Medicare/Medicaid
Medical Assistance- Medical Assistance (MA), also known as Medicaid, pays for health care services for eligible individuals. Click the link to see how to apply and how to find information about providers that accept MA patients.
What are the differences between Medicare and Medicaid?
Insurance 101
In this PCHC training, the following types of insurance are reviewed: Private insurance, Medicare and Medical Assistance as well as the eligibility requirements for each type of insurance. They also hope to help you better understand the coverage within the insurance system, the Department of Public Welfare’s dual eligibility classifications and explain how a letter of medical necessity is written. Take this training |
Dental information |
The Department of Human Services (DHS) is committed to providing recipients with access to quality dental services. This dental section is designed to give recipients helpful information about getting dental services in the Medical Assistance (MA) program, which is also referred to as Medicaid. Listed below are answers to common questions about eligibility, enrollment, MA dental providers, appointments, dental care and emergency services.
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Medical Assistance General Eligibility Requirements
General Eligibility Requirements
You must meet income, resource (in some cases), and other eligibility requirements in order to be eligible for Medical Assistance. These categories are grouped by:
Medical Assistance eligibility is determined using income and household size in comparison to income limits. Age and disability are also factors in determining which income limits apply. (Income limits for the various eligibility groups are listed below.)
Examples of income counted in determining eligibility include:
The income limits for each category are provided in the section for that category.
Resources
Medical Assistance eligibility for some is also determined using resource and household size in comparison to resource limits. (Resource limits for the various eligibility groups are listed below or in the section for that category.)
NOTE: Resource limits do not apply to persons eligible for - Modified Adjusted Gross Income (MAGI) MA, pregnant women, families with children in the household - under their care and control, and those under the age of 21.
Examples of resources counted in determining eligibility include:
Some Medical Assistance eligibility groups have resource limits. The charts below provides specific details:
Non-Money Payment (NMP) Medical Assistance
GA-Related SSI-Related
One Person = $250 One Person = $2,000
Two People = $1,000 Two People = $3,000
Medically-Needy Only Medical Assistance
GA or SSI-Related
One Person = $2,400
Two People = $3,200
Each Additional Person = $300
Medicare Buy-In Programs
Healthy Horizons Cost Sharing, Specified Low-Income Medical Assistance
Beneficiary, Qualifying Individual Categories
One Person = $7,730
Two Persons = $11,600
NOTE: There is no resource exclusion for pregnant women, children under 21 or families with children under 21 for Medicare Buy-In Programs.
Other Eligibility Requirements
Medicare eligibility for those under 65
When you are under 65, you become eligible for Medicare if:
Eligibility for Medicare due to a disability
You may qualify for Medicare due to a disability if you have been receiving SSDI checks for more than 24 months, also known as the two-year waiting period. The two-year waiting period begins the first month you receive an SSDI check. You will be automatically enrolled in Medicare at the beginning of the 25th month that you receive an SSDI check.
If you receive SSDI because you have Amyotrophic Lateral Sclerosis, or ALS, Medicare automatically begins the first month that your SSDI benefits start. You do not have the two-year waiting period.
Social Security—not Medicare—makes the determination of whether you qualify for SSDI checks and administers the program that provides the checks. For more information on the Social Security Disability Insurance program, it is recommended that you contact your local Social Security Administration (SSA) office.
General Eligibility Requirements
You must meet income, resource (in some cases), and other eligibility requirements in order to be eligible for Medical Assistance. These categories are grouped by:
- Adults age 19-64 with incomes at or below 133% of the Federal Income Poverty Guidelines (FPIG) (Identified for Medical Assistance purposes as MAGI-related)
- Individuals who are aged (age 65 and older), blind and disabled. (Identified for Medical Assistance purposes as SSI-related)
- Families with children under age 21
- Special Medical Assistance conditions
Medical Assistance eligibility is determined using income and household size in comparison to income limits. Age and disability are also factors in determining which income limits apply. (Income limits for the various eligibility groups are listed below.)
Examples of income counted in determining eligibility include:
- Wages (certain deductions are allowed)
- Interest
- Dividends
- Social Security
- Veterans' Benefits (except for MAGI MA)
- Pensions
- Spouse's income if living with him/her
- 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)
The income limits for each category are provided in the section for that category.
Resources
Medical Assistance eligibility for some is also determined using resource and household size in comparison to resource limits. (Resource limits for the various eligibility groups are listed below or in the section for that category.)
NOTE: Resource limits do not apply to persons eligible for - Modified Adjusted Gross Income (MAGI) MA, pregnant women, families with children in the household - under their care and control, and those under the age of 21.
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
- Your home
- Revocable and irrevocable burial reserves subject to specified limits
- Burial space and marker
- One motor vehicle
Some Medical Assistance eligibility groups have resource limits. The charts below provides specific details:
Non-Money Payment (NMP) Medical Assistance
GA-Related SSI-Related
One Person = $250 One Person = $2,000
Two People = $1,000 Two People = $3,000
Medically-Needy Only Medical Assistance
GA or SSI-Related
One Person = $2,400
Two People = $3,200
Each Additional Person = $300
Medicare Buy-In Programs
Healthy Horizons Cost Sharing, Specified Low-Income Medical Assistance
Beneficiary, Qualifying Individual Categories
One Person = $7,730
Two Persons = $11,600
NOTE: There is no resource exclusion for pregnant women, children under 21 or families with children under 21 for Medicare Buy-In Programs.
Other Eligibility Requirements
- Identity -- Identity can be verified by a driver’s license, state identification card or another piece of identification.
- Social Security Number (SSN) -- A SSN must be provided for each person applying for Medical Assistance. County Assistance Office staff will help you apply for an SSN for anyone who does not have one.
- Residency -- Medical 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.
- Citizenship -- Medical Assistance 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. 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.
Medicare eligibility for those under 65
When you are under 65, you become eligible for Medicare if:
- You have received Social Security Disability Insurance (SSDI) checks for at least 24 months
- Or, you have been diagnosed with End-Stage Renal Disease (ESRD)
Eligibility for Medicare due to a disability
You may qualify for Medicare due to a disability if you have been receiving SSDI checks for more than 24 months, also known as the two-year waiting period. The two-year waiting period begins the first month you receive an SSDI check. You will be automatically enrolled in Medicare at the beginning of the 25th month that you receive an SSDI check.
If you receive SSDI because you have Amyotrophic Lateral Sclerosis, or ALS, Medicare automatically begins the first month that your SSDI benefits start. You do not have the two-year waiting period.
Social Security—not Medicare—makes the determination of whether you qualify for SSDI checks and administers the program that provides the checks. For more information on the Social Security Disability Insurance program, it is recommended that you contact your local Social Security Administration (SSA) office.
Medicare Part B Durable Medical Equipment
Medicare Part B (Medical Insurance) covers the cost of Medically necessary durable medical equipment (DME) if your doctor prescribes it for use in your home. Medicare DME coverage includes, but isn't limited to:
Medicare Part B (Medical Insurance) covers the cost of Medically necessary durable medical equipment (DME) if your doctor prescribes it for use in your home. Medicare DME coverage includes, but isn't limited to:
- Blood sugar monitors
- Blood sugar test strips
- Canes
- Commode chairs
- Continuous passive motion devices
- Continuous Positive Airway Pressure (CPAP) devices
- Crutches
- Hospital beds
- Infusion pumps & supplies
- Lancet devices & lancets
- Nebulizers & nebulizer medications
- Oxygen equipment & accessories
- Patient lifts
- Pressure-reducing beds, mattresses, and mattress overlays
- Suction pumps
- Traction equipment
- Walkers
- Wheelchairs & scooters