle, and healthcare habits to determine the appropriate coverage levels. When setting up the budget for your premium, consider the other out-of-pocket costs like deductibles and co-payments.

Simpson Benefits offers personalized and affordable health insurance in Pennsylvania. We’ll help you analyze your budget and make a great balance with your out-of-pocket maximums, deductibles, co-payments, and co-insurance.

Simpson Benefits is your best bet if you’re looking for affordable health insurance in Pennsylvania. We provide individuals and families with customized and affordable health insurance plans. We understand the value of having access to quality healthcare coverage, and they strive to make it accessible and affordable for everyone.

Simpson Benefits offers tailored Pennsylvania health insurance plans. Their friendly insurance advisors help you find the right health plan for your needs and budget, providing personalized guidance throughout enrollment.

Affordability is our key focus, with competitive rates and flexible payment options. Our plans provide peace of mind in times of emergencies. In addition to affordability, we pride ourselves on excellent customer service, prioritizing satisfaction, and going above and beyond for clients. We’re available for support and to answer questions.

This blog discusses the importance of health insurance in Pennsylvania and how to obtain it.

We explored different ways to get health insurance, including through employers, the healthcare marketplace, or private providers like Simpson Benefits.

Assessing individual healthcare needs, setting a budget, and selecting the right health plan is crucial. Health insurance offers financial protection for healthcare needs, both routine and emergencies, providing peace of mind. It ensures access to quality healthcare services and helps manage costs. We encourage residents of Pennsylvania to take action by researching providers like Simpson Benefits and comparing plans to find the best fit. Don’t delay securing coverage that includes your essential health benefits for peace of mind and financial security.