Pennsylvania Health Study Guide

Pennsylvania health law has been rebuilt in two significant places over the last few years, which makes this the line most likely to be studied from stale material. The external review process was replaced outright in 2024, and the pre-licensing requirement disappeared in 2025. Add a mini-COBRA whose numbers run consistently shorter than the federal ones and an HMO regime that answers to two different agencies, and you have the whole state-law core.

The marketplace and the Medicaid programme

Pennsylvania runs a state-based exchange — Pennie, created by Act 42 of 2019 and live for the 2021 plan year, which replaced HealthCare.gov for Pennsylvania residents.

Medicaid expanded to 138% of the federal poverty level effective 1 January 2015 — later than most expansion states, and a date worth holding separately from the 2014 that so many states used. The programme is called Medical Assistance, delivered through HealthChoices managed care, and it is administered by the Department of Human Services, not the Insurance Department.

Mini-COBRA — where every number runs short

This is the highest-yield section on the exam, and it is high-yield precisely because everything you memorised about COBRA points the wrong way. Federal COBRA applies at 20 or more employees, runs 18 months, gives 60 days to elect and caps premiums at 102%. Pennsylvania’s Act 2 of 2009 mini-COBRA inverts nearly all of it:

	Federal COBRA	Pennsylvania mini-COBRA
Employer size	20+ employees	2 to 19 employees
Duration	18 months	Up to 9 months
Election period	60 days	30 days
Premium cap	102%	105%
Prior coverage	—	3 continuous months required

The 3-continuous-months prior-coverage condition is the part most summaries drop entirely, and it is exactly the sort of qualifier a well-written item turns on: an employee who started six weeks ago does not get Pennsylvania continuation at all.

External review — learn Act 146, not Act 68

Act 68 of 1998 built Pennsylvania’s original managed-care grievance and external-review process, and a great deal of study material still teaches it. The operative programme today is different.

Act 146 of 2022 created a state-run Independent External Review, live since 1 January 2024 and administered by the Insurance Department. A consumer must first exhaust the insurer’s internal appeal; the Department determines eligibility within five days; the consumer has 15 business days from notice of the assigned Independent Review Organization to submit additional records; and the reviewer has 45 calendar days from assignment to decide. Most requests are resolved in under 60 days. The decision is binding on the insurer, and there is no cost to the consumer.

Prompt pay — one deadline, not two

Pennsylvania applies a single 45-day clean-claim deadline to electronic and paper claims alike, with 10% annual interest on a claim not paid in time (40 P.S. § 991.2166). That is worth noting precisely because several neighbouring states split the deadline by submission method. Pennsylvania does not — if a question tells you how the claim arrived, that detail is scenery here.

The HMO twist — two regulators

An HMO operating in Pennsylvania answers to two agencies. The Insurance Department handles the insurance and financial side; the Department of Health handles care delivery — quality, access and provider networks. Both must license the HMO.

Long-term care — the training that survived

Long-term care sits inside this line rather than requiring a separate credential, but it carries its own training obligation under 31 Pa. Code § 39a.9: 8 hours initially, then at least 4 hours in every subsequent 24-month licensing cycle, completed before you sell, solicit or negotiate LTC insurance. Producers selling Partnership-qualified policies must include a 1-hour Medicaid course inside that initial eight. The LTC free look is 30 days from delivery — the NAIC model figure, though the Pennsylvania right-to-return provision itself proved hard to pin to a section.