Frequently Asked Questions
You don't have to navigate Health Insurance on your own. Our FAQs cover key topics, but we know every situation is unique. If you don’t find the answers you need, contact us.
Working with an agent ensures you get the best coverage at the right price without the stress. We’re happy to guide you through your options and our services cost you nothing!
Medicare
Who is eligible for Medicare?
You are eligible for Medicare if you meet any of the following criteria:
● You are 65 years or older and a U.S. citizen or legal resident who has lived in the U.S. for at least 5 years.
● You are under 65 and have a qualifying disability, receiving Social Security Disability Insurance (SSDI) for at least 24 months.
● You have End-Stage Renal Disease (ESRD)or Amyotrophic Lateral Sclerosis (ALS)(Lou Gehrig’s disease), in which case you may qualify without the 24-month SSDI waiting period.
How do I enroll in Medicare?
If you are already receiving Social Security or Railroad Retirement benefits, you will be automatically enrolled in Medicare Part A and Part B when you turn 65.
If you are not automatically enrolled, you must sign up through the Social Security Administration (SSA):
Online at www.ssa.gov/medicare
By phone at 1-800-772-1213
In person at a local Social Security office
When can I enroll in Medicare?
There are specific enrollment periods when you can sign up for Medicare:
Initial Enrollment Period (IEP) – A 7-month window starting 3 months before your 65th birthday, includes your birth month, and ends 3 months after your birthday month.
General Enrollment Period (GEP) – If you missed your IEP, you can enroll between January 1 - March 31 each year, with coverage starting July 1 (late penalties may apply).
Special Enrollment Period (SEP) – If you continue working past 65 and have employer coverage, you can delay Medicare without penalty. You’ll get an 8-month SEP to enroll after losing employer coverage. It is crucial that the employer group plan has at least 20 employees to avoid incurring a late enrollment period.
Medicare Advantage & Part D Open Enrollment – From October 15 - December 7, you can join, switch, or drop Medicare Advantage and Part D plans.
Do I need a separate prescription drug plan?
If you have Original Medicare (Parts A & B): YES, you need to at least enroll in a Medicare Part D prescription drug plan separately if you want coverage.
If you have Medicare Advantage (Part C): MAYBE, as many Medicare Advantage plans already include prescription drug coverage called (MA-PD plans).
Important: If you don’t enroll in Part D when you’re first eligible and don’t have other creditable drug coverage, you may face a late enrollment penalty that increases your monthly premium permanently.
How long is a Medicare consultation appointment with Stellar Health Benefits?
A typical Medicare consultation with Stellar Health Benefits lasts 1 to 2 hours, depending on your needs. During this time, your agent will review your healthcare needs, compare plan options, and answer any questions to ensure you select the best coverage. The goal is to provide a thorough, stress-free experience so you feel confident in your Medicare choices.
What information do you typically need during a consultation appointment?
To ensure a smooth and efficient Medicare consultation, bring your personal information (full name, date of birth, Social Security number, and contact details) along with your Medicare card if already enrolled. Have details about any current health coverage, including employer or retiree plans, Medicaid, or TRICARE. A list of your medications with drug names, dosages, and preferred pharmacy is essential for finding the best prescription coverage. Lastly, provide a list of your doctors, specialists, and preferred hospitals to ensure your chosen plan includes them in-network.
Are there programs to help with Medicare costs?
Yes! Several programs help lower-income individuals with Medicare costs and we can help you find out if you qualify:
Medicare Savings Programs (MSPs): Helps pay for Part A & B premiums, deductibles, and copayments (based on income).
Extra Help (Low-Income Subsidy - LIS): Reduces Part D prescription drug costs for those with limited income.
Medicaid: If you qualify for both Medicare & Medicaid, Medicaid helps cover additional costs like long-term care & out-of-pocket expenses.
State Pharmaceutical Assistance Programs (SPAPs): Some states offer extra help with prescription drug costs. In Pennsylvania it is called PACE or PACEnet.
For assistance, contact:
● Medicare: 1-800-MEDICARE (1-800-633-4227)
● Social Security (for Extra Help): 1-800-772-1213
● Your State Medicaid Office (visit www.medicaid.gov)
● SPAP for Pennsylvania Residents ONLY: PACE & PACEnet (1-800-225-7223)
Can veterans enroll in Medicare Advantage if they already have VA or TRICARE coverage?
Yes, many veterans choose Medicare Advantage plans to enhance their VA or TRICARE benefits. These plans work alongside your existing coverage to offer additional options. Learn more about Veteran-Focused Medicare Plans.
Affordable Care Act (ACA) & PENNIE
What is PENNIE and how does it relate to the ACA in Pennsylvania?
PENNIE is the official name of Pennsylvania's health insurance marketplace, which was established to help residents of Pennsylvania access health coverage through the Affordable Care Act (ACA). It serves as a platform where individuals and families can shop for and purchase health insurance plans that meet ACA standards, including offering coverage for essential health benefits like hospitalization, preventive services, and prescription drugs. In 2020, Pennsylvania transitioned from using the federal marketplace (HealthCare.gov) to its own state-based marketplace, PENNIE, for better control over state-specific health plans and programs.
Who is eligible to enroll in health insurance through the PENNIE marketplace?
Any legal resident of Pennsylvania who is not incarcerated and does not have access to other qualifying health coverage can enroll through PENNIE. This includes U.S. citizens and lawful immigrants, individuals and families who don’t qualify for Medicaid or Medicare, and those without employer-sponsored insurance. Financial assistance may be available based on income, family size, and other factors.
When is the Open Enrollment Period for health coverage in Pennsylvania?
The Open Enrollment Period for PENNIE typically runs from November 1 to January 15 each year, though extensions may occur based on regulations. To get coverage, you must apply during this period unless you qualify for a Special Enrollment Period (SEP) due to a qualifying life event. A Stellar Health Benefits agent can help determine if your situation qualifies as an SEP. Contact us
What if I miss the Open Enrollment Period?
You should still reach out to our team as there may be a special election period that may work for your situation, or a short term solution that we can help you with. We are here to help!
Is financial assistance available to help pay for health insurance through PENNIE?
Yes, financial assistance is available through PENNIE to help lower health insurance costs. Eligible individuals may qualify for Premium Tax Credits, which reduce monthly premiums, and Cost-Sharing Reductions (CSRs), which lower out-of-pocket expenses like copays and deductibles. Assistance is based on income and family size, and eligibility is determined when you apply through the marketplace.
What documents do I need to apply for health coverage through PENNIE?
When applying for health coverage through PENNIE, you’ll need documents such as Social Security numbers (or legal immigration documents), income details (pay stubs, W-2s, or tax returns), proof of Pennsylvania residency, and information on any current health insurance. If applying for family members, you may also need employer or income-based health coverage details. Having these documents ready will make the process smoother. For assistance, visit the PENNIE website or contact Stellar Health Benefits for expert guidance.
Private Health Insurance Plans
How do I purchase private health insurance in Pennsylvania?
In Pennsylvania, you can buy private health insurance through PENNIE, the state’s ACA marketplace, where you can compare plans and check for financial assistance. You can also purchase coverage directly from insurance companies like Highmark BlueCross BlueShield, UPMC, Geisinger, Capital Blue Cross, Ambetter and Keystone Healthplan.
However, working with a licensed broker gives you:
Access to multiple carriers,
Plan comparisons,
Expert guidance,
and additional customer service beyond what insurance carriers offer alone.
Stellar Health Benefits can help you navigate your options and find the best coverage for your needs at no cost to you.
When can I enroll in a private health insurance plan?
You can enroll in private health insurance during the Open Enrollment Period, which typically runs from November 1 to January 15 each year. If you experience a qualifying life event—such as losing coverage, getting married, or having a baby—you may be eligible for a Special Enrollment Period (SEP) to enroll outside of Open Enrollment. Additionally, Medicaid and CHIP enrollment is available year-round for those who qualify based on income.
What types of private health insurance plans are available in Pennsylvania?
Pennsylvania offers several types of private health insurance plans. HMO (Health Maintenance Organization) plans have lower premiums but require in-network care and referrals. PPO (Preferred Provider Organization) plans offer more flexibility but come with higher out-of-network costs. EPO (Exclusive Provider Organization) plans cover only in-network care, except in emergencies. POS (Point of Service) plans blend HMO and PPO features, requiring referrals but allowing out-of-network care at a higher cost. High Deductible Health Plans (HDHPs) offer lower premiums and can be paired with Health Savings Accounts (HSAs). Other options include Catastrophic Plans for low-cost, worst-case coverage and Short-Term Health Plans for temporary needs, though they may not cover pre-existing conditions.
Not sure which plan is right for you? Contact us for expert guidance and personalized recommendations, it's free!
Are there financial assistance options available for private health insurance?
Yes, financial assistance is available only through PENNIE, Pennsylvania’s health insurance marketplace, for those who qualify based on income. Assistance includes Premium Tax Credits, which lower monthly premiums for individuals earning between 100% and 400% of the federal poverty level (FPL), and Cost-Sharing Reductions (CSRs), which reduce out-of-pocket costs for those earning 100% to 250% of the FPL. Eligibility is determined when you apply through PENNIE. Contact us today for free help getting you the financial assistance you are eligible for.
What is the difference between in-network and out-of-network providers?
In-network providers have contracts with your insurance company, offering lower, negotiated rates for services. Out-of-network providers do not have contracts, often resulting in higher out-of-pocket costs or no coverage at all. Some plans, like PPOs, offer partial out-of-network coverage, while HMOs typically only cover emergencies outside the network.
How do I handle disputes or denials with my private health insurance?
If your health insurance claim is denied or disputed, start by contacting your insurance company for an explanation and possible resolution. If the issue isn’t resolved, you can appeal the denial with supporting documentation. If necessary, file a complaint with the Pennsylvania Insurance Department for further assistance (insurance.pa.gov). In complex cases, consulting an insurance law attorney may help protect your rights.
Vision & Dental Insurance
What services are typically covered under dental insurance plans?
Dental insurance generally covers preventive care (cleanings, exams, X-rays, fluoride treatments) at 100%, with no deductible. Basic services like fillings, extractions, and gum disease treatment are often covered at 70-80% after the deductible. Major services—such as crowns, dentures, and root canals—typically have 50-70% coverage with higher out-of-pocket costs and may require a waiting period. Orthodontic coverage (braces, Invisalign) is sometimes available but usually requires an additional rider. Coverage varies by plan, so reviewing details is important.
What services are typically covered under vision insurance plans?
Vision insurance generally covers annual eye exams to assess eye health and prescription needs. Most plans provide an allowance for eyeglasses (frames and lenses) or contact lenses, often with upgrade options. Coverage details vary, so reviewing your plan’s benefits is important.
Are there waiting periods for vision and dental coverage?
Yes, some dental and vision plans have waiting periods, particularly for major services. Dental insurance typically covers preventive care immediately, but basic and major services (like fillings, crowns, and orthodontics) may have waiting periods of 3 to 12 months. Vision plans usually have no waiting period for eye exams and glasses, but certain procedures may require a waiting period. Coverage varies by plan, so reviewing details is essential.
Can I use my provider with my vision or dental insurance plan?
Yes, but it depends on whether your provider is in-network or out-of-network. In-network providers have agreements with your insurance company, meaning lower costs for co-pays, deductibles, and coinsurance. Out-of-network providers may still be covered, but at a higher out-of-pocket cost, and you may need to submit claims yourself. Coverage varies by plan, so checking your provider’s network status is important.
Do vision and dental insurance plans cover pre-existing conditions?
Most dental insurance plans do not exclude pre-existing conditions, but they may limit coverage for major procedures like crowns or implants, often requiring a waiting period. Vision insurance typically covers common refractive errors (nearsightedness, farsightedness, astigmatism), but other corrective treatments may have waiting periods or exclusions. Coverage varies, so reviewing your plan details is important. A Stellar Health Benefits agent can help you understand your plan coverage and any exclusions.
How do I know if a vision or dental procedure is covered?
To check if a procedure is covered, review your policy’s Evidence of Coverage, which outlines covered services and cost-sharing details. You can also call your insurance provider’s customer service for confirmation. Additionally, your vision or dental provider can verify coverage before treatment to ensure you understand any out-of-pocket costs. We are also here to help you with these questions when choosing a Vision or Dental Insurance plan.
Are there annual maximums or limits on benefits for vision and dental plans?
Yes, most vision and dental insurance plans have annual coverage limits. Dental plans typically have a maximum benefit of $1,000 to $3,000 per year, after which you pay out-of-pocket. Orthodontic coverage may have separate limits. Vision plans often cover one annual eye exam and a pair of glasses or contacts, with set allowances (e.g., $200 toward frames and lenses). Reviewing your plan’s limits helps you plan for any additional costs.