Key Takeaways
- Pennsylvania requires a 10-day free look period for individual health insurance policies
- The Pennsylvania Insurance Department regulates traditional health insurance; HMOs are also regulated under state law
- Pennsylvania requires coverage for mental health parity, mammograms, and other mandated benefits
- Pre-existing condition exclusions are prohibited in the individual and small group markets under ACA
- Pennsylvania operates a federally-facilitated health insurance marketplace (Pennie)
Pennsylvania Health Insurance Policy Requirements
Pennsylvania has comprehensive health insurance regulations that work alongside federal requirements. Understanding these state-specific rules is essential for the licensing exam.
Regulatory Structure
Pennsylvania health coverage is regulated by:
| Agency | Regulates |
|---|---|
| Pennsylvania Insurance Department (PID) | Traditional health insurers, PPOs, disability |
| PID Health Bureau | HMOs and managed care organizations |
HMO Regulation in Pennsylvania
Pennsylvania regulates Health Maintenance Organizations (HMOs) through:
- Pennsylvania HMO Act
- Quality assurance requirements
- Network adequacy standards
- Grievance and appeals processes
- Financial solvency requirements
Free Look Period
Pennsylvania requires a 10-day free look period for individual health insurance:
- Policyholder can return for full premium refund
- Begins when policy is delivered
- Applies to individual health policies
- Same as life insurance free look (10 days standard)
Exam Tip: Pennsylvania's health insurance free look is 10 days for all ages, unlike life/annuity where seniors 65+ get 30 days.
Required Coverage
Pennsylvania mandates coverage for numerous benefits:
State-Mandated Benefits
- Mammography screening
- Diabetic supplies and education
- Colorectal cancer screening
- Mental health and substance abuse parity
- Maternity care
- Childhood immunizations
- Reconstructive surgery after mastectomy
- Clinical trials participation (for certain conditions)
Mental Health Parity
Pennsylvania's Mental Health Parity requirements mandate:
- Mental health benefits comparable to medical benefits
- Same copays, deductibles, and limitations
- Covers mental illness and substance use disorders
- Applies to group and individual plans
Covered Conditions
- Major mental disorders
- Substance use disorders
- Eating disorders
- Autism spectrum disorders
- Serious emotional disturbance (children)
Pre-Existing Condition Protections
Pennsylvania follows federal ACA requirements:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual (ACA-compliant) | Prohibited |
| Small Group | Prohibited |
| Large Group | Limited restrictions under ACA |
| Short-Term Plans | May apply |
Pennie - Pennsylvania's Marketplace
Pennie is Pennsylvania's state-based health insurance marketplace:
- Replaced the federal marketplace in 2021
- Only place to get premium subsidies
- Offers qualified health plans (QHPs)
- Open enrollment and special enrollment periods
Key Features
- Plans categorized by metal tiers (Bronze, Silver, Gold, Platinum)
- Premium tax credits based on income
- Cost-sharing reductions for Silver plans
- Special enrollment for qualifying life events
- Available at Pennie.com
Guaranteed Issue and Renewal
Pennsylvania requires:
Guaranteed Issue
- Insurers must accept all applicants in ACA markets
- Cannot deny coverage based on health status
- Applies to individual and small group markets
Guaranteed Renewal
- Insurers cannot cancel coverage except for:
- Non-payment of premium
- Fraud or misrepresentation
- Plan discontinuation (with notice)
What is the name of Pennsylvania's state-based health insurance marketplace?
How long is the free look period for individual health insurance policies in Pennsylvania?