If you are interested in applying for Medicaid in Pennsylvania – or Medical Assistance (MA), you’ve come to the right place. In this post, we will provide information about Pennsylvania Medicaid eligibility criteria for children and family, pregnancy, the elderly, the blind, and the disabled.
We will explain in detail everything you need to know to successfully apply for Pennsylvania Medicaid.
In addition, we will show you the various ways you can apply, including how to log in to MyCOMPASS PA Portal, and how to contact Pennsylvania Medicaid.
Finally, we will answer some of the most frequently asked questions about Pennsylvania Medicaid Eligibility.
This article on Pennsylvania Medicaid eligibility will cover:
- What is Pennsylvania Medicaid?
- Who is Eligible for Medicaid in Pennsylvania?
- Pennsylvania Medicaid Eligibility Guidelines
- 2021 Pennsylvania Medicaid Income Limit
- How to Apply for Medicaid in Pennsylvania
- What does Medicaid Cover in Pennsylvania?
- Pennsylvania Medicaid Phone Number
- Medicaid Expansion in Pennsylvania
- Pennsylvania Medicaid Card
- FAQs about Medicaid in Pennsylvania
What is Medicaid?
Medicaid is a federal and state health insurance program for people with a low income.
It provides free or low-cost health coverage to millions of Americans, including families and children, pregnant women, the elderly, and people with disabilities.
The Children’s Health Insurance Program (CHIP) offers health coverage to children in families with incomes too high to qualify for Medicaid, but who can’t afford private coverage.
Pennsylvania Medicaid
The Pennsylvania Medicaid program provides medical coverage to low-income individuals and families.
As of 2020, the program, along with the Children’s Health Insurance Program (CHIP) covered 3.2 million people.
This includes about 1.5 million children as shown by the image below.
The Pennsylvania Medicaid program is managed by the Department of Human Services (DHS)
Who is Eligible for Medicaid in Pennsylvania?
The following people may qualify for Pennsylvania Medicaid if they meet certain financial
requirements:
- Adults age 19-64 with incomes at or below 133% of the Federal Income Poverty Guidelines (FPIG)
- Individuals who are aged (age 65 and older), blind and disabled.
- Families with children under age 21
- Special Medical Assistance conditions
Pennsylvania Medicaid Eligibility Guidelines
To qualify for Medicaid in Pennsylvania, an individual must meet the eligibility requirements of the program.
There are several Medicaid programs that people in Pennsylvania can be eligible for. Each program has its own income and asset requirements.
However, all applicants must meet the general requirements below in order to qualify for Pennsylvania Medicaid.
Proof of Identity
Identity can be verified by a driver’s license, state identification card or another piece of identification.
Social Security Number (SSN)
An SSN must be provided for each person applying for Medicaid.
Your county Medicaid Office staff can help you apply for an SSN for anyone who does not have one.
Residency
Medicaid assistance is available to individuals who are residents of Pennsylvania if all other eligibility requirements are met.
There is no requirement regarding the length of time that a person must live in Pennsylvania in order to be eligible.
Citizenship
Medicaid is available to United States citizens, refugees, and certain lawfully admitted aliens. Other aliens may be eligible for limited Medical Assistance benefits if an emergency medical condition exists.
Additionally, U.S. citizens, refugees and legal aliens must submit documentation proving U.S. citizenship or legal alien status.
Household Composition
County Assistance Office staff will determine who are mandatory or optional budget group members in the Medical Assistance application based upon household relationships and individual needs for Medical Assistance.
Income limit
The income requirements for Pennsylvania Medicaid is perhaps the most important eligibility criteria. See below for details about Medicaid income limits by group. and household size.
2021 Pennsylvania Medicaid Income Limit
The PA Medicaid eligibility income limit charts are divided by groups.
For example, the first chart is focused on income limits for children who qualify for Medicaid.
Similarly, the second chart below focuses on the Medicaid income limits for adults in Pennsylvania who qualify for Medicaid.
Pennsylvania Medicaid Income Limit for Children
Below is the income limit for children by age category. Find the age category your child falls into and you will see the income limit by household size.
| Pennsylvania Medicaid Income Limit – Children | ||||||
| Children Medicaid Ages 0-1 | Children Medicaid Ages 1-5 | Children Medicaid Ages 6-18 | Children Separate CHIP | |||
| % FPL | 100% | 215% | 157% | 133% | 314% | |
|
Household Size
|
1 | $12,880 | $27,692 | $20,222 | $17,130 | $40,443 |
| 2 | $17,420 | $37,453 | $27,349 | $23,169 | $54,699 | |
| 3 | $21,960 | $47,214 | $34,477 | $29,207 | $68,954 | |
| 4 | $26,500 | $56,975 | $41,605 | $35,245 | $83,210 | |
| 5 | $31,040 | $66,736 | $48,733 | $41,283 | $97,466 | |
| 6 | $35,580 | $76,497 | $55,861 | $47,321 | $111,721 | |
| 7 | $40,120 | $86,258 | $62,988 | $53,360 | $125,977 | |
| 8 | $44,660 | $96,019 | $70,116 | $59,398 | $140,232 | |
Next is the income limit for adults by category. Find the category you fall into and you will see the income limit by household size.
Pennsylvania has expanded Medicaid to include adults without dependents.
Therefore, adults without dependents can apply for Medicaid in Pennsylvania.
For an update on the Medicaid expansion debate and timeline in Pennsylvania, see our Pennsylvania Expansion update below.
Pennsylvania Medicaid Income Limit for Adults
| Pennsylvania Medicaid Income Limit – Adults | ||||||
| Pregnant Women Medicaid | Adults (Medicaid) Parent/ Caretaker | Seniors & People w/ Disabilities (Medicaid) | Adults (Medicaid) Expansion to Adults | |||
| % FPL | 100% | 215% | 33% | 74% | 133% | |
|
Household Size
|
1 | $12,880 | $27,692 | $4,250 | $9,531 | $17,130 |
| 2 | $17,420 | $37,453 | $5,749 | $12,891 | $23,169 | |
| 3 | $21,960 | $47,214 | $7,247 | $16,250 | $29,207 | |
| 4 | $26,500 | $56,975 | $8,745 | $19,610 | $35,245 | |
| 5 | $31,040 | $66,736 | $10,243 | $22,970 | $41,283 | |
| 6 | $35,580 | $76,497 | $11,741 | $26,329 | $47,321 | |
| 7 | $40,120 | $86,258 | $13,240 | $29,689 | $53,360 | |
| 8 | $44,660 | $96,019 | $14,738 | $33,048 | $59,398 | |
How to Read the Pennsylvania Medicaid Income Limits Charts Above
You cannot have an income higher than the Federal Poverty Level percentage described for your group to be eligible for Medicaid.
Similarly, when you identify the income group that applies to you, the income limit you see refers to the maximum level of income you can earn to qualify for benefits.
For example, if you are pregnant, to qualify for Medicaid, you cannot have an income higher than 215% of the Federal Poverty Level – which for a family of two is $37,453 as shown in the chart above.
How to Apply for Pennsylvania Medicaid
There are 3 ways you can apply for Medicaid in Pennsylvania.
Option 1 – Apply online
You can apply online through the MyCOMPASS PA Portal – as shown in the image below.
If you have an account, you can log in or create your MyCOMPASS PA account. Click here to be taken to the website.
Option 2 – Apply at a County Assistance Office Near You
You can apply in person at the County Assistance Office (CAO) office near you. Click here to locate a CAO office.
Option 3 – Download Application
You can download an application, complete it, and mail it to your County Assistance Office (CAO) office or submit it in person.
Additionally, you can Call the Consumer Service Center for Health Care Coverage at 1-866-550-4355.
Resources LimitsMedicaid eligibility for some is also determined using resource and household size in comparison to resource limits.
However, the resource limits do not apply to the following groups:
- Adults Age 19-64
- Pregnant women
- Families with children in the household – under their care and control
- Children under the age of 21
- CHIP
Examples of resources counted in determining eligibility include:
- Cash
- Checking accounts
- Savings accounts and certificates
- Christmas or vacation clubs
- Stocks and bonds
- Some trust funds
- Life insurance
- Vehicles
- Revocable burial funds
- Non-resident property
Examples of resources not counted in determining eligibility include:
- Your home
- Revocable and irrevocable burial reserves subject to specified limits
- Burial space and marker
- One motor vehicle
As mentioned above, some Medicaid eligibility groups have resource limits. This includes:
- Seniors ages 65 and above
- People with Disabilities
- SSI Recipients
For details on Pennsylvania Medicaid resources limits for these group of applicants, check with your county Medicaid office.
Documents you need to apply
During the application process for Medicaid in Pennsylvania, you will need to have various documents to support your application.
Here’s the list of documents you may have to provide:
- Information about household members (name, date of birth, and Social Security number)
- Rent or mortgage information
- Expenses (utilities, daycare, etc.)
- Vehicle information
- Bank statements
- Income (pay stubs)
- Proof of disability or medical records showing a lasting medical condition
- Recent medical bills
- Proof of citizenship
- Additional information as requested
What happens after I apply for Medicaid in Pennsylvania?
After you submit your Pennsylvania Medicaid application, you may be required to attend an interview with a Department of Human Services (DHS) caseworker.
Whether you will be required to attend an interview depends on your situation:
If you are applying for Medicaid for your child(ren) alone, then no interview will likely be required.
If you are applying for any other benefits at the same time, then an interview will likely be required.
During this interview, you will be required to bring documents that prove the information that you provided on your initial Pennsylvania Medicaid application.
See above for the list of documents that may be required during the interview.
Once you complete this interview, you will receive a call or a letter in the mail that will tell you whether you were approved or denied.
If you are denied benefits, you have the right to appeal but that appeal must be filed within a certain timeframe. As your caseworker for details.
What does Medicaid Cover in Pennsylvania?
Pennsylvania Medicaid covers a variety of medical services. However, the type and amount of services depends on the age of the beneficiary, the type of Medicaid program in which the beneficiary is enrolled.
Additionally, coverage depends on the type of services determined medically necessary by the beneficiary’s Primary Care Provider.
Medicaid services may include:
- Physician
- Hospital
- Family planning (birth control, pregnancy and birth care)
- Home health care
- Nursing home
- Hospice
- Transportation
- Dental and visual
- Community behavioral health
- Services through the Child Health Check-Up program
Furthermore, the Pennsylvania Medicaid program pays the cost of prescription drugs for those who qualify for this coverage.
However, if you are covered by both Medicaid and Medicare, most of your prescription drugs may be provided under the Medicare Part D Prescription Drug benefit.
Pennsylvania Medicaid Phone Number
Here’s how to contact the Pennsylvania Medicaid Agency:
For Medicaid Applicant & Member Services
Call the Consumer Service Center for Health Care Coverage at 1-866-550-4355.
Pennsylvania Medicaid Expansion Update
The state of Pennsylvania expanded Medicaid under the ACA in 2015.
Nearly 700,000 people are covered under Pennsylvania’s Medicaid expansion.
Medicaid expansion has played a significant role in the declining uninsured rate in Pennsylvania.
According to U.S. Census data, the uninsured rate fell from 9.7 percent in 2013 to 5.5 percent in 2017.
Lawmakers passed Medicaid work requirement bills in 2017 and 2018, but Gov. Wolf vetoed them.
Pennsylvania Medicaid Card
Everyone in Pennsylvania who is approved for Medicaid will receive an “ACCESS” Card. This card will serve as proof of your benefits.
Be sure to always keep your access card in a safe place and bring it with you to your medical appointments.
Present the ACCESS Card to your provider each time you obtain medical services.
Your medical provider can use the card to obtain information about your eligibility for benefits, services
available, insurance information, managed care plan enrollment and individual restrictions to services.
If you have other medical/health insurance coverage, be sure to give that information to your caseworker
and show all insurance information (Medicare, Blue Cross or Blue Shield, for example) to your provider.
The provider is required to bill the other insurance before billing Medicaid.
Your provider is required to tell you in advance if your Medicaid Health Care Benefits Package does not pay for a service.
How to get a replacement ACCESS Card
If your ACCESS card is lost or stolen here’s what you need to do:
First, report a lost or stolen ACCESS Card immediately to your caseworker.
Your caseworker will issue you a replacement ACCESS Card with a new card issue number.
This new card must then be used to obtain services.
Second, keep the new ACCESS Card in a safe place.
Additionally, keep the card even if your case is closed. It will not cover services while your case is closed but can be used
again if you become eligible for Medicaid in the future.
FAQs about Medicaid in Pennsylvania
Here are the most frequently asked questions about Medicaid in Pennsylvania:
How do I apply for Medicaid in Pennsylvania?
There are FOUR options available to you to apply for Medicaid in PA:
Online: www.compass.state.pa.us
By Phone: 1-866-550-4355
In-Person: See listing of local County Assistance Offices (CAOs)
By Mail: Send the completed application form, and all supporting documents, to your local CAO. To locate a CAO near you, click here.
Where can I find information about providers accepting Medicaid patients?
If you are eligible for Medicaid and would like to locate providers that accept Medicaid, here’s what you need to do:
You may call the Fee-for-Service Recipient Service Center at 1-800-537-8862. They will provide you with a list of enrolled providers for MA patients.
Additionally, you can search the fee-for-service provider physician directory here.
Does Pennsylvania Medicaid Cover Dental?
The dental services you may get with your Pennsylvania Medicaid coverage are based on your eligibility category, age and need.
Medicaid in Pennsylvania covers all medically necessary dental services for enrolled children.
This includes teeth cleaning, x-rays, cavity fillings, crowns and other services.
Additionally, adults enrolled in MA are eligible at a minimum for surgical procedures and emergency services related to treatment for symptoms and pain.
Also, some adults may be eligible for other dental services.
To find out if you are covered for dental care, call your county assistance office or, if you are in the HealthChoices/Managed Care program, call your managed care organization (MCO).
How do Adults Qualify for Medicaid Expansion in PA?
Medicaid Expansion in Pennsylvania, under the Affordable Care Act (ACA), covers low-income adults age 19-65 who do not otherwise qualify for Medical Assistance.
Pennsylvania adopted Medicaid Expansion, the new adult group created by the ACA, to be effective January 2015.
Here are the eligibility requirements:
- Adults age 19 through 64
- Income limit: 138% of the Federal Poverty Limit
- No resource limit
- Cannot be eligible for Medicare
- For Immigrants: Must have a “qualified” status for five years, unless exempt
from Five Year Bar.
Who is a “qualified” immigrant?
Under United States federal law, the following individuals are “qualified immigrants” for Medicaid purposes:
-
- Lawful Permanent Residents (green card holders);
- Refugees;
- Aslyees;
- Cuban/Haitian entrants;
- Conditional entrants;
- Individuals paroled into the US for more than one year;
- Certain domestic violence & trafficking survivors & their children; and
- Persons granted withholding of deportation/removal
What is the Five Year Bar for “qualified” immigrants?
To be eligible for Medicaid, many qualified immigrants must also have been in a qualified status for at least five years.
However, the Five Year Bar rule does not apply to the following individuals:
- Children or pregnant women (who need only be “lawfully present”)
- Refugees or asylees (even if they now have a green card)
- Cuban/Haitian entrants
- Trafficking survivors
- Immigrants whose deportation is behind withheld
- Certain veterans and their families
- People who have lived in the U.S. continuously since before 8/22/1996 who are now legal immigrants
Pennsylvania Medicaid Eligibility Summary
We hope this post on Pennsylvania Medicaid Eligibility was helpful to you.
If you have any questions about Medicaid in the state of Pennsylvania, you can ask us in the comments section below.
Help us spread the word! If you found this post on Pennsylvania Medicaid Eligibility helpful, help us spread the word by sharing it using the “Share this” button below.
Be sure to check out our other articles about Medicaid.
Difference between Medicare and Medicaid Programs
How to Apply for Coverage by State
Medicaid Income Limits by State
Medicaid Phone Number for Florida
