Making ends meet in today’s economy is challenging for many families, especially those earning low incomes or living at or below the federal poverty level. The financial burden often requires making tough decisions, which may include forgoing healthcare. However, PA Medical Assistance, which is the official Pennsylvania Medicaid program, offers some solutions.
This state program helps about 3.7 million Pennsylvanians access the medical care they wouldn’t otherwise be able to afford. The program aims to help people stay healthy and manage their chronic conditions. With coverage, you can also enjoy peace of mind that any unexpected illness or injury you face won’t make you choose between healthcare and financial freedom; you deserve both.
Pennsylvania’s Medicaid coverage ensures that the state’s children, the elderly, parents, people with disabilities, and adults with very low incomes can also have health insurance. The plan covers everything from general wellness services like annual physicals to emergency surgery, dental care, mental health treatment, and family planning. For those with limited resources, this program can be critical to staying healthy and avoiding the complications of deferred healthcare.
This guide answers the most common questions about the program to help you make well-informed decisions about health insurance for your family and even covers information to include a more comprehensive range of benefits and services by way of private health insurance.
Aside from being a jointly funded program between the federal government and the state, every state still has its own version of Medicaid. Most programs have a unique name but provide the same minimum level of coverage, and PA Medical Assistance is no different. So, what is PA Medical Assistance coverage aiming to achieve?
At its core, Pennsylvania’s Medicaid program gives qualifying residents healthcare at no or low cost. The PA Medical Assistance coverage works like most health insurance programs in that members do not receive any cash or reimbursements for their healthcare services. Instead, they present their Medicaid ID card to service providers and pharmacies at the time of service, allowing providers to directly bill the state (at established rates).
To keep costs in check, Pennsylvania has more stringent requirements for Medicaid eligibility than many other states. For example, in 2018, the Pennsylvania House voted to require some Medicaid recipients to work at least 20 hours per week, look for work, or attend job training. The state may also review employer-sponsored health plans and provide assistance with those premiums rather than provide full benefits.
Those who qualify for medical assistance in Pennsylvania receive benefits through Physical HealthChoices, a Managed Care Organization (MCO). The HealthChoices MCO for your county works with major health plans to ensure you have timely access to quality health services. Still, some program members may need to pay nominal copayments for hospital stays, X-rays, and prescriptions.
Health plans that provide Medicaid benefits in the state of Pennsylvania include the following:
Not all plans are available in every county, but by law, every plan offers members the same benefits. The primary difference between plans is the provider network and the availability of extra services, such as care management, digital tools, and vision benefits. Pennsylvania Enrollment Services has a tool to help you compare different MCO plans and select the one that best meets your needs.
If you aren’t eligible for Medicaid, Pennsylvania has other assistance programs to help you access healthcare. In that case, you may want to explore PENNIE, the state’s health insurance marketplace. You can often find affordable policies here.
Lastly, the Children’s Health Insurance Program (CHIP) provides health insurance for children whose families earn too much to qualify for Medical Assistance but cannot afford other options. Children, pregnant women, people in long-term care or hospice, and those in select programs do not have to make copayments.
When the Department of Human Services approves your application for Medical Assistance, they will mail your confirmation letter and a Medicaid identification card. Once you choose your MCO, you will receive a card from that plan, too. Keep both cards safe because you must present them whenever you go to a doctor or pharmacy.
Are you over 65 and already on Medicare? The Centers for Medicare and Medicaid Services will mail you an identification card with your identification number. You will need to present this card to providers as well.
(Please note that the image of the card displayed may vary depending on the carrier you are enrolled with.)
Are you wondering how to apply for PA Medical Assistance? There are several options available, including the following:
Before you apply online, use the simple screening tool to determine whether you qualify for benefits. Then, set up a COMPASS account and gather the following information:
When you apply for Pennsylvania Medicaid coverage, you should expect the state to ask you for supporting documents. For example, you will need a copy of your identification and a utility bill to prove you’re a resident of the Keystone State. You may also need copies of your bank statements, proof of income from your wage statements or pay stubs, birth certificates, information about vehicle payments and insurance, and proof of citizenship or your lawful immigration status.
Your eligibility for the Medicaid program depends on a list of factors. However, even if you don’t meet all the requirements for state-sponsored healthcare, you may qualify for other options.
To apply to PA Medical Assistance, you must meet the following criteria:
The state of Pennsylvania also opted into Medicaid expansion, which allows low-income, childless adults between the ages of 19 and 64 to apply for benefits. Children and teenagers not eligible for Medical Assistance programs may instead qualify for free or low-cost healthcare via CHIP. Some children with chronic health conditions may qualify for Social Security but can apply for Medical Assistance as secondary insurance.
Low or very low-income people over 65 can also apply for Pennsylvania’s Medicaid program to supplement Medicare benefits. Most people sign up for Medicare at age 65, as it is a federal entitlement program that doesn’t have any income requirements. However, seniors who fall below the income threshold can get help paying for their monthly Medicare premiums and additional coverage for their medical care and prescription costs through Medicaid.
When Pennsylvania’s DHS approves your application for Medicaid, you will receive an identification card, details about the health insurance program, and information about your benefits in the mail. Once you enroll in an MCO, you’ll also receive a card from your insurance carrier directly.
PA Medical Assistance enrollees can remain in the program as long as they are eligible but need to reconfirm this eligibility every year. Although renewals paused during the COVID-19 pandemic in 2020, as of April 1, 2023, the federal law required states to restart Medicaid reviews. So now, when DHS notifies you that it’s time to renew your benefits, you will only have 90 days to submit the requested information.
Failing to respond will result in the termination of your Medicaid benefits in Pennsylvania. Check the COMPASS system to learn your renewal date and submit your information (up to 60 days in advance). Additionally, while you must confirm your information annually, you also must inform DHS when your circumstances change, such as moving, changing jobs, or having another child.
Have you lost or damaged your ID card? Alert DHS and request a replacement. The same applies to your managed care organization card, for which your MCO will need to provide a replacement.
Federal law establishes what PA medical assistance covers on a basic level, and these minimum requirements apply to all state Medicaid plans. However, Individual states and MCOs can offer additional services and benefits, which may or may not be available in every county.
When you enroll in PA Medical Assistance, expect insurance coverage for the following:
Because healthy teeth affect overall well-being, you might wonder what PA Medical Assistance covers in terms of dental care.
Children on Medicaid can receive a full spectrum of medically necessary dental treatments, including checkups, cleanings, fillings, crowns, and other services.
Adults typically get emergency dental care and surgical procedures. However, some adults may be eligible for additional dental coverage, depending on the MCO plan they select. You can also call the MCO to learn more about your potential dental benefits.
For those who have more serious dental issues and anticipate requiring more visits to the dentists, investing in private dental plans in Pennsylvania is advisable.
When your healthcare provider prescribes medication, Medical Assistance covers the cost as long as the drug is on the Preferred Drug List. Some people may have to pay a small copayment for their medication.
Has your doctor prescribed a medically necessary medication not on the list, and there isn’t a viable alternative? They can seek pre-authorization to have Medicaid cover the cost.
Additionally, Medicare beneficiaries who receive PA Medical Assistance must enroll in a Medicare Part D plan to cover the costs of their prescription drugs. However, you may qualify for a subsidy to help cover the cost of a Part D plan, so call the local OAP or Social Security office to learn more.
PA Medical Assistance covers the costs of medically necessary gender transitions and does not explicitly prohibit transgender-related healthcare. In addition, the Pennsylvania program offers comprehensive behavioral health services, such as:
Individuals who are not pregnant and do not otherwise qualify for Medical Assistance but have an income below 215% of federal poverty guidelines can apply for free family planning services. The Family Planning Services Program covers counseling, birth control, and screening and treatment for sexually transmitted infections.
Many patients require additional care, but they go without because of financial concerns, lack of coverage, and restricted access. Investing in quality disability insurance is an excellent way to assist with some of the costs incurred with not being able to work either temporarily or permanently, and to help with the cost of medical needs.
As with other states, Pennsylvania’s Medicaid enrollees can only use these benefits within the Pennsylvania state borders. The only exception is if you’re out of state and have a life-threatening emergency that prevents you from returning home.
Though unlikely, you may also be able to request pre-authorization for services that aren’t available in Pennsylvania or use your benefits in bordering states. However, this also depends on whether those out-of-state providers accept PA Medical Assistance.
If you are traveling outside of Pennsylvania for leisure, invest in proper travelers insurance.
Did you know that federal law allows students to remain on their parents’ health insurance policies until age 26? However, if that isn’t possible and you live in Pennsylvania, you can apply for Medicaid benefits.
Medicaid expansion also allows low-income adults who earn less than 133% of the federal poverty level income to enroll in Medical Assistance. Other options for students include affordable policies from a college or university or getting assistance in purchasing a policy on the PENNIE insurance exchange.
On the other end of the spectrum, the majority of Pennsylvanians over age 65 have health insurance from Medicare, which they pay into over their working life via payroll taxes. Monthly premiums for this federal entitlement program are low, but many low-income seniors need additional help paying them. The state provides several special needs programs to provide this support, which vary by income to include the following:
Medicaid provides coverage for long-term care, home health, and hospice services. Pennsylvania also participates in the Program for All-Inclusive Care for the Elderly, which allows individuals who require a nursing home level of care to remain in their homes. This PACE program provides coordinated, community-based services, and if you’re already on Medicaid, it’s free.
Besides children, adults, the elderly, and disabled Pennsylvannian residents, PA Medicaid coverage extends to the following groups:
Children up to age 21 can receive Medicaid benefits in Pennsylvania that include well-child visits, immunizations, dental care, and other medical services. Medicaid recipients also have access to the Early and Periodic Screening, Diagnostic, and Treatment program.
Native Americans in Pennsylvania can receive free healthcare through tribal clinics and hospitals, the Indian Health Service, and urban health facilities. To receive care at these facilities, people must present a Certificate of Degree of Indian Blood card or a tribal enrollment card.
However, that doesn't mean Native Americans eligible for Medicaid shouldn't apply since the program can serve as extended healthcare for Indian Health Services. With a PA Medicaid card, Native American Pennsylvannians can get referrals to specialized services, like cardiology and X-rays, which might not be available at tribal clinics.
Active military personnel, veterans, and immediate family members can receive healthcare through TRICARE. With TRICARE, members can access military hospitals and approved civilian healthcare professionals, pharmacies, and other facilities. Still, if you're an active or retired military member who qualifies for Oklahoma Medicaid, you can apply for benefits and use them in addition to TRICARE insurance.
Although PA Medical Assistance covers most services, it’s not all-inclusive. For example, the services it doesn’t cover include the following:
It is also important to note that while PA medicaid does provide some assistance towards the cost of burial and funeral services, it certainly doesn’t cover everything. Considering the rising cost of burial and related fees, ensure that your family is secured with comprehensive funeral insurance.
As expected, all PA Medical Assistance plans will offer federally mandated services. Still, extras do appear for many plans that go beyond these minimum requirements. The overview below is of the basic coverages you can access with a Pennsylvania Medicaid plan:
|Primary care visits
|Annual physicals and well-child visits
|Routine lab work and X-rays
|Mental health care
|Emergency services for adults
|Surgery for adults
|Exams and cleanings for children
|Inpatient and outpatient hospital stays
|Alternative and complementary medicine
|Durable medical equipment and supplies
|Home care services
Do the above benefits seem like PA Medical Assistance will make it possible for you or your low-income family to access healthcare in Pennsylvania? If the list seems to lack some of the coverage and flexibility of other insurance options, you may need to think about extending your options a little.
Do you prefer to work with a doctor who doesn’t accept Medicaid? Do I need more help with vision or dental costs or get care out of state? Third-party insurance coverage or an extended policy on top of Medicaid could be the solution. You can use private insurance providers to fill the gaps in your PA Medicaid plan and get the coverage you need. Other types of private insurance, such as life insurance, can help pay for medical costs Medicaid will not cover, especially in the event of your passing.
Consider what you can get from a supplemental policy as follows:
If you’re on the Pennsylvania Medicaid program or applying to join, it’s important to make sense of the health insurance options you’re able to access. Sometimes, the ideal coverage involves both Medicaid and a supplemental policy. If you’d like to explore some options beyond PA Medical Assistance, try Insurdinary for free, no-obligation health insurance quotes from local companies. That way, you can easily find the perfect health insurance coverage for you and your family.
Insurdinary, and its network of partners offer many different types of insurance. In addition to health, dental, disability, life, funeral and travel insurance as discussed on this page, you may also be interested to explore the following: