Medicaid Costs and Coverage in Pennsylvania


Medicaid coverage in Pennsylvania is known as Medical Assistance and it includes a wide range of insurance plans to provide comprehensive, affordable health care coverage to eligible residents. Medicaid cost estimates can vary depending on the beneficiary, the plan he or she picks and the health care services he or she utilizes. Enrollees can find out how much is Medicaid coverage when they sign up for assistance. Review the topics below to discover how much does Medicaid cost Pennsylvania beneficiaries and what services are covered by Medicaid insurance.

How much is Medicaid in Pennsylvania?

Most beneficiaries curious about how much does Medicaid cost are concerned with the out-of-pocket expenses for coverage and treatment. Three types of Medicaid insurance expenses significantly influence out-of-pocket costs. Pennsylvania Medicaid costs can consist of monthly premiums, copayments and deductibles. Premiums and deductibles are fixed amounts, but enrollees pay premiums monthly while the deductible is an annual amount they pay up to for delivered services. Copayments vary by the number and types of medical services rendered. As such, determining how much Medicaid costs enrollees is contingent on their reoccurring premium payment and how often they seek treatment.

Medicaid cost estimates for copayments vary depending upon the service provided. Regardless of on the type of Medicaid insurance plan the beneficiary signs up for, smaller treatments like prescriptions will have a smaller copayment than larger services such as hospital stays. If you need medical care and are not able to pay the copayment at the time of service, then the medical provider will send you a bill and you will be required to pay the copayment at a later date. If you disagree with the amount of copay the provider charged you, then you should talk to the provider first and then call your County Assistance Office if you are unable to resolve the issue. You will need to explain why you think the charge is inaccurate.

The goal of PA Medical Assistance coverage is to keep costs low to make health care coverage affordable for low-income families. Most people covered by one of the types of Medicaid insurance pay a small fee for health care services, known as a copayment. However, some services do not require a copay, including the following services:

  • Laboratory services
  • Family planning and contraception services
  • Home health agency services
  • Emergency care
  • Certain diagnostic tests

For select people, Medicaid coverage does not require copayments. Medicaid cost estimates are much lower for certain populations like children, elderly residents, pregnant women and new mothers. Populations that have less Medical Assistance costs are PA residents who reside in long-term care or hospice facilities, women in certain cancer prevention and treatment programs and children in foster care or adoption assistance programs. Residents may also qualify for the Health Insurance Premium Payment program through their employer if they or at least one of their family members is enrolled in Medicaid. HIPP helps reduce insurance premium costs for low-income workers who meet the income requirements for Medicaid.

For comprehensive details about Medicaid costs, download our free health care guide.

What services are covered by Medicaid in Pennsylvania?

Medicaid costs are kept as low as possible to provide low-income Pennsylvania residents with the health care they need at an affordable price. There are different types of Medicaid insurance in PA but coverage typically includes physical health, mental health and substance-abuse services. Once approved, applicants will receive a notice informing them of costs, benefits and covered health care services. This notice is called a Notice of Action. HealthChoices offers services through managed care organizations, which offer residents with Medicaid coverage a list of approved participating providers in the county where they live. Recipients can select their providers as long as the provider participates in the program.

Services covered by Medical Assistance include both inpatient and outpatient services. Medicaid covers wellness and preventative care services as well as hospitalizations and treatments. Certain enrollees may qualify for additional services like dental and vision. Like CHIP, services covered by Medicaid for children are more comprehensive.

Medicaid coverage for mental health and substance abuse is provided through behavior health managed care organizations. Services covered by Medicaid from these organizations include a range of drug and alcohol treatments and other solutions for mental health needs.

What does Medicaid not cover? Medicaid coverage does not extend to medical professionals who do not participate in the program. While there are some circumstances when patients are referred to a specialist, Medicaid enrollees must have services rendered by an in-network provider. Medicaid does not cover non-essential health services such as cosmetic procedures. Medicaid in Pennsylvania does not cover services such as vasectomy, cosmetic surgery, ambulance services, and some other non-essential health services.

You can find out even more details about Pennsylvania Medicaid costs and coverage in our downloadable guide.

What Health Services Are Available in Pennsylvania?

From Obamacare health insurance plans to Medicaid and Medicare, there are various types of health coverage available in Pennsylvania. Each type of insurance can be accessed through a different application method. To learn about the easiest ways to apply for affordable health care in GA, download our comprehensive guide on health services.

Who Is Eligible for Affordable Health Services in Pennsylvania?

Affordable and free health services are often limited to Pennsylvania residents who meet all established eligibility requirements. Income, age and household size are often key factors taken into consideration when determining an applicant’s qualifications. Discover if you qualify for free or reduced-cost health insurance by reviewing the in-depth information on all program eligibility requirements within our comprehensive guide.