Medicaid Costs and Coverage in Pennsylvania

Those wondering, “How much is Medicaid in Pennsylvania?” should know that costs can vary by program, so residents who are curious about PA Medicaid prices must first decide which Medicaid program they wish to apply to. How much does Medicaid cost for each of Pennsylvania’s different Medicaid programs? Medicaid cost estimates for specific programs usually depend on the financial resources and health statuses of the applicant and his or her family. For some applicants who meet Medicaid eligibility requirements, zero copayment costs can be expected. Medicaid is known as Medical Assistance (MA) in the state of Pennsylvania and is managed by the Department of Health Services (DHS), which oversees all health initiatives throughout the state. Learn more about Medicaid price estimates and find out what services are covered by Medicaid in the sections below.

PA Medicaid Coverage and the Department of Health Services (DHS)

The DHS is in charge of determining what services are covered by Medicaid, as well as determining whether applicants meet eligibility requirements, setting Medicaid application procedures and most aspects of the Pennsylvania MA program. Most Medicaid costs and coverage guidelines must fall in line with federal Medicaid requirements since the DHS is partially funded by the federal government. If you are wondering, “What does Medicaid not cover in Pennsylvania?” you should know that the DHS determines which medical treatments and health care services are not available to all or certain groups of benefit recipients in accordance with federal policies. All types of Medicaid insurance provide coverage for some medical needs and preventative services with or without a copayment. Read on to learn more information about Medicaid coverage and costs in Pennsylvania.

How much does Medicaid cost in Pennsylvania?

PA Medicaid cost estimates for eligible benefits applicants are determined by which MA program the applicant participates in and which medical services the applicant needs. All types of Medicaid insurance in Pennsylvania must include complete coverage (without the requirement of a copayment for eligible medical services) for applicants from the following groups:

  • Children younger than 18 years of age without other health insurance.
  • Pregnant women, including the post-partum period.
  • Residents of hospice institutions.
  • Women in the Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program

In addition to these groups, there are certain other groups that are exempt from Medicaid costs. For residents with PA Medicaid coverage who are not in one of the aforementioned groups or any other group that is exempt from MA costs, some medical services and treatments will require a small copayment. These Medicaid cost estimates include copayments that are usually only a couple of dollars per day, treatment or prescription up to a certain total limit. Pennsylvania Medicaid assistance coverage includes thousands of drugs and medical treatments for all MA recipients, some for free and some for minimal copayments. Learn more about Medicaid services and their related costs by downloading our in-depth Medicaid guide.

What services are covered by Medicaid in Pennsylvania for Free?

When it comes to services covered by Medicaid, if a recipient requires medical treatment but cannot make the necessary copayment, the health care professional is required to provide the service and bill the MA recipient later. Some of the medical services provided free of charge through all types of Medicaid insurance include:

  • Emergency services that are required to prevent serious injury or death.
  • Laboratory services and other necessary diagnostic services.
  • Medical examinations for children and adults younger than 21.
  • Hospice care services and other home health agency services
  • Psychiatric partial hospitalization program services

What services are covered by Medicaid in Pennsylvania?

As mentioned above, which medical services are covered by Medicaid in Pennsylvania depends on rules set forth by the DHS and the federal government. The DHS divides its Medicaid coverage into three categories, each a different sector of health care for MA recipients. Benefit recipients who have questions concerning their benefits can contact a representative from the appropriate benefits group. All health care benefits recipients are covered for many of the medical services in the categories discussed below.

PennsylvaniaMedicaid coverage for physical health needs, including services such as emergency care, wellness checks and doctor’s appointments, preventive care and services, lab tests, X-rays and other necessary diagnostic work. What services are covered by Medicaid for children, pregnant women or other eligible groups? Eligible recipients in these groups may also qualify for dental and vision care, including preventive care and treatments, dental tooth removal, glasses for qualifying conditions and more. To learn more about Medicaid-covered services, download our comprehensive Medicaid guide.

All types of Medicaid insurance in PA include coverage for necessary mental health counseling and illness treatment services. In addition, those receiving coverage through Medicaid have access to rehabilitation services for problems with addiction to tobacco, alcohol or drugs. In some cases, benefit recipients may be able to go to a mental health provider directly, without first receiving a referral from their primary care providers. Children and adults up to the age of 21 are eligible for more comprehensive behavioral health MA coverage than most other benefits recipients through the Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program.

What community services are covered by Medicaid in the state of Pennsylvania? Family planning services, necessary medical equipment and supplies, home health care, skilled rehabilitative therapy, inpatient and hospital care and much more are covered Community Health Choices. Pennsylvania Medicaid coverage in Pennsylvania also includes many outpatient medical services as recommended by a doctor.

What does Medicaid not cover in Pennsylvania?

Those wondering, “What health care services are not covered in Pennsylvania?” must understand that although Medicaid coverage for benefit recipients enrolled in different MA programs can vary, some medical services are not covered by Medicaid regardless of the specific program a recipient receives benefits from. Benefits recipients who are interested in finding out if a required or a requested medical treatment or service is included in their Medical Assistance coverage should contact their nearest DHS or community health office to confirm before receiving the treatment or service. Any medical services received be the applicant that are not covered by Medicaid will have to be paid out of pocket.