Overview of Medicaid in PA
Medicaid is a health care program and allows you manage your health and get care when needed.
Medicaid (also called Medical Assistance in Pennsylvania) is a healthcare program that helps eligible people access physical and behavioral healthcare and other supportive services that they need to live well.
Medicaid serves as a vital safety net for the health and well-being of individuals and families facing financial challenges.
Medicaid helps to provide access to comprehensive healthcare coverage. Most people who qualify for Medicaid will use HealthChoices to access physical healthcare, like annual checkups, care when you’re sick, or appointments to manage other illnesses or health needs. Once you apply for Medicaid, if you’re eligible, you’ll be able to pick a HealthChoices managed care organization to access care.
Medicaid also provides access other important services that people meet their individual health needs through care and services for:
- Mental Health and Substance Use Disorder Treatment for children and adults (Behavioral HealthChoices)
- Long-Term Supports and Services for Older Pennsylvanians and adults with physical disabilities (Community HealthChoices)
- Autistic Pennsylvanians
- Pennsylvanians with Intellectual Disabilities
- Pregnant people
General Eligibility Requirements for Medicaid
Based on factors such as income and employment, you may be eligible to receive Medicaid health benefits.
Medicaid eligibility is based on factors such as a person’s income, family size, age, and disability status. Eligibility for Medicaid can vary based on a person’s specific circumstance, and the best way to find out if you or your loved one are eligible is to complete an application.
The Department of Human Services can help you through the process to determine your eligibility, but as you apply, it’s helpful if you have an idea of how you or your loved one may qualify for Medicaid. This could be based on a need for health insurance, your income, a disability, a need for long-term care, or something else.
No matter your circumstance, there are things you’ll need to have available when you’re ready to apply for Medicaid for yourself and/or a loved one. Be prepared to submit information that verifies your identity, your income, whether you are a U.S. Citizen or legal resident, your Social Security Number, as well as information about anyone else who lives in your household
- Eligibility based on Modified Adjusted Gross income (MAGI):
- Children aged 18 and under
- Pregnant women
- Parents and caretakers of children under 21
- Adults ages 19-64 with incomes at or below 133 percent of the Federal Income Poverty Guidelines (FPIG)
- Family planning services
- Eligibility not based on MAGI
- Individuals 65+
- Individuals who are blind and/or disabled
- Medical Assistance for Workers with Disabilities (MAWD)
- Individuals receiving long-term care (LTC)
- Individuals receiving home and community-based services (HCBS)
Your Income
Medicaid eligibility is determined using income and household size in comparison to income limits set by the federal government.
Examples of income counted when determining eligibility include:
- Wages and income
- Spouse’s income (if living in the same household)
- Interest & dividends on investments
- Social Security
- Veterans' Benefits (except in some cases)
- Pensions
Examples of income not counted when determining eligibility include:
- Temporary Assistance for Needy Families (TANF) benefits
- Supplemental Security Income (SSI)
- Supplemental Nutrition Assistance Program (SNAP) benefits
- Low Income Home Energy Assistance Program (LIHEAP) benefits
- Foster Care payments
- Certain housing or utility subsidies
- Weatherization Payments
- Child Support Payments (only for MAGI MA)
Your Resources
Resources are also sometimes considered when applying for Medicaid. Resources include money contained in bank accounts, life insurance, vehicles, owned property (aside from your primary residence), and more.
When you’re completing your application, the Department of Human Services will tell you if your application needs a review of resources based on your specific circumstances.
Other Eligibility Requirements
Your Identity
Your identity can be verified by PA driver's license, PA identification card, or a government-issued passport.
Your Social Security Number (SSN)
A SSN must be provided for each person applying for Medicaid (with some exceptions). If you don’t have a social security number, reach out to your local County Assistance Office to apply for one.
Your PA Residency
Medicaid is available to Pennsylvania residents, regardless of how long you’ve been a Pennsylvania resident.
Your Citizenship
Medicaid is available to United States citizens, refugees, and lawfully admitted non-citizens. Other non-citizens may be eligible for limited Medical Assistance benefits if an emergency medical condition exists. U.S. citizens, refugees and lawfully admitted non-citizens may need to submit documentation proving U.S. citizenship or lawful non-citizen status if their citizenship can’t be verified through electronic sources.
Your Household
Your local County Assistance Office can help determine who the mandatory or optional budget group members are, based upon household relationships and individual needs, when you apply for Medicaid.
Income limits for specific eligibility groups
Medicaid for Children with Special Needs
Medicaid for Children with Special Needs (PH95) provides full and free Medical Assistance (MA) coverage to children up to age 18 with disabilities whose parents make too much money to qualify for traditional Medicaid categories.
Application Process
There are a few ways you can apply for Medicaid.
If you’re looking for standard health coverage, you can apply online via COMPASS, in-person at a County Assistance Office, by phone, or via mail.
If you are applying for Medicaid coverage because of an intellectual or physical disability or certain health condition (like a breast cancer diagnosis), there may be different materials to submit. Learn more:
- Intellectual disabilities and autism
- Physical disabilities and long-term care for Older Pennsylvanians
- Breast and Cervical Cancer Prevention and Treatment Program
No matter your specific situation, when you are applying for Medicaid, you may need the following information ready to help you complete your application:
- Proof of household income from jobs, child support, and other income sources
- Federal tax filing information
- Social Security Numbers and date(s) of birth for yourself and/or the person you are applying for
- Current or recent health insurance information (if available)
- Proof of citizenship and identity
- This can be a birth certificate, driver's license, or other state-issued ID
- Non-U.S. Citizens must provide documentation showing lawful residence in the U.S.
- Resource information, such as bank accounts, vehicles, homes, property, life insurance, etc.
Frequently Asked Questions about Medicaid
Medicaid covers a broad range of physical and behavioral health services, including doctor visits when you’re sick, preventive care like health screenings, vaccines, hospital stays, prescription medications, mental health and substance use disorder care, and more.
Check coverage details for:
- Breast and Cervical Cancer Screening and Treatment
- Dental Service
- HealthChoices
- Health Insurance Premium Payment (HIPP) Program
- Home and Community-Based Services
- Limited English and Interpreters
- Medical Assistance Transportation Program (MATP)
- Medical Assistance Benefits for Workers with Disabilities
- Medical Assistance for Children and Pregnant Women
- Mental Health and Substance Abuse
- Prescription Drug Coverage
If you apply for and qualify for Medicaid, you'll get more information about how to use your benefits and have the opportunity to pick a HealthChoices managed care organization (MCO), to help you coordinate your care. Your MCO works with providers, and you can contact your MCO to find doctors in your community.
If you are not eligible or lost your Medicaid/Medical Assistance coverage, you may be able to get low-cost or even no-cost health coverage through Pennie™, Pennsylvania’s official health and dental insurance marketplace.
Pennie’s open enrollment runs from November through January every year, but depending on your personal situation, you may qualify for a special enrollment period.