Pennsylvania Medicaid Definition
Medicaid is a wide-ranging, jointly funded state and federal health care program for low-income individuals of all ages. However, this page is focused on Medicaid eligibility, specifically for Pennsylvania residents, aged 65 and over, and specifically for long term care, whether that be at home, in a nursing home or in assisted living. Make note, Medicaid in Pennsylvania is called Medical Assistance (MA).
Income & Asset Limits for Eligibility
There are several different Medicaid long-term care programs for which Pennsylvania seniors may be eligible. These programs have slightly different eligibility requirements and benefits. Further complicating eligibility are the facts that the criteria vary with marital status and that Pennsylvania offers multiple pathways towards eligibility.
1) Institutional / Nursing Home Medicaid – is an entitlement (anyone who is eligible will receive assistance) & is provided only in nursing homes.
2) Medicaid Waivers / Home and Community Based Services (HCBS) – Limited number of participants, which means there may be waitlists to receive services. Provided at home, adult day care, or in assisted living.
3) Regular Medicaid / Aged Blind and Disabled – is an entitlement (fulfilling the eligibility requirements ensures one will receive assistance) and is provided at home or adult day care.
The table below provides a quick reference to allow seniors to determine if they might be immediately eligible for long term care from a Medicaid program. Alternatively, it is worth taking the Medicaid Eligibility Test. IMPORTANT, not meeting all the criteria below does not mean one is not eligible or cannot become eligible for Medicaid in Pennsylvania. More.
|2020 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||$2,349 / month||$2,000||Nursing Home||$4,698 / month (Each spouse is allowed up to $2,349 / month)||$4,000 (Each spouse is allowed up to $2,000)||Nursing Home||$2,349 / month for applicant||$2,000 for applicant & $128,640 for non-applicant||Nursing Home|
|Medicaid Waivers / Home and Community Based Services||$2,349 / month||$2,000||Nursing Home||$4,698 / month (Each spouse is allowed up to $2,349 / month)||$4,000 (Each spouse is allowed up to $2,000)||Nursing Home||$2,349 / month for applicant||$2,000 for applicant & $128,640 for non-applicant||Nursing Home|
|Regular Medicaid / Aged Blind and Disabled||$793.10 / month||$2,000||None||$1,190.30 / month||$3,000||None||$1,190.30 / month||$3,000||None|
What Defines “Income”
For Medicaid eligibility purposes, any income that a Medicaid applicant receives is counted. To clarify, 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.
When only one spouse of a married couple is applying for nursing home Medicaid or a Medicaid waiver, only the income of the applicant is counted. Said another way, the income of the non-applicant spouse is disregarded. However, with regular Medicaid, 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.
There is also a Minimum Monthly Maintenance Needs Allowance (MMMNA), which is referred to as a Community Spouse Monthly Maintenance Needs Allowance (CSMMNA) in Pennsylvania. This is the minimum amount of monthly income to which the non-applicant spouse of a nursing home Medicaid applicant of a HCBS Medicaid applicant is entitled. As of July 2019, this figure is $2,113.75 / month (this amount will increase again in July 2020). Living costs, such as rent / mortgage and utility costs, are considered when determining a community spouse’s monthly income allowance, with the maximum allowance set at $3,216 / month (this figure will increase in January 2021). This spousal impoverishment rule allows the Medicaid applicant to transfer income to the non-applicant spouse to ensure he or she has sufficient funds with which to live. To be clear, this income allowance does not extend to non-applicant spouses of those applying for regular Medicaid.
What Defines “Assets”
Countable assets include stocks, bonds, investments, savings, and checking accounts. However, for Medicaid eligibility, there are many assets that are considered exempt (non-countable). For instance, Pennsylvania allows an extra $6,000 exemption, which is in addition to the asset limits listed above, for a total asset limit of $8,000. However, there is an exception. If the applicant has income in excess of the $2,349 / month income limit, rather than the total asset limit of $8,000 ($2,000 plus $6,000 disregard), the total asset limit is $2,400. Stated differently, in order for an applicant to have an asset limit of $8,000, his or her income must be under $2,349 / month. Other asset exemptions include personal belongings, household items, a vehicle, irrevocable burial trusts, and one’s primary home, given the Medicaid applicant or his or her spouse lives in the home and the home equity is valued under $595,000 (in 2020). One exception for the home to be considered exempt remains; single applicants who do not live in their primary home, but communicate an “intent” to return.
For married couples, as of 2020, the community spouse (the non-applicant spouse of a nursing home Medicaid applicant or a HCBS Medicaid waiver applicant) can retain half of the couple’s joint assets up to a maximum of $128,640, as the chart indicates above. If the couple’s total assets are $25,728 or less, the community spouse is entitled to 100% of it. This, in Medicaid speak, is referred to as the Community Spouse Resource Allowance (CSRA), and in Pennsylvania is also known as the non-applicant spouse’s “protected share”. Like the spousal income allowance, this resource allowance is intended to prevent community spouse’s from becoming impoverished and does not extend to non-applicant spouses of regular Medicaid applicants.
It’s important to be aware that Pennsylvania has a 5-year Medicaid Look-Back Period. This is a period of 5 years in which Medicaid checks to ensure no assets were sold or given away under fair market value in order to meet Medicaid’s asset limit. If one is found to be in violation of the look-back period, a period of Medicaid ineligibility will ensue.
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 – In a nutshell, one may still be eligible for Medicaid services even if they are over the income limit if they have high medical bills. In Pennsylvania, this program is called the Medically Needy Only Medical Assistance (MNO-MA) program. Sometimes referred to as a “Spend-down” program, the way this program works is one’s “excess income,” (their income over the Medicaid medically needy eligibility limit), is used to cover medical bills, which may include nursing home bills. As of February 2020, the medically needy income limit for an individual is $425 and $442 for a married couple. Pennsylvania has a six-month “spend-down” period, so once an individual / couple has paid their excess income down to the Medicaid eligibility limit for the period, they will qualify for the remainder of the six-month period. Make note, the asset limits for Medicaid qualification via the Medically Needy Pathway are different than those listed above. For MNO-MA, the asset limit is $2,400 for a single individual and $3,200 for a married couple. There is no additional asset disregard.
Unfortunately, the Medically Needy Pathway does not assist one in spending down extra assets for Medicaid qualification. Said another way, if one meets the income requirements for Medicaid eligibility, but not the asset requirement, the above program cannot assist one in reducing their extra assets. However, one can “spend down” assets by spending excess assets on non-countable ones, such as home modifications, like the addition of wheelchair ramps or stair lifts, prepaying funeral and burial expenses, and paying off debt.
2) Medicaid Planning – the majority of persons considering Medicaid are “over-income” or “over-asset” or both, but still cannot afford their cost of care. For persons in this situation, Medicaid planning exists. By working with a Medicaid planning professional, families can employ a variety of strategies to help them become Medicaid eligible. Read more 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 nursing home care is a medical need and they meet the program’s financial criteria. As such, nursing home care is an entitlement. However, the state also provides assistance for some residents who have both the medical and financial need for nursing home care, but wish to reside outside of a nursing home. These services are called Home and Community Based Services, and they are not necessarily entitlement programs. Waiting lists may exist.
1) Pennsylvania Department of Aging (PDA) Waiver – Covers adult day care, home care, and home modifications, among other supports that help nursing home qualified persons to remain living at home. As the Community HealthChoices Program (more information below) rolls out in phases, enrollment from the PDA waiver to Community HealthChoices will be mandatory.
2) Services My Way (SMW) – This is a program option that allows seniors receiving services via the PDA Waiver to self-direct their own care. Beneficiaries are able to choose their own care providers, including the ability to hire some family members to provide care.
3) Community HealthChoices (CHC) Program – This is a Medicaid managed care program for “dually eligible” (Medicaid and Medicare) state residents and persons who are physically disabled. CHC is in the process of being rolled out, but is not yet statewide. (The final phase was set to begin in January 2020). It also provides many of the same benefits as the PDA Waiver.
How to Apply for Pennsylvania Medicaid
To apply for long-term care Medicaid, elderly Pennsylvania residents can do so online at COMPASS or fill out a paper application, “Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services” and either drop it off or mail 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, as they should be able to answer Medicaid program questions and offer 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.