Begin Main Content Area

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 consider:
What options are available if I need to buy insurance on my own?
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 are:

-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 a plan?
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 Department.
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 services. 
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 information?
For more information, and to fill out an application through the FFM, visit 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.