Pennsylvania Health Insurance (PA)

As full-scale implementation of the provisions of the 2010 Patient Protection and Affordable Care Act progresses, all the states are faced with aligning their insurance regulations with federal law. A major point on which the health care reform package focused was insurance exclusions for pre-existing conditions. Such exclusions are no longer allowed for children, who also may remain on their parents’ health policies until age 26. For the next two years, adults with pre-existing conditions will be able to purchase coverage through high-risk pools, which will be replaced on January 1, 2014 with the federally mandated health care exchanges.

General Insurance Regulations

Currently, insurers in Pennsylvania may exclude coverage for pre-existing conditions for 12 months with a five-year look-back period. On policies that include coverage for dependent, adopted children and newborns are automatically covered for a period of 31 days. (Some insurers require a 30-day probation period.)

Blue Cross Blue Shield in Pennsylvania must provide coverage for all residents regardless of health status. Rates may be set, however, according to not only the applicant’s overall health condition, but also their age, gender, and the size of their family.

Health Care Exchange

Pennsylvania is continuing to study options for the implementation of a health care exchange, but there has been no substantive progress since April 2011. If the federal timetable is not met by January 1, 2013, the U.S. Department of Health and Human Services will assume responsibility for the project.

Pre-Existing Condition Insurance

The Pre-Existing Condition Insurance Program in Pennsylvania is known as PA Fair Care. The coverage includes benefits for primary and specialty care as well as hospitalization and prescription medications. Premiums are set at $283.20 a month with a $1000 in-network deductible and an in-network out-of-pocket limit of $5000.


Eligibility for Medicaid is figured according to income as a percentage of the current Federal Poverty Level. In Pennsylvania, children under one year of age can receive Medicaid at 185% FPL, ages 1-5 at 133%, and ages 6-19 at 100%.

Pregnant women are qualified for benefits at 185% FPL, parents at 31%, adults (state funds only) at 200%, and disabled Social Security recipients at 74%.


Approximately 18 percent of residents in Pennsylvania receive Medicare benefits, with more than 2,225,000 relying on a prescription drug plan.

The state also offers a Long Term Care assistance program, as well as the Pharmaceutical Assistance Contract for the Elderly (PACE) to further offset prescription costs.