PlanMath PA

Check our numbers yourself

Everything this site shows comes from official public sources. This page shows you, step by step, where to find each piece in those sources and how to read it, so you can check any number without trusting us.

Before you start

  • Every source here is public and free. You need a web browser, a PDF viewer with a search box, and for the larger files a spreadsheet program. Nothing needs an account.
  • The PDFs are long. Use the search box (Ctrl+F, or Cmd+F on a Mac) with the words this page gives, such as a plan ID or a table name.
  • Plan IDs look like 33709PA0870007-01. The first 5 digits are the insurer's company ID; the two digits after the dash say which version of the plan it is (-01 sold on Pennie, -00 sold off Pennie, -04 to -06 the extra-help Silver versions).
  • This page covers where the data comes from. How we turn it into a 5-year cost, a tax credit estimate and an insurer grade is on How we calculate; the default care prices and the chances of unexpected care, with their sources, are there too.
  • The examples are for plan year 2027. Each year the same pages carry the new year's files.

Your county and rating area

What the site shows

After you enter a ZIP code, the estimator works out your county. The footer then shows it with its rating area, for example "Dauphin County (Rating Area 6)". Every price depends on the rating area.

The official source

CMS (the federal Centers for Medicare & Medicaid Services) publishes which Pennsylvania counties make up each of the state's 9 rating areas. The U.S. Census Bureau publishes which counties each ZIP code area lies in.

Step by step

  1. Open CMS: Pennsylvania geographic rating areas.
  2. Find your county in the list. The number next to it is your rating area.
  3. If you are not sure which county a ZIP code is in, the Census Bureau's 2020 ZIP code to county relationship file lists every ZIP code area (ZCTA) with the counties it touches. It is a large text file: open it in a spreadsheet and filter on your ZIP code.

Matching it to the site

  • The rating area number is the one the rate tables in the next section call Rating Area (or RATING AREA ID).

How often it changes

Rarely. The rating areas are set by the state and have not changed for years; the Census file is from 2020.

Watch out for

  • A ZIP code can cover parts of two or more counties. The price follows the county, so pick the county you live in.
  • ZIP code areas (ZCTAs) are the Census Bureau's version of ZIP codes. A few post office box ZIP codes have no area of their own.

Back to the contents

The plan list and the prices

What the site shows

Every plan sold on Pennie in your county: its name, insurer, metal level (Bronze, Silver, Gold, Platinum, Catastrophic), network type (HMO, PPO, EPO, POS), and its full monthly premium for each person's age, before any tax credit.

The official source

Insurers must have their rates approved by the PA Insurance Department before they can sell. The Department posts each insurer's rate filing and its decision on it. Each spring CMS also publishes the official plan files for Pennie (the State-based Exchange Public Use Files, or PUF). Pennie's shopping tool, where you enroll, shows the same plans and prices. For 2027 the CMS file is not out yet (it usually comes in May), so the site's 2027 prices come from the Department's 2027 rate decisions. For 2026 the same decisions matched the CMS file to the cent for every Pennie plan.

Step by step

  1. Open the PA Insurance Department's ACA health rate filings page.
  2. Find the individual market table for plan year 2027 and the row of the insurer you want.
  3. Open the PDF in the "Final Rate Change Decision Summary" column: the Department's decision. For example, Highmark Inc.'s 2027 decision.
  4. Use your PDF viewer's search for Plan Design Summary. It lists every plan offered for the year: plan ID, name, metal, network, whether it is sold on Pennie and off (On/Off) or only off Pennie (Off), its rating areas and its counties.
  5. Search for Rates Table Template. These pages have one row per plan, rating area and age (0-14, 15, 16 … 63, 64 and over), with the Individual Rate and the Individual Tobacco Rate per month. Check that the sheet's effective date is 1/1/2027.
  6. Search for the plan's 14-character ID (for example 33709PA0870007, without the ending after the dash). Go to your rating area and each person's age, and read the rate.
  7. Add up one rate per person. Only the three oldest children under 21 are charged. For a smoker 21 or older, use the tobacco rate if the plan has one.
  8. Once the CMS file is out, you can check against it: on the CMS State-based Exchange PUF page, download the Pennsylvania zip for the plan year (for 2026, pennsylvaniasbepuf2026.zip). Open the Rates file (PARates….csv) in a spreadsheet and filter on PLAN ID, RATING AREA ID and AGE; read INDIVIDUAL RATE and INDIVIDUAL TOBACCO RATE. The Plans file has each plan's name, metal and network; the ServiceAreas file has its counties.
  9. On pennie.com, browse the plans for your ZIP code and ages without asking for financial help: Pennie then shows full prices, which should equal the ones above.

Matching it to the site

  • Plan IDs end in a dash and two digits: -01 is the version sold on Pennie, -00 a version sold off Pennie, and -04, -05, -06 the reduced cost-sharing versions of a Silver plan (see the tax credit section). The rate tables use the 14 characters before the dash, because every version of a plan has the same price.
  • The first 5 digits are the insurer's company ID: 33709 is Highmark Inc., 15983 Ambetter, 98517 Oscar.
  • The estimator lists plans by name. To find a plan's ID, search for its name in our published plan file (plans-2027.json). The How we calculate page lists every decision page the prices were read from.

How often it changes

Once a year. The decisions are posted in October for the next year; the CMS file comes about May of the plan year. Prices do not change during the year.

Watch out for

  • Use the decision, not the "Rate Change Summary": the summary is the filing as first requested, before the Department cut it. Decisions show approved rates.
  • A plan filed as On/Off is meant for Pennie, but check Pennie's shopping tool when it opens (November 1 each year) to be sure it is sold there.
  • Some decisions hold two copies of the rate sheet (an earlier version and the revised one). Use the one effective January 1 that the decision approves.
  • The CMS file only has plans sold on Pennie. Plans sold only off Pennie are in the decisions alone.

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Tax credits, extra Silver help and the poverty level

What the site shows

When you ask for it, the estimated monthly tax credit, which plans it lowers, the reduced cost-sharing (CSR) version of Silver plans, and under "If your income changes" the income limits in dollars.

The official source

The credit is set by federal law and IRS rules. HHS publishes the poverty guidelines; the IRS publishes each year's table of how much of your income you are expected to pay; the benchmark plan comes from the plan prices above.

Step by step

  1. Open the HHS poverty guidelines. For 2027 plans the site uses $15,960 for one person plus $5,680 for each extra person (the guidelines published the year before the plan year).
  2. Divide your household income by that amount and multiply by 100: that is your income as a percent of the poverty level.
  3. Open IRS Rev. Proc. 2026-26: applicable percentage table and required contribution for 2027. Its table gives the share of income you are expected to pay for the benchmark plan at your percent.
  4. Find the benchmark: the second-cheapest Silver plan sold on Pennie in your county, priced for the ages in your household (with the steps in "The plan list and the prices").
  5. Credit = benchmark premium − (income × your share ÷ 12), never below zero. The rule is 26 CFR 1.36B-3. How we calculate shows the table and every limit we apply.
  6. Cost-sharing reductions: above 138% and up to 250% of the poverty level, Silver plans on Pennie come in a version with lower costs. Look up its own benefits summary (next section) under its own plan ID: -06 up to 150%, -05 up to 200%, -04 up to 250%.

Matching it to the site

How often it changes

Once a year: HHS updates the poverty guidelines in January, and the IRS publishes the next year's table in the summer.

Watch out for

  • Use the table for the right plan year: the percentages change every year.
  • At or below 138% of the poverty level, adults in Pennsylvania usually qualify for Medical Assistance (Medicaid) instead.
  • Plans sold off Pennie and small-business plans never get the credit or the CSR versions.
  • From 2027, fewer lawfully present immigrants qualify for the credit. Check your own status with Pennie.

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Benefits: deductibles, copays and coinsurance

What the site shows

Each plan's deductibles, out-of-pocket maximum, and what you pay for doctor visits, tests, drugs and hospital care, and a link to the plan's official benefits summary.

The official source

Federal law requires every insurer to publish a Summary of Benefits and Coverage (SBC) for each plan, in the same format for every company. The insurer writes it, and it is the official short statement of the plan's costs.

Step by step

  1. The quickest way: in the estimator, open a plan and click "Plan's official benefits summary". It opens the exact file we read.
  2. Or go to the insurer's own SBC pages (list below) and find the plan by name or plan ID.
  3. Check the year at the top of page 1 (for example "Coverage Period: 01/01/2027 - 12/31/2027") and that the plan name matches.
  4. Page 1, "Important Questions": "What is the overall deductible?" and "What is the out-of-pocket limit for this plan?" give the individual and family amounts. "Are there services covered before you meet your deductible?" lists what is paid before it.
  5. The table that follows ("Common Medical Event", "Services You May Need") gives each service. Read the column for in-network providers ("You will pay the least"). A note such as "deductible does not apply" tells you the cost starts before the deductible.
  6. The last pages have three coverage examples (having a baby, managing type 2 diabetes, a simple fracture), which show how the deductible and copays add up.

Where each insurer posts its SBCs

Matching it to the site

  • Each rule on the site comes from one cell of the SBC. Where a cell gives two prices (say, an office and a hospital), the plan's notes on the site say which one we used.
  • When a plan has more than one network tier, the site uses tier 1, the preferred doctors and hospitals, as the CMS file does.
  • Once the CMS file is out, its Plans file (columns such as TEHB DED INN TIER 1 INDIVIDUAL and TEHB INN TIER 1 INDIVIDUAL MOOP) must give the same deductible and out-of-pocket maximum as the SBC. A plan where they differ is left out.

How often it changes

Once a year, for the new plan year. Insurers post them in the fall, some only around November 1.

Watch out for

  • SBCs are per plan ID. A Silver plan's CSR versions (-04, -05, -06) have their own SBC with lower costs, and the version sold off Pennie (-00) can be a separate file. Never use one plan's SBC for another.
  • Many SBCs do not print the plan ID. Match the plan name, metal level, network and deductible.
  • Early in the fall an insurer's address for next year can still serve this year's file. Check the coverage period.
  • The CMS file has a column for the SBC address, but it is empty for every Pennsylvania plan.
  • Some insurer sites run a robot check first (Geisinger, Independence). A normal browser gets through.

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Plans sold only off Pennie

What the site shows

Plans marked "Off Pennie only", at their full price. You buy them from the insurer, not on pennie.com.

The official source

They are ACA plans whose rates the PA Insurance Department approved, in the same rate decisions as the Pennie plans. CMS does not list them, because they are not sold on Pennie.

Step by step

  1. Open the insurer's decision from the ACA health rate filings page, as for Pennie plans.
  2. In the Plan Design Summary (or Table 10, "Plan Rates"), find the rows whose exchange column says Off.
  3. Read their prices in the Rates Table Template, the same way as above.
  4. For benefits, open the insurer's SBC for the plan ID ending in -00. Highmark's file names end in -00_…_SBC.pdf, Independence's in -off.pdf, and Geisinger titles them "(Off Exchange Only)".

Matching it to the site

  • The estimator tags them "Off Pennie only" and never subtracts a tax credit from them.
  • An off-Pennie plan that is identical to a Pennie plan of the same insurer (same benefits, prices and counties) is not listed twice.

How often it changes

Once a year, with the rate decisions in October.

Watch out for

  • A plan filed "On/Off" that Pennie does not sell counts as off Pennie.
  • A few off-Pennie plans have no SBC at all. Their benefits come from the decision's benefit summary exhibit (for example Exhibit A_BenSummary), and the plan on the site says so.

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Small-business plans

What the site shows

Plans marked "Small business": the plan list, the full premium for your family, and the price for the coverage start month you choose.

The official source

The PA Insurance Department approves small-group rates too, on the same page, in a separate table. Benefits come from each insurer's SBCs where it publishes them; where it does not, from the benefit documents it filed with the Department through SERFF (next section).

Step by step

  1. On the ACA health rate filings page, find the "Small Group Market Plans" table for 2027. It also gives each company's requested and approved change and its market share.
  2. Open the decision PDF, for example UPMC Health Network's 2027 small-group decision.
  3. Search for Rates Table Template (Capital Blue Cross: RATE PAGES). Small-group rates come in four sheets, in force from January 1, April 1, July 1 and October 1. A business pays the sheet in force on its start date for 12 months.
  4. The Plan Design Summary lists the plans; a county exhibit lists where each one is sold.
  5. For benefits, use the insurer's source in the list below.

Where each insurer's small-business benefits are

  • Capital Blue Cross: its 2027 small-group benefit grid (form PSI-504), which links each plan's SBC. Two plans have no SBC of their own; their benefits come from Capital's SERFF filing CABC-134923379.
  • Geisinger: one SBC per plan ID, for example 22444PA0060062-00.
  • Highmark: its public small-group SBC search on shop.highmark.com, for example one January SBC. One plan missing from the search comes from SERFF filing HGHM-134875102.
  • Independence Blue Cross: no SBCs. Its official "Benefit Highlights" are linked from one page per metal level, for example Gold (2027).
  • UPMC: no public SBCs. The benefit tables ("Benefit Matrix" spreadsheets) are in its SERFF form filings.
  • UnitedHealthcare: SBCs only in its SERFF form filings, named by UnitedHealthcare's plan code.

Matching it to the site

  • There is no CMS file for small-group prices, so we check that every rate follows the state's age curve and that the decision's rates are the approved ones, not the requested ones.
  • A benefits link on the site that says "search SERFF for …, file …" gives the tracking number and the file name to open.
  • Highmark's and UnitedHealthcare's small-group SBCs carry no plan ID: match the company, counties, deductible, out-of-pocket maximum and copays against the decision's Rate Pages.

How often it changes

Once a year, with the rate decisions in October, plus the four quarterly sheets inside each decision.

Watch out for

  • As for individual plans, the "Rate Change Summary" is what was requested; the decision is what was approved.
  • Some file names on pa.gov are misspelled (in 2026 several were "decsion"). Search the table, not the address.
  • "Level-funded" plans are not ACA small-group plans and have no public rates. They are never on the site.

Back to the contents

SERFF Filing Access, step by step

What the site shows

The benefits of UPMC's and UnitedHealthcare's small-business plans, and of a few other plans whose insurer publishes no SBC, come from documents insurers filed with the PA Insurance Department.

The official source

SERFF is the system insurers use to file rates and forms with state insurance departments. It is run by the NAIC (National Association of Insurance Commissioners). SERFF Filing Access is its public website, where anyone can read the filings a state has made public.

Step by step

  1. Open SERFF Filing Access for Pennsylvania in your browser.
  2. Read the user agreement and accept it.
  3. Start a filing search. Type the SERFF tracking number (for example UPMC-134929393), or search by company name and the type of insurance.
  4. Open the filing from the results. Its page lists the forms and the supporting documents.
  5. Click "Download Zip File". You get one zip with every public document of the filing.
  6. Unzip it and open the folder "Supporting Document Attachments". There you find the Benefit Matrix spreadsheet (UPMC), a zip of SBCs (UnitedHealthcare: "2027 PA SB Filing.zip", a zip inside the zip), or the plan's SBC PDF (Highmark).
  7. Where the tracking numbers come from: each rate decision lists its form filings, for example UPMC's "Form Filing SERFF Tracking #" (decision p. 12) or the "SERFF Form Number" in UnitedHealthcare's rate change summary (p. 3, item 13).

The 2027 small-business filings we use

  • UPMC Health Network: UPMC-134929393, UPMC-134931169, UPMC-134929314, UPMC-134929403.
  • UPMC Health Benefits: UPMC-134931390, UPMC-134931422, UPMC-134931432, UPMC-134931444.
  • UPMC Health Plan: UPMC-134931224.
  • UnitedHealthcare Insurance Company: UHLC-134903606, UHLC-134903709. UnitedHealthcare of Pennsylvania: UHLC-134903707.
  • Highmark Inc. (one plan): HGHM-134875102. Capital Blue Cross (two plans): CABC-134923379.

Matching it to the site

  • On the site, these plans' benefits link reads "search SERFF for <tracking number>, file <file name>".
  • UPMC's spreadsheet has one column per plan; the site cites the spreadsheet row of each rule.

How often it changes

Insurers file their forms for the next year in the spring and summer; the Department approves them before the fall.

Watch out for

  • SERFF Filing Access's terms forbid automated downloads. Download each filing by hand, as we do.
  • A filing's sample SBC can be for a different plan than the one you want. Check the deductible, out-of-pocket maximum and copays against the decision.
  • Some files come in more than one version (a name ending in "-V2"). Use the latest.

Back to the contents

Years on the marketplace

What the site shows

On each insurer's card on Compare insurers: since when it (or the company it took over from) has sold individual plans in Pennsylvania.

The official source

CMS's yearly plan files: the HealthCare.gov Plan Attributes files for 2014-2020, and the Pennie (State-based Exchange) files from 2021.

Step by step

  1. For 2014-2020, download a year's Plan Attributes file, for example 2016. Open the CSV in a spreadsheet.
  2. Filter StateCode = PA, MarketCoverage = Individual, DentalOnlyPlan = No, then look for the insurer's 5-digit ID at the start of StandardComponentId.
  3. For 2021 on, use the Pennsylvania zips on the CMS State-based Exchange PUF page (Plans file, ISSUER ID).

Matching it to the site

  • A year counts when the company ID has at least one individual medical plan that year.

How often it changes

Once a year, when CMS publishes the new plan files (about May).

Watch out for

  • When a company moves its plans to a new ID (UPMC Health Options 16322 became UPMC Health Network 16481 in 2027), look up both IDs.

Back to the contents

Claims denied and appeals

What the site shows

The share of claims each insurer denied, how many internal appeals members filed per 1,000 denials, and the Pennsylvania average.

The official source

The PA Insurance Department's Transparency in Coverage Report for ACA Health Plans, which collects these counts from every insurer selling ACA plans.

Step by step

  1. Open the Transparency in Coverage Report (November 2025, 2024 claims).
  2. Table 1 (page 4) gives each insurer's claims received and denied, and the statewide total.
  3. Table 3 (page 6) gives the internal appeals.
  4. Denial rate = claims denied ÷ claims received. Appeals per 1,000 denials = internal appeals ÷ denied × 1,000.
  5. Earlier years: the 2024 edition (2023 claims, pages 5 and 7) and the 2023 edition (2020-2022 claims, pages 4 and 6).

Matching it to the site

  • The report names the legal company (for example "Capital Advantage Assurance Co."). Each plan ID's first 5 digits tell you which company sells it.

How often it changes

Once a year, about November, with the previous year's claims.

Watch out for

  • A denial is not always a refusal of care: many are for paperwork reasons, such as a missing form.
  • CMS's own claims files (Transparency in Coverage) stop at 2018; see "Older claims data" below. The current figures are the Department's.

Back to the contents

Rate changes and the price change of the same plan

What the site shows

Each insurer's approved (and requested) average rate change for next year, its history since 2019, the change in price of the same plan from one year to the next, and the statewide average.

The official source

The PA Insurance Department's rate filings pages and its announcement of the year's rates; for the same plan's price, the CMS plan files.

Step by step

  1. On the ACA health rate filings page, the individual market table gives each insurer's requested and approved change for next year.
  2. Earlier years are on the archived rate filings page.
  3. The statewide average is in the Department's announcement: Pennsylvania Insurance Department: Pennsylvania releases ACA 2027 health insurance rates (15.97% for 2027).
  4. Price change of the same plan: in two years' CMS Rates files, find the same 14-character plan ID, take the age-40 rate in the same rating area, and compare. The site shows the middle (median) of those changes per insurer.

Matching it to the site

  • The approved average weighs each plan by its members and covers plans sold off Pennie too, so it can differ from the change of any one plan.

How often it changes

Once a year, in October for the next year. The same-plan change needs the new CMS file (about May).

Watch out for

  • Your own change can be larger or smaller than the average, and the tax credit usually absorbs much of it.

Back to the contents

Market size and people in each plan

What the site shows

How many people each insurer covered in Pennsylvania's individual market, its share of that market, and how many people were in each plan.

The official source

The insurers' rate filing summaries, posted by the PA Insurance Department.

Step by step

  1. From the ACA health rate filings page, open the insurer's "Rate Change Summary", for example Ambetter's 2027 summary.
  2. Find the covered lives (members) as of February 1 and the market share.
  3. For each plan, Table 10 ("Plan Rates") gives "Total Covered Lives" per plan ID, with its status for next year (E existing, M modified, N new, DM or DNM discontinued).

Matching it to the site

  • The site rounds the people in a plan to the nearest 100 from 1,000 up.

How often it changes

Once a year, with the rate filings.

Watch out for

  • A discontinued plan's members are sometimes counted in the plan they move into, not on their own row.

Back to the contents

Share of premiums spent on care, and rebates

What the site shows

The share of premium money each insurer spent on medical care (the medical loss ratio), rebates it paid, and the share it expects to spend next year.

The official source

CMS's Medical Loss Ratio files, from the reports every insurer must file each year. Insurers below 80% in the individual market must pay rebates.

Step by step

  1. Open the CMS Medical Loss Ratio data page and download a year's file, for example 2024.
  2. In MR_Submission_Template_Header.csv, find the insurer's row with business_state = PA and its hios_issuer_id.
  3. In the Part 3 file, row "4.1 Preliminary MLR", column cmm_individual_total, is the share spent on care (three years together). Row "5.4 Rebate amount" is the rebate.
  4. The expected share for next year is on page 1 of the insurer's rate decision (see "The plan list and the prices").

Matching it to the site

  • The site shows the individual market only ("cmm_individual" columns), not the company's employer business.

How often it changes

Once a year, about September, for the previous reporting year.

Watch out for

  • The CMS ratio averages three years and is counted differently from the projection in the rate decision. Do not compare them directly.

Back to the contents

Results in the rate filing

What the site shows

What each insurer took in as premiums and paid as claims in a year in the individual market, and its gain or loss after taxes.

The official source

The PA Insurance Department's rate decisions: their "Key Information" box repeats what the insurer reported.

Step by step

  1. From the ACA health rate filings page, open the insurer's "Final Rate Change Decision Summary".
  2. Page 1 has the "Key Information" box: premiums, claims and the after-tax result for the year two years before the plan year.
  3. Earlier years are in older decisions on the archived rate filings page.

Matching it to the site

  • The year on the site is the results year (for a 2027 decision, 2025), not the plan year.

How often it changes

Once a year, in October.

Watch out for

  • A company new to the market shows $0 there. The site leaves such a year out instead of showing zeros.

Back to the contents

Complaints

What the site shows

The number of complaints filed with the state about each insurer, and its complaint index (1.0 is average for a company its size).

The official source

The PA Insurance Department's Consumer Complaint Comparison Tool.

Step by step

  1. Open the Consumer Complaint Comparison Tool.
  2. Choose the year and the line of business "Accident and Health", and run it.
  3. Find the company's legal name in the table: it gives the number of complaints and the index.

Matching it to the site

  • The tool counts the whole company (all its health business, not only its Pennie plans). Find the legal name in the rate decision if the brand name differs.

How often it changes

Once a year.

Watch out for

  • A company with almost no premium can show a meaningless index; the site leaves out companies with under $1 million of premium.

Back to the contents

Executive pay

What the site shows

The pay of each company's best-paid executives (the top three, plus the chief executive), as the company reports it.

The official source

Nonprofit insurers report pay to the IRS on Form 990; it is public, and ProPublica shows each filing. Companies with shares on the stock market report it to the SEC in their yearly proxy statement (form DEF 14A).

Step by step

  1. Nonprofits: open ProPublica Nonprofit Explorer and search the name or tax ID (EIN), for example Geisinger Health Plan (23-2311553).
  2. Open the latest full filing and go to Part VII, Section A. Total pay = columns D + E + F (pay from the organization, pay from related organizations, and estimated other pay).
  3. Public companies: open the latest proxy statement and find the "Summary Compensation Table". Read the "Total" column for the newest year.

Matching it to the site

  • The site adds the three Form 990 columns into one total, and copies the proxy statement's total as printed.

How often it changes

Form 990s appear about November for the tax year before last (later with an extension). Proxy statements come in March or April.

Watch out for

  • Form 990s lag one to two years behind.
  • A proxy statement's total counts stock and option awards at their value when granted, not what the person later received.
  • A public company is the national parent: its pay covers its business in every state, not just Pennsylvania.
  • A health system's 990 lists hospital executives too. The site shows only people listed on the plan's own filing.

Back to the contents

Quality ratings (CMS stars)

What the site shows

The 1 to 5 star rating of each insurer's plans, overall and for medical care, member experience and plan administration, by plan type.

The official source

CMS's Quality Rating System, the federal rating of marketplace plans.

Step by step

  1. Open the CMS marketplace quality downloads page and download the Quality Rating System file for the plan year, for example plan year 2026.
  2. Open the file in a spreadsheet and keep the Pennsylvania rows.
  3. Find the insurer's 5-digit ID and the product type (HMO, EPO, PPO). The overall rating and the three summary ratings are in their own columns.

Matching it to the site

  • A plan gets the rating of its own type; a POS plan uses its insurer's HMO rating. "Not rated" is CMS's word for a type too new or too small.

How often it changes

Once a year, about October, for the coming plan year.

Watch out for

  • The file named for plan year 2026 holds ratings computed in 2025.

Back to the contents

The member survey

What the site shows

What members said about their plan: the rating of the plan, customer service, getting needed care and getting care quickly.

The official source

CMS's QHP Enrollee Survey, a federal survey of marketplace members.

Step by step

  1. From the same CMS downloads page, download the Enrollee Survey file, for example plan year 2026.
  2. Keep the Pennsylvania rows, then find the insurer's ID and product type.
  3. Read the case-mix adjusted scores for the four measures.

Matching it to the site

  • As for quality ratings, each plan type is scored on its own.

How often it changes

Once a year, about October.

Watch out for

  • Small plans may have too few answers to be scored.

Back to the contents

Medicare star ratings

What the site shows

The star rating of the Medicare Advantage plans run by the same company (or its group), with complaints, members leaving, appeals and survey scores.

The official source

CMS's Medicare Part C and D Star Ratings, the federal rating of Medicare plans.

Step by step

  1. Open the CMS Part C and D performance data page and download the star ratings data tables, for example the 2027 tables.
  2. In the summary ratings table, find the contract number. The site names it on each insurer's card, for example H3954 for Geisinger Health Plan.
  3. Read the overall, Part C and Part D stars. The measure data file has the complaints, members choosing to leave, appeals and survey measures.

Matching it to the site

  • When a company has no Medicare contract of its own, the site shows its group's contract with the most Pennsylvania members, and names that sister company.

How often it changes

Once a year, about October. CMS sometimes posts a revised table months later.

Watch out for

  • These rate the company's Medicare plans, not its Pennie plans.

Back to the contents

Ratings by other organizations

What the site shows

A few values from NCQA, AM Best and J.D. Power, and links to where you can look up the rest.

The official source

NCQA reviews health plans; AM Best rates insurers' ability to pay claims; J.D. Power surveys members. Their ratings are licensed, so we copy only a few from their public pages.

Step by step

  1. On Compare insurers, each insurer's card has "Ratings by other organizations" with a link to its NCQA report card.
  2. On the report card, read the accreditation of the marketplace ("Exchange") products and the ratings of the employer and Medicaid products.
  3. AM Best and J.D. Power values link to the press release they come from, with its date.

Matching it to the site

  • NCQA rates most companies' employer or Medicaid plans, not their Pennie plans.

How often it changes

NCQA updates its report cards each fall; press releases have their own dates.

Watch out for

  • These sites block scripts; a normal browser opens them.

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Independent external reviews

What the site shows

On Compare insurers, under "What if a claim is denied": how many external reviews the Department handled and how often the insurer's decision was overturned.

The official source

The PA Insurance Department's Health Coverage Annual Report.

Step by step

  1. Open the 2025 Health Coverage Annual Report (page 17) or the 2024 report (page 12).
  2. Read the number of eligible cases and the number where the insurer's decision was overturned.
  3. To ask for a review yourself, see the Department's request a review page.

Matching it to the site

  • Share overturned = overturned ÷ eligible cases.

How often it changes

Once a year, in the summer, for the year before.

Watch out for

  • These are statewide totals, not per insurer.

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Older claims data (2015-2018)

What the site shows

In each insurer's "Past data" fold: claims received and denied in 2015-2018, when Pennsylvania used HealthCare.gov.

The official source

CMS's Transparency in Coverage files for plans sold on HealthCare.gov.

Step by step

  1. Download a year's file, for example the 2020 release (2018 claims).
  2. Open the issuer table, keep State = PA, and find the insurer's Issuer_ID.
  3. Read the claims received and denied.

Matching it to the site

  • The site shows these in a separate table, because CMS counted them differently from the Department's current report.

How often it changes

No longer updated.

Watch out for

  • Each file is named for the plan year it was released in, two years after the claims.

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