Question 1

What are the primary managed care policies available to Pittsburgh residents?

Accepted Answer

Pittsburgh residents can choose from a range of managed care policies, including HMO, PPO, and POS options. With HMO plans, healthcare services are channeled through the policyholder's primary care physician. These plans also require patients to obtain referrals prior to consulting specialists. PPO plans offer greater flexibility since patients are not obliged to have a primary care physician. In contrast, POS plans allow patients to select their primary care physicians and require referrals when accessing network specialists.

Question 2

Which health insurance providers are the top choices among older residents in Pittsburgh when it comes to health coverage?

Accepted Answer

The most popular health insurers for seniors in Pittsburgh include UPMC, Aetna, and Humana. While Cigna and Ambetter are licensed in Pennsylvania, they only provide plans for individuals under the age of 65 in certain areas. Humana, Aetna, and UnitedHealthcare do not provide individual marketplace insurance in the state, but they offer health insurance products tailored to seniors and groups.

Question 3

What are the basic enrollment periods that allow Pittsburgh residents to sign up for Original Medicare or a Medicare Advantage plan?

Accepted Answer

The initial enrollment period starts three months before a Pittsburgh resident's birth month. The special enrollment period accommodates those seeking Medicare enrollment after the age of 65 or those facing significant life events. The open enrollment period spans from January 1st to March 31st. It allows policyholders to make a one-time switch in their Medicare Advantage plans.

Question 4

Where can Pittsburgh residents file appeals or complaints related to health insurance?

Accepted Answer

Residents of Pittsburgh who have had a medical claim denied can submit an appeal through the Filing Health Insurance Appeals page, which is accessible at https://www.insurance.pa.gov/Coverage/Pages/appeals.aspx. For inquiries related to insurance matters or to register a complaint against insurance companies, agents, or brokers, individuals can access the Consumer Services Bureau at https://www.insurance.pa.gov/Consumers/Pages/default.aspx.

Question 5

Who is eligible for the University of Pittsburgh’s health insurance program?

Accepted Answer

The University of Pittsburgh extends its Medical Plan to full-time undergraduate students, full-time and part-time graduate students without an academic appointment, and full-time and part-time graduate students with an academic appointment. The medical plan does not have pre-existing condition restrictions or annual benefit caps. However, note that out-of-network coverage is available but at a reduced benefit level.

Question 6

How can you find affordable health insurance?

Accepted Answer

Affordable insurance is available through employers, Medicare, Medicaid, and the federal Health Insurance Marketplace, which offers subsidies in the form of tax credits. You can also purchase coverage through private insurance companies and independent agents. Nearly half of all Americans have employer-sponsored health insurance, and about 10% of the population is uninsured.

Question 7

What is health insurance?

Accepted Answer

Health insurance policies are contracts that require an insurer to pay some or all of a beneficiary's health care expenses in exchange for a premium and deductible. Plans cover preventive care and emergency medical services arising from an injury or illness. They may also offer optional coverage for dental and vision.

Question 8

How do health insurance companies make money?

Accepted Answer

Health insurance companies make money by collecting premiums from consumers and reinvesting the funds. Federal law requires insurers to put approximately 80-85% of collected funds toward claims, and 15-20% is used to pay for administrative expenses.

Question 9

What is subsidized health insurance?

Accepted Answer

Subsidized health insurance is available exclusively through the Health Insurance Marketplace. This system applies federal tax credits that can reduce or eliminate premiums. Tax credits are available to consumers who earn up to 400% of the federal poverty level based on household size.

Question 10

What is a health insurance deductible?

Accepted Answer

A deductible is a fixed amount you must pay out-of-pocket before normal copays or coinsurance rates apply. Under the Affordable Care Act, some services, such as annual physicals and wellness screenings, must be covered at no charge.

Question 11

Is it illegal to not have health insurance?

Accepted Answer

No. Starting in 2019, the federal government eliminated the penalty that applied to individuals who could afford health insurance but chose not to purchase it. Financial penalties still apply in California, Massachusetts, New Jersey, Rhode Island, Vermont, and Washington, D.C.

Question 12

Does health insurance cover therapy?

Accepted Answer

All Marketplace plans must cover behavioral health care services, including counseling, inpatient care, and substance abuse treatments. However, there are coverage limits, and preauthorization may be required.

Question 13

What is a copay?

Accepted Answer

A copay is a fixed price that you pay at the time of service after your deductible is satisfied. Insurance companies set specific rates for primary and specialty care and other services, such as emergency room visits and X-rays. Alternatively, plans may have coinsurance rates that require beneficiaries to pay a certain percentage of covered charges.

Question 14

What is the Health Insurance Marketplace?

Accepted Answer

The Health Insurance Marketplace is a federal service designed to help consumers compare and purchase subsidized health insurance plans that comply with the Affordable Care Act. A number of states operate their own insurance marketplaces, including California, Colorado, New York, and Pennsylvania.

Question 15

How can you find health insurance without a job?

Accepted Answer

Individuals who don't have access to health insurance through their job can purchase ACA-compliant plans through the Health Insurance Marketplace. Off-exchange plans are also available through private insurers and independent agents. The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives certain individuals who are losing their coverage the right to maintain the same plan for a limited time period.

Question 16

Can you cancel health insurance at any time?

Accepted Answer

Consumers can cancel their health coverage at any time. Cancellations may be effective immediately or at a specified date. However, you must wait until Open Enrollment to sign up for a new plan unless you qualify for a Special Enrollment period.

Question 17

Can you have more than one health insurance policy?

Accepted Answer

It's possible to have primary and secondary health insurance. This is most common with Medicare and Medicaid beneficiaries, including dual enrollees and individuals who purchase supplemental plans. Secondary plans can cover some additional expenses, but you're still responsible for premiums and deductibles.

Question 18

Is health insurance pretax?

Accepted Answer

Premiums for employer-sponsored health plans are generally deducted from the worker's pretax income. The same is true for voluntary contributions made to Flexible Spending Accounts and Health Savings Accounts that are paired with a qualifying high-deductible health plan.

Question 19

How long can a child stay on a parent\'s health insurance policy?

Accepted Answer

Children can stay on their parents' health insurance plan until their 26th birthday. There's a 60-day special enrollment period following this date. Exemptions allow disabled adult children to remain on their parents' policy beyond this age.

Question 20

Do you have to pay a health insurance deductible upfront?

Accepted Answer

In most cases, out-of-pocket expenses for approved services count toward your deductible. However, it's increasingly common for hospitals to request all or part of the deductible upfront when scheduling major services, such as CT scans and surgeries.

Question 21

Do employers have to offer health insurance?

Accepted Answer

The Affordable Care Act requires companies with at least 50 full-time employees to make essential health benefits available to 95% of their workforce. Companies that choose not to offer such benefits may have to pay a penalty.

Question 22

Is there a tax credit for having health insurance?

Accepted Answer

The Advance Premium Tax Credit is a federal tax rebate designed to lower the cost of health insurance plans purchased through the Marketplace. Eligibility is based on income and household size. Consumers can decide how much of their tax credit to put toward their premiums.

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Frequently Asked Questions

Introduction

What are the primary managed care policies available to Pittsburgh residents?

Which health insurance providers are the top choices among older residents in Pittsburgh when it comes to health coverage?

What are the basic enrollment periods that allow Pittsburgh residents to sign up for Original Medicare or a Medicare Advantage plan?

Where can Pittsburgh residents file appeals or complaints related to health insurance?

Who is eligible for the University of Pittsburgh’s health insurance program?

How can you find affordable health insurance?