Cost and Coverage of Medicaid in Pennsylvania

Pennsylvania Medicaid coverage, also known as HealthChoices, allows eligible individuals and families to access various health care services at a low rate or for free. Individuals who have asked “How much is Medicaid?” should realize that Medicaid cost estimates are based on the applicant’s household income, in addition to the medical services sought.

In this section, we will cover the following:

  • How much does Medicaid cost in Pennsylvania?

  • What services are covered by Medicaid in Pennsylvania?

  • What does Medicaid not cover in Pennsylvania?

  • Types of Medicaid insurance in Pennsylvania

How much does Medicaid cost in Pennsylvania?

The majority of PA Medicaid coverage enrollees are required to pay copays for various medical services. The copayments have to be paid when the service is being rendered. Unless a recipient fall under the following groups, he or she has to pay copayments for most Medicaid services: members receiving hospice care, residents of a long-term care facility or other medical institution, pregnant women (including post-partum period), eligible members that are below 18 years or women enrolled in the Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program.

Some PA Medicaid services do not charged copayments, and are offered for free to all PA Medicaid enrollees. The services include family planning services and supplies, EPSDT (Early and Periodic Screening, Diagnosis and Treatment Program) for enrollees below 21 years, and medical examinations requested by the Department of Human Services to determine mental competency, employability or public assistance eligibility.

What Services are Covered by Medicaid in Pennsylvania?

Most people wonder what services are covered by Pennsylvania Medicaid. Medicaid coverage encompasses various services, either wholly or partially. For non-eligible services, members may be required to make a copayment. Some of the Medicaid services covered include:

  1. Pharmacy benefits
    Medicaid coverage allows for the cost of various prescription drugs. The coverage includes prescription drugs that are in the List of Allowed Drugs as well as over-the-counter medication. Depending on the recipient’s eligibility, he or she may have to pay Medicaid copayments for various drugs.

  2. Transportation services
    Medicaid also encompasses the use of non-emergency medical transportation (NEMT). The service is offered when a member has no other way to receive a ride. Examples of non-emergency medical transportation include rides using specialized medical vehicles, non-emergency ambulances, public transportation (such as a city bus) and other types of vehicles.

  3. Health check services
    Pennsylvania Medicaid services also cover complete health checks. The services include treatment of health problems diagnosed during checkup for members under 21 years. The Medicaid checkup services include vision and hearing screening, physical examination, health and developmental history, dental screening and a referral to a dentist from age 1 and urine and blood lab tests.

  4. Autism treatment services
    Autism services are offered by behavioral treatment providers. Applicants can contact their health providers to find out who offers the service.

  5. Chiropractic, vision and hearing services Pennsylvania Medicaid coverage caters for chiropractic, vision and hearing services. However, the services are offered with some restrictions. For example, only members under 21 years get eyeglasses and hearing aids.

  6. Dental services
    Medicaid enrollees aged 21 years or below are entitled to comprehensive dental services, including fillings and crowns. Adults are only entitled to emergency dental services such as treatment of an infection, fever, swelling, severe dental pain or injury to the teeth.

  7. Family planning services
    PA Medicaid coverage includes family planning services to all members, including minors. If you are not comfortable discussing family planning matters with your primary care provider (PCP), your health plan can help you choose another family planning doctor from its network.

  8. Mental health and substance abuse services
    The PA Medicaid program covers mental health and substance abuse (drugs and alcohol) for all members. The services recipients get depends on whether the have dependent children living with them, in addition to the location of their doctor.

What Does Medicaid Not Cover in Pennsylvania?

PA Medicaid coverage does not cater for the services listed below:

  • Services deemed not medically necessary

  • Prescription drugs for enrollees over 21 years and eligible for limited Medicaid benefits

  • Cosmetic or plastic surgery, except in cases of surgery repairing disfigurement or injury

  • Personal convenience items (television, telephone, etc.) while hospitalized, unless if considered medically necessary

  • Intermediate care facilities or skilled nursing

  • Infertility services and reversal of vasectomy

  • Experimental, unproven or uncertified medical procedures

  • Boarding expenses (residential care that has not been authorized)

  • Services covered by programs like Veterans Administration, worker’s compensation or other insurance programs

  • Services offered by providers not in the health plan’s network, unless with prior authorization, family planning or emergency situations

PA Medicaid services are regularly reviewed. Before concluding this section on what is not covered by Medicaid, keep in mind that if a service or item is not covered, the provider will inform the applicant before providing it. Some providers will ask recipients to sign a private payment form for services or items not covered by Medicaid.

Types of Medicaid Insurance in Pennsylvania

There are different types of Medicaid insurance for which enrollees can apply. The State of Pennsylvania has contracted different health plans to provide Medicaid related services to eligible members. The health plans have networks of facilities, clinics, and doctors that provide the health care services covered by Medicaid. The plans include Molina Healthcare, Unity Health Insurance, Blue Cross Blue Shield, Aetna Better Health of Pennsylvania and UPMC Health Plan

The types of Medicaid insurance in Pennsylvania an applicant signs up for will determine the providers he or she will be using when in need of medical services. If one does not choose a health plan, the plan will be automatically be assigned to him or her. If you already know a specific primary care provider that you would like to work with, find out which health plan he or she is enrolled in.



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