Medicaid in Pennsylvania is also referred to as Medical Assistance (MA), and provides health insurance to low-income families, children, pregnant women, disabled persons, and adults age 65 or older. This program is administered by the Pennsylvania Department of Public Welfare, and offers a total package of medical benefits to anyone who qualifies. Whether you are sick or in need of financial assistance, if you need coverage, MA may be able to help. In order to qualify, members must meet the income limits for their eligibility group. Once a person is found eligible, they have access to a multitude of services, from the most simple exam to complex disease management. This program is ideal for pregnant women also, as it covers you throughout your pregnancy, delivery, and sixty days postpartum to keep you and your new baby healthy. Other individuals may also qualify if they receive other forms of public assistance such as TANF or SSI, they are automatically enrolled in MA.
Each Pennsylvania free clinic and community health center is linked to the MA program, offering care at no cost to all MA members. All care received through MA providers is also complementary, which includes medical, dental, and vision benefits. For special health conditions, MA makes sure you get the supplies, treatment, and tests you need to stay healthy, even if you need care in the home. Waiver programs make long-term care possible for those who need assistance while living in a nursing home or their own residence through MA. Children are the most covered group in the state, and MA provides a great number of services to give them the opportunity to grow up healthy and get any type of care they need. The MA program only covers medically necessary services, and all care is free.
In order to qualify for MA, you must be a resident of Pennsylvania, fit into one of the following eligibility groups, and be a U.S. citizen or legal resident. Children and teens who live on their own can apply for themselves, or a parent/guardian/caretaker can apply for a child who lives with them. Pregnant women are required to prove their pregnancy with documentation from a physician. Aged, blind, and disabled applicants have both income and asset limits to meet for enrollment in MA. Each group is assigned a percentage of Federal Poverty Level to meet according to their household size. Find your group to determine if you and your family qualify.
View the current Federal Poverty Level.
- Pregnant Women & Infants 185% FPL
- Children Ages 1-5 133% FPL
- Children Ages 6-19 100% FPL
- Parent (employed or unemployed) 26% FPL
- Aged, Blind or Disabled 100% FPL
Qualified Medicare Beneficiaries (QMB) 100% FPL
Medicaid covers your premiums, coinsurance, and deductibles.
Specified Low-Income Medicare Beneficiaries (SLMB) 120% FPL
Medicaid covers your premiums only.
Covered Benefits & Access to Care
Both physical and mental health care are covered by MA, including physician services, hospital care, emergency room visits, maternity, dental, medical supplies, and rehabilitative services. Physical, occupational, and speech therapy is offered to those who need it, as well as substance abuse treatment.
Depending on the part of Pennsylvania you live in, you will either have access to HealthChoices managed care or Fee-For-Service, and your benefits will vary based on which program you use. HealthChoices managed care works with a health plan to coordinate your care, assigning a primary care physician to direct your health care needs. Your PCP will recommend which providers to go to and what services to use when you are in need of care.
Fee-For-Service members will receive a list of approved MA providers throughout the area, and providers who may accept MA from their County Assistance Office. As a Fee-For-Service member, you must contact a provider in advance before you use any service.
How to Apply
If you feel you may qualify for MA, you should certainly apply for benefits. The most efficient way to apply is online through COMPASS, but you may also fill out a form by printing one from home, or picking one up at a local health department office. Many hospitals and doctor’s offices also keep MA applications available. Applying through COMPASS also allows you to see what other assistance you may qualify for, such as food stamps, heating and energy assistance, and cash assistance.
1. Pennsylvania Department of Public Welfare. “Health Care/Medical Assistance.” http://www.dpw.state.pa.us/foradults/healthcaremedicalassistance/index.htm.
2. Pennsylvania Department of Public Welfare. “Physical Health Options.” http://www.dpw.state.pa.us/foradults/healthcaremedicalassistance/medicalassistanceoptionsphysicalhealth/index.htm.