Understanding Health Insurance
You have to start somewhere. Let's break down the essentials of getting yourself insured.
What is the Affordable Care Act?
The Affordable Care Act (ACA) — sometimes called Obamacare — is the health care reform law that makes health plans available to people who are looking to buy their own health plan.
Coverage options when you’re uninsured
If you don’t have, or lose, coverage through your employer, you have a few different options for staying insured.
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ACA
Quality, affordable individual and family plans that cover preexisting conditions, the 10 Essential Health Benefits, and more.
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CHIP
Health coverage for uninsured children and teens under age 19. CHIP plans can be low-cost or free depending on household income.
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COBRA
COBRA is a federal program that allows you to extend employer benefits for a limited time after you lose your job.
Affordable Care Act (ACA) basics
Understanding insurance networks
What are the main differences between these types of provider networks?
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PPO
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EPO
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HMO
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PCP Required
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No
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No
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Yes
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Out-of-Network Coverage
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Out-of-network coverage typically costs more than in-network coverage, but emergency and urgent care are always covered at in-network rates. Highmark Individual and Family Plans cover routine care from out-of-network providers at two different levels: Routine care from an out-of-network provider in Pennsylvania may cost more than seeing an in-network provider. Routine care from an out-of-network provider outside of Pennsylvania may cost more than seeing an out-of-network provider in Pennsylvania. |
For medical emergency and urgent care only.
Emergency and urgent care are always covered at in-network rates. |
For medical emergency and urgent care only.
Emergency and urgent care are always covered at in-network rates. |
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Referrals needed
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No
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No
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Not Always
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Frequently asked questions
- Any U.S. citizen, U.S. national, or otherwise lawfully present in the U.S.*
- Individuals not currently incarcerated.
- Individuals not enrolled in a Medicare plan.
* Only a requirement for purchasing plans on the marketplace. There is no citizenship requirement for purchasing plans directly though Highmark or other health insurance companies.
- If you experience a major life event, you may qualify for a Special Enrollment Period to sign up for an individual or family plan
- Examples of qualifying life events: loss of employer-based coverage, birth of a child, move to a new ZIP code
- A Special Enrollment Period is your only opportunity to enroll in an individual or family plan outside of the annual Open Enrollment Period
You can purchase individual or family ACA plans via:
- Online marketplaces, also known as federal or state government exchanges. If you’re eligible for financial help, these plans can help lower your monthly premiums and out-of-pocket costs.
- Direct from Highmark. These plans don’t offer financial help, but you will find some additional plan options here.
- The annual Open Enrollment Period starts on November 1 in PA, DE, and WV and November 16 in NY. The end date varies by state.
- PA, DE, and WV: January 15
- NY: January 31
- For coverage that begins on January 1, regardless of state, enroll by December 15.
- Special Enrollment Periods last for 60 days from the qualifying life event.
Common terms
If you're confused by health insurance terms, you're not alone. There are five common terms you need to know.
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