Shapiro Administration Releases New Report on the State of Pennsylvania’s Health Insurance Market

​Annual review shows that Pennsylvanians covered under individual and small group plans will see greater coverage in several areas in 2025

Harrisburg, PA - To further its efforts to promote transparency to consumers, the Pennsylvania Insurance Department (PID) today announced the availability of the first Pennsylvania Affordable Care Act and Qualified Health Plans (QHP) Summary Report - a report explaining how PID reviews health insurance products and enforces laws to ensure a fair insurance market and equitable treatment of consumers.

"The Shapiro Administration will not stop pushing for insurance plans and benefits that work for all Pennsylvanians," said Pennsylvania Insurance Commissioner Michael Humphreys. "We're proud of the expanded benefits that will be offered to Pennsylvanians in 2025. We worked with insurers to expand benefits to specifically address coverage concerns that we've heard directly from individuals and families across the Commonwealth. Further, understanding what benefits must be covered by insurance can be complicated. The QHP summary report followed our annual analysis of plans and provides important transparency into our health insurance markets."

The summary report provides an overview of the Pennsylvania health insurance market and outlines how PID analyzes health insurers' compliance with rules and regulations related to products and rates.

QHPs are certified by the Insurance Department to ensure compliance with all federal and state health insurance laws, including the Affordable Care Act. By law, these insurance plans may not deny insurance coverage for pre-existing conditions, and they must cover a core essential set of services (such as preventive and primary care, mental health and substance use disorder care, emergency services, and many others). While all QHPs must comply with and include benefits required under federal and state law, insurers may incorporate additional benefits or features to their health plans to better serve their consumers. This report seeks to show the differences between health plans sold in the Commonwealth's individual and small group markets, and Pennsylvanians using this report can now better know what their policy covers so they can take full advantage of their benefits.

The review found that, for plan year 2025, Pennsylvanians covered under individual and small group plans will see full coverage of:

• Applied Behavior Analysis (ABA) therapy for autism spectrum disorder;
• HIV Pre-Exposure Prophylaxis (PrEP) Integral Services with no cost sharing; and
• At least one kind of HIV PrEP medication with no prior authorization or cost-sharing.
  

Pennsylvanians will also see that several insurers:

• Removed prior authorization requirements on certain drugs, meaning Pennsylvanians are no longer required to seek permission from an insurer when prescribed specific medications;
• Moved certain drugs to lower-cost formulary tiers, making those drugs more affordable for Pennsylvanians;
• Added certain drugs to their formulary, providing consumers with greater access to specific medications; and
• Further clarified coverage of certain Essential Health Benefits for consumers.

Pennsylvanians with questions about their insurance, health plan or a denied claim should contact the Insurance Department Consumer Services Bureau online or at 1-877-881-6388. Consumers looking to learn more about health insurance should visit the Department's dedicated Health Insurance page.

Individuals interested in obtaining health insurance may purchase a QHP on Pennsylvania's health insurance marketplace, PennieOpens In A New Window. Those purchasing insurance on Pennie may qualify for tax credits. Pennie's open enrollment period for plan year 2025 is open now through January 15, 2025.

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