Guide to Medicaid in Pennsylvania

In 2015, Pennsylvania became one of 41 states to adopt the Affordable Care Act (ACA) Medicaid expansion. This currently provides healthcare coverage to nearly 3.6 million Pennsylvania residents. In addition to pregnant women and children, the Medicaid health insurance plan in Pennsylvania, also called Medical Assistance (MA), is available to low-income adults, disabled persons, and seniors who meet certain requirements. 

Eligibility for Pennsylvania Medicaid

Since adopting the ACA Medicaid expansion in 2015, Pennsylvania has implemented targeted enrollment strategies to help eligible Pennsylvanians gain coverage. To qualify for Medicaid in Pennsylvania, residents must meet certain income, age, disability designation, citizenship status, and/or healthcare needs requirements.

Income requirements

In some cases, Medicaid eligibility in Pennsylvania is based on an applicant’s modified adjusted gross income (MAGI), which has a built-in 5% income disregard. However, this does not apply to all applicants, as the state separates eligibility for medical assistance by MAGI and non-MAGI groups. 

MAGI-eligible applicants include:

• Children aged 18 and younger
• Pregnant women
• Parents and caretakers of children younger than 21
• Adults aged 19 to 64 with incomes at or below 133% of the Federal Income Poverty Guidelines (FPIG)
• Individuals in need of family planning services

For these groups, DHS determines Pennsylvania Medicaid eligibility using the MAGI deduction.

Non-MAGI eligible applicants include:

• Individuals aged 65 and older
• Individuals who are blind and/or disabled
• Individuals applying for Medical Assistance for Workers with Disabilities (MAWD)
• Individuals seeking long-term care (LTC) or home and community-based services (HCBS)

For these groups, DHS determines Pennsylvania Medicaid eligibility without the MAGI 5% income disregard.

To be eligible for Pennsylvania Medicaid based on your income, your MAGI or non-MAGI income must not exceed the percentage of the federal poverty level (FPL) established for your eligibility group. The Medicaid income limits in Pennsylvania for each eligibility group are as follows:

• 215% for children aged 0 to 1
• 157% for children aged 1 to 5
• 133% for children aged 6 to 18
• 314% for children under the separate CHIP program
• 215% for pregnant women
• 33% for parents/caretakers
• 133% for adults eligible under the ACA expansion

Age requirements

Pennsylvania Medicaid is open to residents of all ages, including those 65 and older, who qualify based on their income.

Disability requirements

Individuals who are blind and/or disabled can receive Medicaid in Pennsylvania if they meet certain income and resource requirements. Disabled persons who are employed and have a salary that exceeds the Medicaid income limits in Pennsylvania may be eligible for the Medical Assistance for Workers with Disabilities (MAWD) program, which requires a small monthly premium. 

Citizenship or immigration status

Pennsylvania Medicaid is available to United States citizens and certain lawfully admitted non-citizens. Other non-citizens may qualify for limited Medicaid benefits if they have an emergency medical condition. When applying for Medicaid in Pennsylvania, applicants must submit documentation to prove their U.S. citizenship, refugee, or lawful non-citizen status and must be an official resident of Pennsylvania.

Pennsylvania Medicaid benefits

Pennsylvania Medicaid provides a full scope of health benefits to enrollees, including medical, dental, vision, prescription drugs, and some long-term care services. 

Medical services covered

Health services covered by Pennsylvania Medicaid vary slightly between eligibility groups, with children receiving the most comprehensive benefit package. 

For adults aged 21 and older, the Pennsylvania Medicaid ‘Adult’ benefit package may include the following: 

• Physician services
• Prescription drugs
• Primary care provider (PCP) services
• Certified registered nurse practitioner services
• Chiropractic services
• Podiatrist services
• Clinic services
• Crisis services
• Durable medical equipment
• Emergency room/ambulance services
• Family planning services and supplies
• Federally qualified health center services/rural health clinic services
• Home health services
• Hospice services
• ICF/IID and ICF/ORC (requires an institutional level of care)
• Inpatient drug and alcohol services
• Inpatient hospital services
• Inpatient mental health services
• Laboratory services
• Medical supplies
• Methadone maintenance
• Mobile mental health treatment
• Non-emergency medical transportation (only to and from covered services)
• Nursing facility services
• Nutritional supplements
• Optometrist services
• Outpatient drug and alcohol services
• Outpatient hospital services
• Partial psychiatric hospitalization
• Peer support services
• Prosthetics and orthotics (orthopedic shoes and hearing aids are not covered)
• Psychiatric clinic services
• Radiology services (X-rays, MRIs, CTs)
• Renal dialysis services
• Targeted case management services — behavioral health is limited to individuals with SMI only and other than behavioral health is limited to individuals in the target group
• Therapy (physical, occupational, speech)
• Habilitative and rehabilitative (only when provided by a hospital, outpatient clinic, or home health provider)
• Tobacco cessation

Prescription drug coverage

Pennsylvania Medicaid covers a substantial portion of prescription drug costs, but it may require some recipients to pay a small copayment: 

• $1 for each prescription and refill for generic drugs
• $3 for each prescription and refill for brand-name drugs

Some medications to treat certain medical conditions may not have a copayment.

Dental coverage

Medicaid recipients in Pennsylvania receive comprehensive dental service coverage. Some of the dental services Pennsylvania Medicaid covers include:

• Oral examinations, limited to one per year
• Prophylaxis (cleaning), limited to one per year
• Root canals, with certain exceptions
• Crowns, with certain exceptions 
• Full dentures, limited to one in each arch every seven years
• Partial dentures to replace two front teeth or four back teeth, excluding third molars, limited to one in each arch every seven years
• Relining of dentures, limited to one in each arch every two years

Vision coverage

Vision coverage under Pennsylvania Medicaid includes the following:

• Optometrist services
• Contact lenses (limited to individuals with aphakia)
• Eyeglass frames and lenses (limited to individuals with aphakia)

Long-term care services

In Pennsylvania, long-term care is sometimes referred to as long-term living. Under Pennsylvania Medicaid, long-term care includes a wide range of assistive services provided to recipients based on their specific needs. Included services can range from getting assistance with activities of daily living at home to receiving advanced medical care in a nursing facility.

Services for children and pregnant women

Medicaid in Pennsylvania provides a full range of medical benefits for children and pregnant women. 

Medical Assistance for Children and Pregnant Women benefit package includes the following:

• Children’s health services (any kind of medically necessary care, including yearly checkups)
• Complete health and physical examinations, including checks on the child’s physical and mental development
• Immunizations
• Laboratory tests, including testing of the level of lead in the child’s blood
• Dental, vision, and hearing screenings
• Health education
• Physician services
• Services provided by school-based service providers
• Ambulance services
• Certified registered nurse practitioner services
• Chiropractic services
• Physical therapy
• Podiatrist services
• Prescription drugs
• Preventive services
• Clinic services
• Dental services
• Diagnostic services
• Eyeglasses
• Family planning services and supplies
• Home health services
• Hospice services        
• Inpatient hospital services
• Inpatient and outpatient behavioral health services (mental health or substance abuse treatment)
• Laboratory tests
• Nursing facility services
• Occupational therapy services
• Optometrist services
• Outpatient hospital services
• Prosthetic devices
• Radiology services (X-rays, MRIs, CTs)
• Rehabilitative services
• Renal dialysis services
• Screening services
• Speech, hearing, and language therapy services
• Targeted case management services
• Transportation help

These services are available in facilities across the state of Pennsylvania, including in hospitals, clinics, federally qualified health centers, rural health clinics, community health centers, physician offices, and certified registered nurse practitioner offices.

The Pennsylvania Medicaid ‘Children’s’ package also includes the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT). The EPSDT is a federally-funded care program with a focus on primary care. It is the most important part of Pennsylvania Medicaid and is free to all children younger than age 21 who receive Medicaid. EPSDT provides regular checkups for children enrolled in Medicaid and fully covers the cost of medical services, treatments, and follow-up care.

Children who do not qualify for Pennsylvania Medicaid may be eligible for the Children’s Health Insurance Program (CHIP). CHIP is available statewide and provides free or low-cost insurance for uninsured children up to age 19. Free CHIP is open to children in families whose income is below 208% of the FPL. Low-cost CHIP is open to children whose family income is 208% to 314% of the FPL. 

For pregnant women, the Pennsylvania Medicaid ‘Presumptive Eligibility for Pregnant Women’ benefit package includes the following:

• Maternity services from physicians, certified nurse midwives, and birth centers
• Home visits from a nurse
• Family planning services and supplies
• Ambulance services
• Ambulatory surgical center (ASC) services
• Non-emergency medical transportation (only to and from covered services)
• Case management
• Mental health services
• Prescription drugs
• Chiropractic services
• Clinic services
• Dental services
• Drug and alcohol services
• Durable medical equipment (includes orthotics and prosthetics)
• Hospice services
• Laboratory tests
• Medical supplies
• Optometrist services
• Podiatrist services
• Radiology services (X-rays, MRIs, CTs)
• Renal dialysis services
• Nursing facility services

How to apply for Pennsylvania Medicaid

To apply for Medicaid, Pennsylvania residents can apply online, by mail, or in person. 

Required documents for application

When you apply for Pennsylvania Medicaid, you must submit documentation proving your U.S. citizenship, refugee, or lawful non-citizen status. All applicants who have one must provide their SSN on the Medicaid Pennsylvania application.

The application also asks for documents to prove your income, such as pay stubs, tax returns, or bank statements.

Online application process

To submit a Pennsylvania Medicaid application online, go to the COMPASS website. You will need to create a COMPASS account to access and complete the online application for Pennsylvania Medicaid. 

Paper application process

To submit a paper application for Pennsylvania Medicaid, download, print, and complete the application, then mail it to your local county assistance office (CAO).

In-person application process

To apply for Pennsylvania Medicaid in person, find your local county assistance office (COA) and make a visit during its listed office hours.

Cost of Pennsylvania Medicaid

There is no monthly premium for Pennsylvania Medicaid. However, some covered services may require recipients to pay a small copayment (e.g., some prescription drugs cost $1 or $3 per prescription/refill). 

Additional Pennsylvania Medicaid resources

• https://www.compass.state.pa.us/compass.web/Public/CMPHome
  • Use this link to apply for and manage your Medicaid benefits. You can also find out if you qualify for Medicaid here. 
• https://pennie.com/
  • If you don’t qualify for Medicaid, use this link to shop the ACA Marketplace and find a health insurance plan with a monthly premium that suits your budget. 

Pennsylvania Medicaid FAQ

How can I find a doctor who accepts Medicaid?

To find a doctor who accepts Medicaid in Pennsylvania, use the online DHS Provider Service Directory. 

How do I renew my Medicaid coverage?

To renew your Pennsylvania Medicaid coverage online, visit www.dhs.pa.gov/COMPASS and log in to your account. Alternatively, you can call 1-866-550-4355 to complete your renewal over the phone with a representative.

How do I appeal a denied claim?

If your application for Medicaid is denied or your existing benefits are reduced, suspended, or terminated, you can appeal the decision by requesting a fair hearing. You must file appeals for a denied Pennsylvania Medicaid claim in writing, and they must be adjudicated by the Bureau of Hearings and Appeals (BHA).  

How do I report Medicaid fraud?

To report Medicaid fraud by a provider, fill out an online MA Provider Compliance Response Form. 

To report Medicaid fraud by a recipient, fill out an online MA Compliance Response Form or call the Fraud Hotline at 1-844-DHS-TIPS. 

You can also report Medicaid fraud in Pennsylvania by writing to DHS at:

Department of Human Services
Office of Administration
Bureau of Program Integrity
P.O. Box 2675
Harrisburg, PA 17105-2675