All plans offered to people who purchase an Individual and Family plan must include the 10 Essential Health Benefits (EHBs) listed below:

1. Hospitalization
2. Prescription drugs
3. Laboratory services
4. Pregnancy, maternity and newborn care
5. Ambulatory outpatient services
6. Emergency services
7. Mental health and substance use disorders
8. Rehabilitative care
9. Preventive and wellness services
10. Chronic disease management

During Open Enrollment, which runs from November 1, 2023 to January 19, 2024 this year, you can buy a new plan, renew your plan, or make changes to your plan.

During the Special Enrollment Period, after January 19, 2024, you may be able to shop for or make changes to your plan if you have had a qualifying life, including loss of health coverage, changes to your household like getting married or having a baby, or a change in residence.

If you applied for coverage through Pennie®, Pennsylvania’s official health coverage marketplace, and want to make changes to your plan, you will need to contact Pennie.

With the Affordable Care Act, the federal government created four categories of coverage to help people more easily compare plans from different health insurance companies: Bronze, Silver, Gold and Platinum. Plans are assigned to one of these levels based on what percentage of the cost of health care services is covered by the health insurance company.

All products cover the Essential Health Benefits (EHBs) set forth by the ACA, such as doctor visits, prescription drugs, X-rays and hospital stays. The major differences are in what you pay when you need these services and the monthly cost of the health plan.

A primary care physician (PCP) is the doctor you see for most of your health care needs. HMO plans from Jefferson Health Plans require you to choose a PCP. To find a primary care physician, use our online directory.

HMO plans from Jefferson Health Plans require you to choose doctors and hospitals within our HMO network. If you need assistance finding the right in-network provider, use our online directory. You will save more when you chose an in-network provider or facility.

Yes. With JeffConnect, you can access a board-certified provider 24/7. JeffConnect is a convenient and affordable alternative to an office visit or urgent care when you have a medical concern that is not an emergency.

HMO stands for Health Maintenance Organization. HMO health plans require you to select a primary care physician, or PCP who will be your main medical contact for routine care and to refer you to other in-network providers when needed for specialty care. Services are covered when you seek care from providers within the HMO network. If you go outside of the network for care, typically only emergency services are covered.

Yes. All plans from Jefferson Health Plans cover mental health and substance abuse services.

Your health care coverage is considered in-network when you use a provider, hospital, or facility that participates in our HMO network. To find out if a provider is in-network, use our online directory

Yes. With Jefferson Health Plans, you are covered for medically necessary services for unexpected illnesses or emergency care no matter where you seek care.

Yes. All Jefferson Health Plans provide prescription drug coverage. Many plans offer low-cost Tier 1 and Tier 2 generic prescription drugs to have you save.

The drug formulary is a list of medications selected by Jefferson Health Plans for their medical effectiveness, positive results and value. It includes all generic medications plus a defined list of brand-name medications. You can save money by utilizing medications that are included on the formulary.

To locate a participating pharmacy, use our convenient search tool.

Yes. Our health plans actually offer low-cost generic Tier 1 and Tier 2 drugs with no deductibles. Generic drugs are as safe and effective as brand-name drugs and could cost less.

A copayment, or copay, is the fee you pay when you see a doctor or receive other services.

A deductible is the amount you pay each year before your health plan starts paying for covered services. For example, if your plan has a $1,000 deductible, you will need to pay the first $1,000 of the costs for health services. Once you have paid this amount, your insurance will begin to pay a portion, or all, of your health care costs, depending on the health plan.

If you choose a health plan with a high deductible, you will have a lower monthly premium. If you choose a health plan with a low deductible, you will have a higher monthly premium.

This is the maximum amount you’ll pay for health care services in a plan year. Care for covered services you receive after you reach the out-of-pocket maximum will be fully covered by the health plan. Out-of-pocket maximums vary by plan and can be found in your benefits brochure. The out-of-pocket maximum does not include premiums or charges for covered services that are not Essential Health Benefits (EHBs).

During Open Enrollment, which runs from November 1, 2023 to January 15, 2024 this year, you can buy a new plan, renew your plan, or make changes to your plan.

During the Special Enrollment Period, after January 15, 2024, you may be able to shop for or make changes to your plan if you have had a qualifying life, including loss of health coverage, changes to your household like getting married or having a baby, or a change in residence.

If you applied for coverage through Pennie, Pennsylvania’s official health coverage marketplace, and want to make changes to your plan, you will need to contact Pennie.

This is a tax credit you can take in advance of your monthly health insurance payment (or “premium”) based on your expected income. If you qualify for a premium tax credit based on your income, you can use some or all of this tax credit to lower your premium payment. Keep in mind that premium tax credit is available only available on plans purchased on the marketplace.

This is a discount that lowers the amount that you pay out-of-pocket for healthcare expenses, including your deductibles, copayments, and coinsurance. After you reach the out-of-pocket maximum, your health plan covers 100% of all covered services. If you qualify for cost-sharing reductions, you must enroll in a plan in the Silver category to get the extra savings. Keep in mind that, like the Premium Tax Credit, Cost-Sharing Reductions are available only on plans purchased on the marketplace.

Jefferson Health Plans include providers that are in-network and are grouped into Tiers, Tier 1 and Tier 2. Your cost will vary depending on which Tier your provider is in, with Tier 1 providers costing less and Tier 2 providers costing more. Both Tiers provide you with access to high quality, affordable providers.