Pennsylvania Medicaid Definition
Medicaid is a jointly funded state and federal health care program for low-income individuals of all ages. The focus of this page, however, is Medicaid eligibility for senior Pennsylvania residents, aged 65 and over. Specifically, long-term care is covered. While Medicaid-funded nursing home care and assisted living services is available, PA Medicaid also pays for non-medical support services to help frail seniors remain living at home or in the home of a loved one.
Medicaid in Pennsylvania is called Medical Assistance (MA). Pennsylvania’s Department of Human Services administers the state’s program.
Income & Asset Limits for Eligibility
There are several Medicaid long-term care programs for which Pennsylvania seniors may be eligible. These programs have differing eligibility requirements and benefits. Further complicating eligibility is that the criteria vary with marital status and that Pennsylvania offers multiple pathways towards eligibility.
1) Institutional / Nursing Home Medicaid – This is an entitlement program; Anyone who is eligible will receive assistance. Benefits are provided only in nursing homes.
2) Medicaid Waivers / Home and Community Based Services (HCBS) – These are not entitlement programs; There are a limited number of participants and waitlists to receive benefits may exist. Intended to prevent and delay the need for nursing home admissions, services and supports are provided at home, adult day care, or in assisted living. More on waivers.
3) Regular Medicaid / Aged Blind and Disabled – This is an entitlement program; Meeting the eligibility requirements ensures one will receive assistance. Various long-term care services, such as personal care assistance or adult day care, may be available.
The table below provides a quick reference to allow seniors to determine if they might be immediately eligible for long term care from a PA Medicaid program. One can also take the Medicaid Eligibility Test. IMPORTANT: Not meeting all the criteria does not mean one is ineligible or cannot become eligible for Medicaid in Pennsylvania. More.
|2022 Pennsylvania Medicaid Long Term Care Eligibility for Seniors|
|Type of Medicaid||Single||Married (both spouses applying)||Married (one spouse applying)|
|Income Limit||Asset Limit||Level of Care Required||Income Limit||Asset Limit||Level of Care Required||Income Limit||Asset Limit||Level of Care Required|
|Institutional / Nursing Home Medicaid||$2,523 / month*||$2,000‡||Nursing Home||$5,046 / month ($2,523 / month per spouse)*||$4,000 ($2,000 per spouse)‡||Nursing Home||$2,523 / month for applicant*||$2,000 for applicant & $137,400 for non-applicant‡||Nursing Home|
|Medicaid Waivers / Home and Community Based Services||$2,523 / month†||$2,000‡||Nursing Home||$5,046 / month ($2,523 / month per spouse)†||$4,000 ($2,000 per spouse)‡||Nursing Home||$2,523 / month for applicant†||$2,000 for applicant & $137,400 for non-applicant‡||Nursing Home|
|Regular Medicaid / Aged Blind and Disabled||$863.10 / month||$2,000||Help with ADLs||$1,294.30 / month||$3,000||Help with ADLs||$1,294.30 / month||$3,000||Help with ADLs|
†Based on one’s living setting, a beneficiary may not be able to keep monthly income up to this level.
‡Pennsylvania allows an extra $6,000 exemption, which is in addition to the asset limits listed. There is one exception. If an applicant has income over $2,523 / month, rather than the total asset limit of $8,000 ($2,000 plus $6,000 disregard), the asset limit is $2,400.
What Defines “Income”
Any income that a Medicaid applicant receives is counted. This income can come from any source. Examples include employment wages, alimony payments, pension payments, Social Security Disability Income, Social Security Income, IRA withdrawals, and stock dividends. An exception exists for Covid-19 stimulus checks and Holocaust restitution payments, which are not counted as income.
When only one spouse of a married couple applies for nursing home Medicaid or a Medicaid waiver, only the income of the applicant is counted. This means the income of the non-applicant spouse is disregarded and does not impact the income eligibility of their spouse. The non-applicant spouse (often called the community spouse), however, may be entitled to a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their applicant spouse. In Pennsylvania, this is called a Community Spouse Monthly Maintenance Needs Allowance (CSMMNA) and is the minimum amount of income a non-applicant spouse is said to require to avoid spousal impoverishment. The MMMNA in PA is $2,288.75 (effective 7/1/22 – 6/30/23). If a non-applicant’s monthly income falls under $2,288.75, income can be transferred from their applicant spouse, bringing their income up to this level.
A non-applicant spouse can further increase their spousal income allowance if their housing and utility costs exceed a “shelter standard” of $686.63 / month (effective 7/1/22 – 6/30/23). However, in 2022, a spousal income allowance cannot put a non-applicant’s monthly income over $3,435. This is the Maximum Monthly Maintenance Needs Allowance. Learn more about how the spousal income allowance is calculated.
Income is counted differently when only one spouse applies for regular Medicaid / Aged Blind and Disabled; The income of both spouses, regardless of if one or both spouses are applying for benefits, is counted towards the income limit. For additional information on how income is counted for Medicaid eligibility purposes, click here.
What Defines “Assets”
Countable assets include stocks, bonds, investments, savings, and checking accounts. There are also many assets that are considered exempt (non-countable). Exemptions include personal belongings, household items, a vehicle, irrevocable burial trusts, and generally one’s primary home. For home exemption, the Medicaid applicant must live in it or have intent to return, and in 2022, their home equity interest must not be greater than $636,000. Equity interest is the amount of the home’s value owned by the applicant. If the applicant has a spouse that lives in the home, it is automatically exempt.
All assets of a married couple are considered jointly owned regardless of the long-term care Medicaid program for which one is applying. However, a spousal impoverishment rule permits the non-applicant spouse of a Medicaid nursing home or waiver applicant a Community Spouse Resource Allowance (CSRA). In Pennsylvania, this is the non-applicant spouse’s “protected share”. In 2022, the community spouse (the non-applicant spouse) can retain 50% of the couples’ assets, up to a maximum of $137,400, as the chart indicates above. If the non-applicant’s half of the assets falls under $27,480, 100% of the assets, up to $27,480 can be retained by the non-applicant.
Pennsylvania has a 5-year Medicaid Look-Back Period that immediately precedes one’s date of long-term care Medicaid application. During this period, Medicaid checks to ensure no assets were gifted or sold under fair market value. When persons have done this, even non-applicant spouses, the Medicaid agency assumes it was done to meet Medicaid’s asset limit. Violating the look back period results in a penalty period of Medicaid ineligibility.
Qualifying When Over the Limits
For Pennsylvania residents, 65 and over, who do not meet the eligibility requirements in the table above, there are other ways to qualify for Medicaid.
1) Medically Needy Pathway – Pennsylvania has a Medically Needy Only Medical Assistance (MNO-MA) program for seniors who have income over Medicaid’s income limit. Sometimes called a “Spend-down” program, persons can become income-eligible by spending the majority of their income on medical expenses, including nursing home bills. In 2022, the medically needy income limit (MNIL) is $425 / month for an individual and $442 / month for a couple. The “spend down” amount, which can be thought of as a deductible, is the difference between one’s monthly income and the MNIL. In PA, the spend down amount is calculated for a 6-month period. Once one has met their spend down, they will be income eligible for Medicaid services for the remainder of the period. The MNO-MA asset limits are $2,400 for an individual and $3,200 for a couple. There is no additional asset disregard. More about the medically needy pathway.
2) Asset Spend Down – Seniors who have assets over Medicaid’s limit can still become Medicaid eligible by spending down extra assets. This can be done by spending countable assets on non-countable ones, such as home modifications (i.e. the addition of wheelchair ramps or stair lifts) prepaying funeral and burial expenses, and paying off debt. Remember, assets cannot be gifted or sold under fair market value, as this violates Medicaid’s look back rule. It is recommended one keep documentation of how assets were spent as proof the look back rule was not violated.
3) Medicaid Planning – The majority of persons considering Medicaid are “over-income”, “over-asset”, or both, but they still cannot afford their cost of care. For these persons, Medicaid planning exists. By working with a Medicaid planning professional, families can employ a variety of strategies to help them become Medicaid eligible, as well as to protect their home from Medicaid’s estate recovery program. More on Medicaid Planning or connect with a Medicaid planner.
Specific Pennsylvania Medicaid Programs
Pennsylvania law requires that the state Medicaid program pay for nursing home care for all residents, regardless of their length of residency, if there is a medical need and the program’s financial criteria is met. The state also provides assistance for some residents who qualify for nursing home care, but wish to reside outside of a nursing home. These services are called Home and Community Based Services.
1) Community HealthChoices (CHC) Program – This is a Medicaid managed care program for “dually eligible” (Medicaid and Medicare) aged and physically disabled state residents. A previously available waiver program, the Pennsylvania Department of Aging (PDA) Waiver, has transitioned into this program. Available benefits via CHC may include adult day care, personal care assistance, home modifications, home health services, and more. A program option, Services My Way (SMW), allows persons to self-direct their own care. Beneficiaries are able to choose their own care providers, including the ability to hire some family members.
2) Program of All-Inclusive Care for the Elderly (PACE) – The benefits of Medicaid, including long-term care services, and Medicare are combined into one program. Additional benefits, such as dental and eye care, may be available.
How to Apply for Pennsylvania Medicaid
Elderly Pennsylvania residents can apply online for long-term care Medicaid / Medical Assistance at COMPASS or fill out a paper application, “Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services”, and submit it to their local County Assistance Office (CAO). Persons can also apply in person at their CAO or over the phone by calling the Health Care Coverage Consumer Service Center at 866-550-4355. Persons might also find their local Area Agency on Aging office helpful in answering Medicaid program questions and offering application assistance.
Prior to submitting a Medical Assistance application in Pennsylvania, seniors must be positive that all eligibility requirements (covered in detail above) are met. Persons over the income and / or asset limit(s), should strongly consider Medicaid planning for the best chance of acceptance into a Medicaid program. The application process can be lengthy and challenging, as documentation must be included with the application. Read more on the application process for long-term care Medicaid.