Pennsylvania Medicaid / Medical Assistance

Medicaid, also called the Medical Assistance (MA) program in Pennsylvania, is a government health insurance program that helps certain people get health care services at a lower cost. This includes people who are older, blind, or living with a disability.

What does Pennsylvania’s Medical Assistance program cover?

Pennsylvania Medicaid / Medical Assistance pays for routine and acute health care services. This includes:

• Visits to health care providers (including physicians and nurse practitioners)
• Inpatient and outpatient hospital services
• Early and periodic screening, diagnostic, and treatment services
• Preventive care (e.g., vaccinations)
• Lab tests and X-rays
• Dialysis services
• Mental health services
• Substance use treatment
• Rural health clinic services
• Medical transportation
• Long-term care (e.g., nursing facility care, home health services)

Most states also cover optional services such as:

• Physical, respiratory, and occupational therapy
• Home- and community-based care
• Case management
• Prescription drugs
• Dental and vision care

Since the program serves those with limited income and resources, people with Pennsylvania Medicaid pay few to no out-of-pocket costs.

To get coverage once you are enrolled, you must go to health care providers that take part in the Medicaid program.

How do I know if I qualify for Medicaid in Pennsylvania?

Generally, to be eligible for Medicaid in Pennsylvania, you must:

• Be a Pennsylvania resident
• Be a U.S. citizen or a qualified non-citizen
• Meet specific income and/or asset limits

For certain Medicaid programs, you must also meet additional requirements. If you need help with your health care coverage and costs, you should apply for Medicaid even if you think you are over the income limit or your assets are too high. This is because:

• Not all types of income are counted toward the income limit.
• You may qualify for a different form of health care assistance. For example, if you have Medicare, you may qualify for a Medicare Savings Program (MSP).
• If you are over the income limit, but you have very high medical costs, you may be able to qualify for the Medicaid Spend-down Program.

What are the different Medicaid programs in Pennsylvania?

You may be able to get health coverage if you fall into one of the following categories:

Medical Assistance for the Aged, Blind, Disabled (ABD)

To receive Medicaid coverage under this category, you must be age 65 or older, blind, or living with a disability.

Medical Assistance for Workers with Disabilities (MAWD)

If you have a disability and are working, this program may provide you with health care benefits. In some situations, working and earning money could prevent you from getting help from public benefit programs, such as Medicaid. This program allows you to work and still keep your health care coverage. However, you may need to pay a premium, which is typically 5% of your countable monthly income.

Home and Community-Based Services (HCBS) Waivers

This Medicaid program helps older adults and people with disabilities get care at home instead of moving into a nursing home. These services can include help with bathing, dressing, meals, housework, medical equipment, and more. The aim of this program is to help people stay safe, healthy, and independent in their own homes or communities for as long as possible.

Medicaid – State Blind Pension (SBP)

This program provides health care coverage to people who are legally blind, have low income, receive State Blind Pension (SBP) cash benefits, and do not qualify for Supplemental Security Income (SSI).

Nursing Home Medicaid

This program helps pay for care in a Medicaid-approved nursing home if you have low income and limited assets, and you need daily help from a nurse. It covers things like room and board, help with daily activities (such as bathing or dressing), meals, and medical care. To qualify, you must meet certain health and financial guidelines.

Medicaid Spend-down/Medically Needy Only (MNO)

The Medically Needy Only (MNO) program lets you get Medicaid benefits even if your income is higher than Medicaid program guidelines. It works by letting you spend down your income so that you meet Medicaid income limits. The spend-down amount is the amount of income that is over the Medicaid limit. This amount is different for each person.

To get Medicaid / Medical Assistance benefits, you must submit current paid or unpaid medical bills equal to or greater than your monthly spend-down amount. Once your medical bills reach this amount, you will get Pennsylvania Medicaid coverage for the rest of the calendar month. While using Medicaid to pay for your medical expenses, you should use a health care provider who takes part in the Medicaid program.

Examples of health care-related expenses to spend down your income on include:

• Medications
• Paid medical bills
• Unpaid medical bills (if they were outstanding 3 months prior to the date of your Medicaid application)
• Nursing home care
• Health-related home renovations, such as wheelchair ramps or chair lifts
• Transportation to medical appointments

How do Medicare and Medicaid work together?

Medicaid pays for some services not covered by Medicare. If you get Medicare, you may also be able to get help from Pennsylvania Medicaid. Millions of Americans have both Medicare and Medicaid coverage. This is called being "dual eligible."

If you have Medicare and qualify for full Pennsylvania Medicaid coverage, the state will pay your Medicare Part B (Medical Insurance) monthly premiums. Depending on the level of Medicaid you qualify for, the state might also pay for:

• Your share of Medicare costs, like deductibles, coinsurance, and copayments
• Part A (Hospital Insurance) premiums, if you have to pay a premium for that coverage

In addition, if you are dual-eligible for Medicare and Medicaid:

• You will automatically be signed up for the Low-Income Subsidy (LIS)/Extra Help program through Medicare Part D (prescription drug coverage). This program helps people with low income pay for their medicines.
• You may be able to get your coverage through a Medicare Advantage Special Needs Plan (SNP) instead of having original Medicare with separate Medicaid coverage. This plan can help you manage the health care services you need. SNPs may also offer more benefits than what you already get from original Medicare. In some cases, you may have no monthly premiums and/or you may pay lower co-payments. All SNP plans are different, so check with the plans to see what they cover and if you can enroll.

Note: SNPs are not available in every community. To find out if there is an SNP in your area, visit the Medicare website or call 1-800-633-4227 or 1-877-486-2048 (TTY).

How do I prepare to apply for Pennsylvania Medicaid?

When you apply for Pennsylvania Medicaid, you’ll be asked for important information to help determine if you qualify for benefits. Before you start, gather some basic information to make your application process easier: 

• A document that shows your age, such as your birth certificate or driver’s license
• Your Social Security card
• Pay stubs for anyone in your household who has earned income
• Documentation that shows any other form of income, such as letters from Veterans Affairs (VA) or the Social Security Administration (SSA)
• Information about your financial assets, such as bank account or investment account statements.

The quickest and easiest way to apply for Pennsylvania Medicaid is online through the COMPASS website. To apply online, you will need to sign into an existing account or create a new account. Once you are logged in, you may complete and submit the Medicaid application. All your personal information is kept 100% confidential and protected by special security technology.

Apply through NH Easy

You can download and print a paper Health Care Coverage application, complete it, and mail it to your local County Assistance Office. You can also drop it off in person at the office.

How can I get help with my application?

• Contact your local County Assistance Office directly.
• Visit a Benefits Enrollment Center (BEC), if there’s one near you. See if there’s one in your area.

NCOA also has a HelpLine you can call to get free support. To get started today, call 1-800-794-6559.