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Am I Eligible for $0 Premium Medicaid in Pennsylvania?


Whether you just moved to Pennsylvania or have been living in Pennsylvania for some time, it is important to understand your health care options. Truthfully, it can be confusing. This is true whether you are seeking coverage through your job or are seeking coverage under the Affordable Care Act. Matter of fact, even if you are offered coverage through an employer, you still may be eligible for Medicaid in the state.

In this post, we want to talk about obtaining Medicaid in Pennsylvania: a benefit for low income households that is often $0. A common question is what is Medicaid? Not only will we address this question, but we will also discuss the eligibility requirements of Medicaid coverage.

Our objective? To demystify Medicaid in Pennsylvania so that you can decide whether you want to pursue coverage.

A Basic Primer on Medicaid in Pennsylvania

As you may already know, Medicaid is a federal and state program that helps patients with limited income or resources pay for their medical costs. In Pennsylvania, Medicaid is also known as Medical Assistance (“MA”).

Whenever discussing this program, one of the first questions centers on who is eligible for MA. The Pennsylvania Department of Human Services provides some helpful guidance on eligibility requirements. To determine your eligibility, you can click here to complete a short questionnaire.

Essentially, Medicaid eligibility in Pennsylvania is broken down into two different camps.

The first camp is solely based on income levels while the second camp is based on individuals with a life-sustaining disability.

The First Camp

Let’s start with the first camp. Ultimately, single adults aged 19 to 64 with incomes at or below 133 percent of the Federal Income Poverty Guidelines are likely eligible for MA. The U.S. Department of Health and Human Services provides a helpful table showing the Federal Income Poverty Guidelines. You can find it below:

When determining income thresholds in the first camp, MA in Pennsylvania doesn’t care about assets. Instead, eligibility is determined by your taxable income and household size. Income can include everything from wages and interest to dividends and social security. Things that aren’t considered income include Roth IRA distributions, living off savings, and monetary family gifts. Less common income sources also include Supplemental Security Income (“SSI”), Foster Care payments, and Temporary Assistance for Needy Family (“TANF”) benefits.

Most commonly this camp suits the following:

1. Individuals with socioeconomic challenges.

2. College students who have minor income(under $16,970) who satisfy a majority of their own expenses.

3. Small businesses, particularly startups with little to no income.

4. Retirees who are living off of non-taxable savings but can’t afford to lose their retirement nest egg to health insurance costs leading up to their age 65.

5. Person’s divorced providing for several dependents.

The Second Camp

Along with low-income individuals, MA is available to people with life-sustaining disabilities. If you are medically ill and hoping to leverage Medicaid for medical expenses, you may be able to do so. Some of the scenarios include if you are a minor with a disability. If so, you may qualify for a PH-95 exception, which does not consider income or resources.

Another scenario is if you are an adult that is considered “Medically-Needy.” In Pennsylvania, it is technically called the “Medically Needy Assistance (“MNO-MA”) program. This is a situation where you may still be eligible for MA even if you are over the income limit because of your high medical bills. If you qualify for the MNO-MA program, you must limit your resources to $2,400 for a household of one, $3,200 for a household of two, and $300 for each additional person.

Most commonly this camp suits the following:

1. Newborn’s with medical complications.

2. Seniors forced to accept early retirement due to health concerns.

3. Individuals living on a fixed disability income.

These are just two situations where you may still be able to qualify for Medicaid without meeting the income threshold. That being said, we encourage you to complete the short questionnaire referenced above to determine whether you are eligible.

What if I’m declined? Are there other options?

If you are declined for MA coverage, all hope isn’t lost. You may be able to qualify for Cost Sharing Reductions and Premium Tax Credits through Healthcare.gov. We encourage you to explore Healthcare.gov to find ways that you can reduce some of your medical expenses. You can also contact your local county assistance office (“CAO”) to learn about your options.

You’re Eligible? Next steps…

Assuming that you are eligible for MA, you can explore the different types of Pennsylvania Medicaid programs. According to the Pennsylvania Department of Human Services, there are essentially two types of care that are available. They are (1) physical health options and (2) mental health/substance abuse services options.

Most counties have multiple insurers to cover the doctors that you wish to visit. You can click on this link to learn more. As you can see, Pennsylvania’s mandatory managed care program for MA recipients is called the Physical HealthChoices Program. Every Pennsylvania county has coverage through many well-known insurance companies. Some of them include Aetna, AmeriHealth Caritas, Gateway Health Plan, UnitedHealthcare, and UPMC. You will want to do your own due diligence to find the plan that best suits your needs. A common concern is that “I’ve heard providers don’t take Medicaid.” In most cases, that’s simply not true. Certain types of providers like allergists and dermatologists that are often family owned private practices tend to be more selective in who they partner with, but that’s true for all types of insurance in these cases.

What’s the cost?

The good news is that many plans have zero premium, zero deductibles and zero coinsurance. You will also find that health, dental, and vision are included. That being said, there may be some copayment requirements for certain adults. Specifically, those adults who are capable of working and paying at least a portion of the costs may need to meet a set copay amount. This copay amount may be used to cover things like clinic appointments, emergency room visits, and prescriptions. The copay amount can be around $3 for each transaction, but patients who receive general assistance may have copays of around $6 per transaction. Whichever bucket that you fall into, you can see that these plans are financially compelling.

Again, you will need to complete some independent research to find the plan that works best for you. But nonetheless, there are affordable options out there that can provide you with good, quality health care at an extremely low price.

To learn more about the plans that are available to you, we recommend that you work with a community based organization who partners with your County Assistance Office. Case workers at your CAO can provide a wealth of information about MA and how you can obtain coverage for you and your family. We are happy to help, or to find your local CAO’s contact information, feel free to click here.

A Compelling Option for Those Looking for Health Care Coverage

As you can see from the discussion above, Pennsylvania’s Medicaid plans can be compelling options for health care coverage. Importantly, however, these plans are not available to everyone. Not only do you need to be a Pennsylvania resident to take advantage of MA, but you need to meet certain income or medical requirements. If you are unclear about whether you are eligible, one of the best things you can do is to speak with a representative from your local CAO. He or she will be able to guide you through the process.

In the end, obtaining Medicaid coverage can be just the thing you need. If you would like to learn more about Medicaid coverage in Pennsylvania, don’t hesitate to contact us. We would be happy to walk you through your options and help you understand the best options going forward.

© 2020 PA Health Advocates, LLC

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