Health Insurance for Seniors
Throughout your adult life, you have probably had health
insurance mostly through your employer or your spouse’s
employer. Employer-provided insurance
has costs for employees such as paying a portion of the monthly premium, a deductible,
and co-pays for certain services.
If you are retiring and are not yet 65 -- something that is
more common in today’s economy -- you may now be faced with the need to buy
private health insurance for the first time.
Some employers may offer health insurance for their retirees or a fixed
amount per month to help pay private insurance premiums. You should discuss any company assistance
with your human resources office before retiring.
However, in many cases, you will be on your own to purchase
health insurance coverage for yourself and your family after retirement. This can be very expensive, and finding the
most affordable plan that offers the coverage you need can be challenging. Here are some questions you may want to
What options are available if I need to buy insurance on my
Fortunately, the Affordable Care Act (ACA) has made more
options available to individuals and families who need to buy their own health
insurance. Under the ACA, insurance
companies that sell plans directly to individuals and families (referred to as
the private market) can no longer deny insurance or charge more because of
pre-existing conditions, so any individual or family can now purchase coverage
in the private market. Additionally,
Pennsylvania residents may compare plans and purchase private health insurance
through what is called the Federally-Facilitated Marketplace (FFM).
One advantage of using the Federally-Facilitated Marketplace
to buy your health insurance is that you may be eligible for a subsidy to help
pay your premium. Currently, premium
subsidies are available for families of four with annual incomes below $95,400,
for couples with incomes below $ 62,920, and for individuals with incomes below
$46,680. Additional financial assistance
is available for families of four with annual incomes below $59,625, couples
with annual incomes below $39,325, and individuals with annual incomes below $29,175.
While private insurance can be purchased outside of the FFM,
you can only receive financial assistance if you purchase your insurance
through the FFM. Additionally, your
children may be eligible for a subsidized version of CHIP or, depending on your income, you may be eligible for Medicaid.
There are four different levels of health plans sold in the
private market, either through the FFM or directly to consumers. The levels are determined by how much you
will have to pay out-of-pocket for your health care, not by the quality or
level of care offered. The four levels
-Bronze—which has the lowest monthly premium, but highest our-of-pocket expenses, such as deductibles and co-pays;
-Silver—this has a more standard monthly premium and out-of-pocket costs;
-Gold—higher monthly premiums, lower out-of-pocket costs;
-Platinum—this plan has the highest monthly premium, and lowest out-of-pocket costs.
How can I compare benefits and understand what is covered by
All plans in the private market, including those sold on the
FFM, offer the same core set of benefits called Essential Health Benefits (these include
doctor’s visits, prescriptions, hospitalizations, rehabilitative services, and
more). This lets consumers compare plans
on an “apples to apples” basis. Plans
may include additional benefits but cannot cover less than these Essential Health
Benefits. All plans offered in Pennsylvania’s
private health insurance market are approved by the Pennsylvania Insurance
All insurance companies must provide consumers with a
Summary of Benefits and Coverage and a glossary of commonly used terms before
enrollment or renewal. This is designed
to help consumers compare plans and understand the benefits and coverage limits
of their plan clearly and concisely.
Using the benefits summary, consumers can compare insurance
options based on covered benefits, excluded services, deductibles and other
out-of-pocket costs, as well as other features that may be important to
them. The doctors and other providers who
participate in each plan is listed in that plan’s provider directory. The prescription drugs covered by each plan are listed in what is called that plan’s drug formulary.
Whether a doctor or other health care provider participates
in a given insurance plan is important. Participating providers typically provide services at what are called
“in-network” rates, which are usually much lower than providers who do not participate in
a given health plan. Costs for you to
see non-participating providers are considered “out of network” and are
usually much higher. While the
summary of benefits provides examples of costs you can expect, exact pricing and out-of-pocket costs
will depend on the specific plan chosen and the provider delivering the
If you have questions, you should check with the individual
companies or your insurance agent for information about these health plans.
Where can I go to apply for coverage or get more
For more information, and to fill out an application through
the FFM, visit www.healthcare.gov. Filling out the application here will also
help you determine whether you are eligible for programs such as Medicaid or a subsidized level of
CHIP. Consumers using the FFM can also get help understanding options and
enrolling in coverage by using the FFM’s Find Local Help tool
Note: There is an
open enrollment period during which anyone can purchase private health
insurance through the FFM. The next enrollment period is from November 1, 2015, through January 31,
2016. However, if your circumstances
change, like losing insurance because you are no longer employed or moving, you
can sign up anytime. There is no open
enrollment period for Medicaid or CHIP.
If you are considering buying private insurance, either
through the FFM or the private market, there are a number of questions you
should ask. For a list of questions,
visit the PA Health Options website. Remember to check to see if dental and vision
coverage are included or available under each plan.
Our Bureau of Consumer Services staff is also here to help
you work through the process. You may visit the bureau's website, file a complaint,
or contact a representative who can help you at 1-877-881-6388.