Pennsylvania Medicaid Eligibility and Enrollment
- Pennsylvania Medicaid covers services for residents who meet specific requirements. Read on to learn more about the Medicaid program and find out how to apply.
What Is Pennsylvania Medicaid?
In the United States, Medicaid is a joint effort between the federal government and state governments. The federal government sets minimum requirements for the program, and state governments are responsible for meeting those guidelines. Pennsylvania's Medicaid program is known as Medical Assistance and covers a wide range of medical and behavioral health services. In some cases, Pennsylvania Medicaid also covers community services for people with qualifying disabilities.
Pennsylvania Medicaid Expansion
Under the Affordable Care Act, many states expanded their Medicaid programs, making it possible for some applicants to qualify for coverage based solely on their income. The expansion program was designed to increase the number of low-income citizens covered by Medicaid.
Pennsylvania is one of the states that decided to expand its Medicaid program after the Affordable Care Act went into effect. As a result, adults with incomes at or below 133% of the federal poverty level are now eligible for Medicaid coverage, even if they do not meet requirements related to age or disability status. Due to the expansion, Pennsylvania qualifies for enhanced federal matching payments, reducing the state's share of Medicaid costs.
Covered Services
Medicaid programs are required to cover several mandatory services, including X-ray services, laboratory testing, physician care, home health services and hospital care. For covered individuals under the age of 21, the federal government requires each Medicaid program to cover periodic screening tests. Medicaid is also required to cover diagnostic tests and treatments when one of these screening tests uncovers a potential health problem.
In addition to the mandatory services spelled out in the federal guidelines, states are also allowed to structure their Medicaid programs to cover optional services, such as hearing aids, vision care and dental care. Pennsylvania Medicaid covers a variety of optional services, including the following:
- Prescription drugs
- Optometry services
- Case management services
- Dental care
- Kidney dialysis
- Outpatient treatment for drug and alcohol abuse
- Transportation to medical appointments
- Birthing center services
- Podiatric care
- Chiropractic care
Out-of-Pocket Costs
Although Medicaid recipients pay no monthly premiums for their health coverage, Pennsylvania Medicaid does require some individuals to pay co-payments for certain services.
- Hospital care: $3 per day ($21 maximum per stay)
- Prescriptions: $1 per fill of a generic drug; $3 per fill of a brand-name drug
- X-rays: $1 per test
- Nuclear medicine: $1 per test or treatment
- Radiation therapy: $1 per treatment
Who Is Eligible for Medicaid in Pennsylvania?
To qualify for Medical Assistance, applicants must meet certain eligibility guidelines. Income is one of the most important criteria. Because Pennsylvania is one of the states that expanded its Medicaid program after the ACA was implemented, applicants with household incomes at or below 133% of the federal poverty level qualify for coverage even if they don't meet other eligibility requirements.
What Is the Maximum Income to Qualify for Medicaid in PA?
The maximum income to qualify for Medicaid depends on the size of the applicant's household, as outlined below.
|
Household Size |
Maximum Annual Income (Gross) |
| 1 | $19,392 |
| 2 | $26,228 |
| 3 | $33,064 |
| 4 | $39,900 |
| 5 | $46,737 |
| 6 | $53,573 |
| 7 | $60,409 |
| 8 | $67,245 |
Citizenship and Residency Requirements
Applicants must live in Pennsylvania and meet one of the following citizenship requirements:
- U.S. citizen
- U.S. national
- Legal alien
- Permanent resident
Additional Eligibility Requirements
Applicants who don't qualify on income alone must meet at least one of the following requirements:
- Have a disability
- Have a household member with a disability
- Pregnancy
- Responsible for a child no older than 17
How Do I Enroll in Medicaid in Pennsylvania?
In Pennsylvania, it's possible to apply for Medical Assistance online, on the telephone, on paper or in person.
Online Applications
Individuals who prefer to apply online should visit the COMPASS website. COMPASS helps connect eligible Pennsylvanians to a variety of services, including Medical Assistance and energy assistance (LIHEAP). With a COMPASS account, it's also possible to reapply for benefits when necessary.
Telephone Applications
Telephone applicants should call the Consumer Service Center for Health Care Coverage. The telephone number is (866) 550-4355.
Paper Applications
Download a paper application from the Pennsylvania Department of Human Services website. The paper application is used to apply for Medical Assistance, SNAP benefits and cash assistance. Once the application is complete, it should be returned to the closest County Assistance Office. The Pennsylvania Department of Human Services maintains a list of assistance offices on its website.
In-Person Application
Individuals who would like to apply in person should contact their local County Assistance Office.
Contact Information for Pennsylvania Medicaid
Consumer Service Center for Health Care Coverage: (866) 550-4355
COMPASS Helpline: (800) 692-7462
