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PA Medicaid Eligibility Handbook & Benefit Guide

The Pennsylvania Medicaid program, often called the Pennsylvania Medical Assistance (MA) program, covers about 20% of the Pennsylvania population. That includes about one in every six adults, three out of every eight kids, half of all PA disabled people, and one out of every six Medicare beneficiaries! That’s right - you can have both Medicare and Medicaid at the same time! Whether you can benefit from both programs or just one, this guide can help you determine whether or not Pennsylvania Medical Assistance can provide the healthcare insurance you need.

Click below to learn more about PA Medicaid:

Pennsylvania Medicaid Eligibility

To qualify for Pennsylvania Medicaid, you must legally reside in the state of Pennsylvania and have a financial need. Financial need is based on income (wages, interest, Social Security Disability Insurance, veteran benefits, pensions, spouse income) and does not include Supplemental Security Income (SSI), child support/foster care payments, and other government subsidies. Some resources are considered as well, like money in a checking or savings account, stocks and bonds, and non-residential property. Your house, vehicle (unless you have more than one in your name), and burial savings are not included.

Your income cannot exceed more than the following (based on your household size):

Pennsylvania Medicaid Eligibility

PA Welfare Income Guidelines

The income requirements for PA Welfare programs are fairly close to those for PA Medical Assistance. For example, in 2019, a household of two cannot earn more than $1,784 to qualify for food stamps in Pennsylvania (SNAP), but a family of two can earn up to $1,945 to qualify for PA Medical Assistance.

Are Medicare and Welfare the Same Thing?

Medicaid and welfare are not the same thing and do not work together. The term welfare refers to pure financial benefits, while Medicaid acts as a form of health insurance. It is common for people who qualify for welfare in Pennsylvania to also qualify for Medicaid, but they are not the same program, and the qualifications are different.

Yellow Access Cards

Everyone in Pennsylvania who receives either Medicaid or welfare (or both) will receive an “access” card with different colors based on which programs you qualify for. This card will serve as proof of your benefits. Be sure to always keep your yellow access card in a safe place and bring it with you to your medical appointments. Your doctor can use the card to figure out what benefits you have.

Pennsylvania Medicaid Expansion

In 2015, Pennsylvania Governor Tom Wolf expanded the PA Medicaid program, resulting in over 700,000 new beneficiaries. The expansion also added over 600 more dentists, about 450 nurse practitioners, and almost 4,500 more physicians. With these additions came a large decrease in the Pennsylvania uninsured rate, a huge increase in employment (15,500 jobs added), a decrease in hospitals going without payment, and an overall healthier Pennsylvania.

Benefit List

Since Medicaid is a state-based program, there are some federal regulations, but states have some freedoms when it comes to eligibility and benefits for Medicaid programs. All Medicaid programs are required to provide coverage for hospital services, screenings and diagnostics, nursing facilities, home health, doctor visits, lab/x-ray tests, birth centers and family planning, and non-emergency medical transportation, but some states (like Pennsylvania) add additional benefits, like dental.

CHIP (Children's Health Insurance Program)

The Pennsylvania Children’s Health Insurance Program is comprehensive and includes benefits for expecting mothers and their newborn babies, as well as:

  • Immunizations
  • Routine well-visits
  • Prescription drugs
  • Dental, vision, and hearing
  • Hospitalization and emergency care
  • Mental health and substance abuse
  • Rehabilitation and therapies (mental and physical)
  • Hospice/palliative services
  • Medically necessary dental services, including orthodontics

Pennsylvania Medicaid Dental Benefits

Pennsylvania Medical Assistance covers all dental services for enrolled children as long as they are deemed medically necessary. This can include regular cleanings, x-rays, fillings, crowns, etc. Adults in the medical assistance program are covered for medically necessary surgeries and emergency procedures, but only some adults in unique cases are eligible for cleanings, x-rays, fillings, crowns, etc.

Non-Emergency Medical Transportation

If you are enrolled in Medicaid and do not have a reliable means of transportation, your county can provide public transportation (usually at no charge). If public transit is not available, you can receive a mileage reimbursement or a taxi or wheelchair-accessible van. This service is only available for transportation to and from medical appointments that are also covered by Medicaid. For more information, contact the party responsible for the Medical Assistance Transportation Program in your county.

Have Questions? Ask a Benefits Advisor in Your Area

PA Medicaid Providers

The best way to find doctors in Pennsylvania who accept PA Medicaid is by using an online doctor search tool like doctor.com or ZocDoc. Through these tools, you can enter the type of insurance you have (Medicaid), your location (usually by zip code), and the type of doctor you are looking for. You can then read reviews and compare doctors in your area before you schedule your first appointment.

PA Medicaid Covered Drugs

The medical assistance program includes a list of “preferred” drugs that are considered the best in their class based on effectiveness and safety. These drugs are almost always covered, while non-preferred drugs will only be covered when medically necessary. Some drugs, whether preferred or not, will require prior authorization from the Pennsylvania Medicaid program before they can be administered with Medicaid insurance coverage. You can look for your drug on the Pennsylvania Department of Human Services Preferred Drug List here, or type in the name or code for your drug here to see if it’s on the list.

Pennsylvania Prescription Assistance Program

The Pennsylvania Prescription Assistance Program works at over 60,000 pharmacies in Pennsylvania, including large chains like Walgreens and CVS. The program is available to EVERYONE in Pennsylvania for FREE, but is not an alternative to health insurance with prescription drug coverage. You may be able to save up to 75% on your prescriptions. However - the card will not cover your copayments, and in some cases cannot be combined with insurance. That means that it may actually be cheaper for you to use your insurance than the Prescription Assistance Program. We also have a prescription discount card of our own that you can download by clicking the image below:

Rx Discount Card | Medicare Plan Finder

How to Apply for Medicaid PA

To apply for Medicaid in Pennsylvania, visit “COMPASS.” Before you start your application, you may want to gather the information you’ll need. Look for proof of household income, tax filing information, Social Security numbers, other health insurance information, proof of property, proof of citizenship, etc.

PA Medicare and Medicaid

You can have both Medicare and Medicaid benefits if you meet the qualifications for both programs. Know that when you become eligible for Medicare, the PA Medicaid program will no longer cover your prescription drugs. You will have to enroll in a Medicare plan that includes prescription drug coverage, like Part D or Medicare Advantage. The good news about qualifying for both programs is that you can enroll in a “dual-eligible special needs plan,” or DSNP. Through a DSNP, you can have some or all of your Medicare out-of-pocket costs covered. We can help you find a DSNP plan in your area and get you enrolled ASAP!

Special Needs Plans | Medicare Plan Finder

Have questions? Ask a Benefits Advisor!