Home >> Frequently Asked Questions
- What is Medicaid?
- Does each state have their own Medicaid program?
- How is the Medicaid program funded?
- Who administers Medicaid in Pennsylvania?
- How many people are covered by Medicaid?
- Who is eligible for Medicaid in Pennsylvania?
- What are the mandatory federal eligibility categories?
- Does Pennsylvania Medicaid cover any special populations?
- What medical services does Pennsylvania Medicaid cover?
- What is a Medicaid waiver?
- Does Pennsylvania Medicaid offer any waivers?
- Who do I contact to apply for Medicaid in Pennsylvania?
What is Medicaid?
The Medicaid program was created by the federal government in 1965 under Title XIX of the Social Security Act. It has evolved over time from principally being a welfare program that provided health services to people who received cash assistance, into a public health insurance program that finances essential health and long-term care for Americans and legal immigrants with disabilities and low incomes. Medicaid provides health insurance coverage for many low-income individuals; offers long-term care assistance to individuals over the age of 65 and individuals with disabilities; covers gaps in the Medicare program; and funds institutions that serve a disproportionate number of low-income patients with special needs.
Does each state have their own Medicaid program?
Though created and part-financed by the federal government, Medicaid is administered and co-funded by each state. Governed by the regulations in Title 42 of the Code of Federal Regulations, the states are required to provide specific groups of people with mandatory services in order to qualify for federal matching payments. Within those parameters, states have the freedom to develop their own state Medicaid programs to meet these federal requirements. The states also have the ability to broaden Medicaid coverage to include additional groups, vary benefit packages and modify services under federal law and through waivers. Even though Medicaid is a voluntary program, every state participates along with American Samoa, Guam, Noethern Mariana Islands, Puerto Rico, Virgin Islands and Washington DC.
How is the Medicaid program funded?
Medicaid is jointly funded by both federal and state governments. The federal government reimburses states for a portion of the cost of their Medicaid programs depending on the state's per capita income. For example, the Federal Medical Assistance Percentage in Pennsylvania in 2007 is 54.39%, which means that of every 100 dollars spent on services and populations covered by Medicaid, $54.39 is paid by the federal government and $45.61 is paid by the state.
Who administers Medicaid in Pennsylvania?
The federal Centers for Medicare and Medicaid Services (CMS) provides regulatory oversight and monitors the Medicaid program rules. In Pennsylvania, the Medicaid Program is called Medical Assistance and it is managed by the Department of Public Welfare (DPW). Within the DPW, it is administered by the Office of Medical Assistance Programs (OMAP) and the Office of Income Maintenance (OIM). OIM sets eligibility standards and conducts eligibility determinations and recertifications through local county assistance offices. OMAP establishes medical benefits, provider payments and beneficiary cost-sharing levels and reimburses medical providers.
How many people are covered by Medicaid?
In 2005, 42.5 million individuals, or about 14 percent of the population, were covered by Medicaid in the United States. In 2006, there were 1,833,769 Medicaid recipients in Pennsylvania on the average month. This represented 14.8 percent of the Commonwealth's population.
Who is eligible for Medicaid in Pennsylvania?
In 2006, 14.8 percent of Pennsylvania's population was eligible for Medicaid on the average month. In most cases, to be eligible for Medicaid in Pennsylvania, an individual must: (1) fit into a specified coverage group; (2) meet the income requirements for that group (calculated as a percentage of the Federal Poverty Level); (3) meet the resource/asset requirement for that group; (4) be a United States citizen or lawful alien; and (5) be a Pennsylvania resident.
Under federal law, Pennsylvania is only required to cover certain individuals under Medicaid. These individuals are known as "mandatory categorically needy." However, federal law also permits Pennsylvania to expand Medicaid coverage to optional individuals, but still receive federal matching payments.
What are the mandatory federal eligibility categories?
- Individuals that meet the requirements of the Aid to Families with Dependent Children program (AFDC) in 1996 when the AFDC program was terminated and replaced by Temporary Assistance for Needy Families (TANF). The people who are currently covered under this category are low-income adults with children.
- Children under age six whose family income is at or below 133 percent of the Federal Poverty Level (FPL);
- All children who are over the age of 6 and under the age of 19, in families with incomes at or below the FPL;
- Pregnant women whose family income is below 133 percent of the FPL;
- Supplemental Security Income (SSI) recipients - these are individuals who meet the SSI disability criteria or who are 65 and over. They must also meet certain income and asset requirements. For individuals, their income must be less than 76 percent of the FPL and their assets cannot exceed $2,000.
- Recipients of adoption or foster care assistance under Title IV of the Social Security Act;
- Special protected groups - typically individuals on SSI who lose their cash assistance due to earnings from work or from increased social security benefits, but who may keep Medicaid for a period of time.
- Certain Medicare beneficiaries - Medicaid must pay Medicare premiums and/or cost share for Medicare beneficiaries who fall within certain income and asset levels.
Does Pennsylvania Medicaid cover any special populations?
While the states must cover individuals who fall into the groups specified above, they may extend Medicaid coverage to optional categorically related groups and still receive federal matching funds. These optional groups fall within defined categories and broaden the scope of eligibility by increasing income limits, resource limits and medical conditions.
Pennsylvania has extended eligibility to a number of optional populations, such as: (1) individuals who are in an institution, such as a nursing home, and whose income is under 300 percent of the FPL; (2) individuals who would be eligible if institutionalized, but who are receiving care and home and community-based services (HCBS) waivers; (3) children with disabilities, regardless of their family's income and assets; (4) certain individuals with disabilities that work and have a family income of less than 250 percent of the FPL, who would qualify for SSI if they did not work; and (5) certain uninsured or low-income women who are screened for breast or cervical cancer through a program administered by the Centers for Disease Control and Prevention (CDC).
Pennsylvania also covers "medically needy" individuals. Medically needy individuals would be eligible for Medicaid under one of the mandatory or optional groups, except that their income and/or resources are above the eligibility level. However, if their medical spending is very high and reduces their available income to within the prescribed limits, they can receive care through Medicaid. Single individuals are also covered by Pennsylvania Medicaid through the "General Assistance" program. These individuals qualify for coverage under the General Assistance program because they are unable to work due to a temporary or permanent disability, are a pending SSI recipient, are blind or fit into other General Assistance related categories, such as domestic violence victims.
What medical services does Pennsylvania Medicaid cover?
| Mandatory Medicaid Services | "Optional" Medical Services* |
Medically Necessary is a service or benefit that is reasonably expected to prevent the onset of an illness, condition or disability; reduce or ameliorate the physical, mental or developmental affects of an illness, condition, injury, or disability; assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate for members of the same age. |
|
| *Adults eligible under the Medically Needy Only Medicaid category are not eligible for these services with some exceptions. | |
What is a Medicaid waiver?
The Secretary of the U.S. Department of Health and Human Services is authorized under Section 1915(c) of the Social Security Act to waive certain Medicaid statutory requirements. These waivers allow the states to cover home and community-based services for specific populations to avoid institutionalization. Waivers may increase optional and additional Medicaid services, such as, respite care, environmental modifications and family training.
Does Pennsylvania Medicaid offer any waivers?
Pennsylvania offers home and community-based services waiver programs. Some of these waivers include: AIDS waiver, Elwyn Waiver, Michael Dallas Waiver, Attendant Care Waiver, COMMCARE Waiver, CSPPPD/OBRA Waiver, Independence Waiver, Consolidated MR Waiver and Person/Family Directed Support MR Waiver.
Who do I contact to apply for Medicaid in Pennsylvania?
You would need to contact your County Assistance Office and they will determine your Medicaid eligibility. Please access the list of Pennsylvania county assistance offices in the "Resources" section of the PMPC web site.