Share This Article

Medicaid Facts Pennsylvania

Medicaid is a huge topic. Even if you already know the basics of what Medicaid is and how it works, you still may have more questions than answers rolling around in your head. With this article, we’d like to shed some light on this important matter. Medicaid helps millions of Americans, and it might be able to help you, as well.

What is Pennsylvania Medicaid?

Let’s start with the big picture. What is Medicaid, anyway? This is a government program that helps individuals and families who lack the resources to pay for the high medical expenses of insurance and health care. While that statement sounds pretty simple, the application of such a program can be rather complex in a country with over 300 million citizens. To make the system work, it is necessary to have many rules, regulations, procedures, and more for who receives these benefits.

On a national scale, Medicaid is a huge program that allows millions of people to access health care they could not otherwise afford. In excess of 70 million people receive Medicaid benefits in one form or another, which is a significant percentage of the population as a whole. If you aren’t sure whether or not you will qualify for benefits, it’s worth your time to at least pursue the possibility. Qualifying for benefits can be a big boost to your personal finances, so explore the requirements for benefits to see if you may be eligible.

Why is Medicaid Important?

The importance of Medicaid can be seen on both a personal and national level. For the individual, this is an important program because it offers access to affordable health care for those who might not be able to get that care otherwise. For individuals and families, accessing the care they need without running into financial difficulties as a result is a huge benefit. Without access to Medicaid benefits, millions of people would simply not receive the health care coverage they require, and a variety of negative health outcomes would likely be the result for those individuals.

On the national level, Medicaid helps to promote overall public health and wellbeing. For instance, by covering millions of kids who might not have health care otherwise, those kids are given a better opportunity to succeed in school, stay healthy, and make it to college. With so many people benefitting across the country, it’s easy to see how Medicaid has had a positive impact on the population.

How Did Medicaid Start?

It’s easy to think of something as pervasive and important as Medicaid as having been in place forever, but of course, that is not the case. In fact, as a health insurance program itself, Medicaid is relatively new in the big picture. It was officially created in 1965, and it has gradually evolved since that time to become the modern program that we know today. Created originally as part of the Social Security Amendments of 1965, the program was designed as a cooperative effort to provide necessary health care services to individuals who meet criteria.

Who Pays for Medicaid?

One of the interesting things about the Medicaid program is the way it is conducted as a collaborative effort between the federal government and the individual states. It is actually up to each individual state to administer their own program, while remaining within the federal guidelines. As far as the financial burden of the program, it is a combination of state and federal dollars that pay for the health care being provided to those who receive benefits.

Some individuals who pursue Medicaid benefits run into confusion because the eligibility requirements vary from state to state. While the federal government does set baseline standards that the states need to follow, the states then have latitude within those standards to establish their own specifications. This is a necessary part of the program since different states have different cost of living levels, demographics, etc. So, when you are looking into Medicaid details for your own application, always be sure that you are looking at the standards that apply to your state.

What Is Included in My Medicaid Coverage?

Now that we’ve established the basics of what Medicaid is and why it is important, let’s take a closer look at what it is that Medicaid has to offer you and your family. If you do qualify, you’ll find that there are many benefits you can take advantage of to save money while getting the care you need.

As mentioned above, states are required to follow guidelines set forth by the federal government when designing and implementing their Medicaid programs. As part of those guidelines, there are some benefits that each state is required to provide, and some that are optional. As you might imagine, the benefits that land in the mandatory category are some of the core human services often involved with health care, including the following –

Hospital services. There is perhaps no more important health care service than the ability to visit a hospital. This is where emergency care happens, of course, but hospitals also house surgeries and many other types of care. Medicaid mandates that both inpatient and outpatient services are included in the benefits when states design their plans. So, if you receive Medicaid benefits, you can rest assured that hospital services will be covered.

Physician services. Again, this is a core piece of the healthcare puzzle. Seeing a physician is an important part of maintaining your health, whether you are going for a well-check or to have a cardiologist examination for something that has been bothering you recently. Just as with hospital services, physician services are mandatory benefits for enrollees in the Medicaid program.
Home health and nursing facility services. Many seniors who receive Medicaid benefits are in need of significant care, whether it is at their own home or in a nursing facility. Specifically, moving to a nursing facility can be a necessary step for many individuals as they age – but it is often cost-prohibitive if they think about paying for it on their own. With Medicaid benefits, it becomes possible to get the care that is so badly needed.

Additionally, if you need caregiver help you can use Medicaid to hire a CDPAP aide.

Lab and X-ray services. These kinds of services often go hand-in-hand with the care one will receive from a physician or hospital. Lab testing or x-rays are a common piece of the healthcare puzzle, and their inclusion here helps individuals know their care will be covered even if testing is needed.
Transportation to medical care. This is another extremely important point, which is why it finds itself on the mandatory list. For those who are in a position to need Medicaid coverage to receive health care, they might not have the resources to deal with a bill for ambulance transportation to the hospital. Therefore, Medicaid covers these services as part of the benefits extended to everyone who is eligible.

The list above does not touch on all of the mandatory benefits included with Medicaid, but it is a start. From there, an optional list of benefits is available for states to decide which of those services they will cover as part of their plan. Some of these optional benefits are provided by most states, but it’s always important to check the specifics of your state’s plan before you proceed.

Prescription drug coverage. As you might imagine, covering prescription drug costs is an important part of the Medicaid system in many states. While it is an optional part of the program, this is one that all states tend to adopt, although their specific rules will vary. Take some time to familiarize yourself with how this part of Medicaid works in the state where you hope to receive benefits.
Physical therapy. Another one of the important optional benefits available through Medicaid is physical therapy. There are countless reasons why one may be referred to a physical therapist, and PT can be an important part of the road to a full recovery. Not all states include physical therapy benefits in their program, but many do.
Dental services. You might not think about dental services first when imagining what will be covered by Medicaid, but some states offer this optional coverage for their citizens. While dental care is often not as costly as other types of medical care, it certainly can add up – especially when invasive treatments are needed.
Occupational therapy. For many people with disabilities, occupational therapy is a critical part of maintaining their ability to do the things they want and need to do each day. Without this therapy, it might be difficult for some individuals to maintain their quality of life. Fortunately, some states include occupational therapy as part of their Medicaid programs.
Non-emergency transportation. Above, we mentioned that coverage for ambulance service is mandatory for states to provide under Medicaid. However, it’s also possible that you will receive coverage for non-emergency transportation when you need to get to and from appointments. A lack of transportation is a common issue, especially for those in their elderly years. Covering the cost of non-emergency transportation makes it easier for more people to take advantage of the services they are provided under the Medicaid umbrella.

There are many other optional benefits available in different states, which is yet again why it’s so important to understand what’s offered to you and how it can work to improve your life. Taking advantage of the Medicaid benefits available to you could be one of the biggest positive steps you take toward securing your finances and keeping life on track.

Who Needs Medicaid?

The simple answer to this question is that individuals who are unable to pay for their own health care need Medicaid to provide that care for them. For instance, an individual who does not qualify for an employer-sponsored health insurance plan may need Medicaid, provided that they meet the relevant qualifications for the program. Anyone who thinks they may need Medicaid is encouraged to at least seek further information regarding their qualifying status. If you do qualify, getting benefits can take a big financial burden off of your shoulders.

So, what will determine whether or not you qualify for Medicaid? Largely, your eligibility is going to be determined by your income. The basis for evaluation is something known as the federal poverty level. If you are unfamiliar with this concept, it’s simple enough – each year, the federal government sets an income number that serves as the poverty level for families of various sizes.

For instance, the federal poverty level in 2019 for a household with a single member was $12,490. Anyone living alone and earning under that amount would be said to be living under the poverty line. Along the same lines, the poverty guideline for a family of four was $25,750 in 2019. You don’t necessarily need to be below the poverty line in order to qualify for Medicaid coverage, but this is the measure that is used to evaluate income and determine eligibility for medical assistance. Your eligibility will depend on many factors, but if you earn less than 200% of the federal poverty guideline for your household size, you may qualify.

How Does Medicaid Check Income?

You may be wondering how the local Medicaid administration in your state will know how much money you make. Generally speaking, it will be tax returns that offer the necessary inside to an individual’s or family’s income, size of household, etc. If you have filed a tax return for the previous year, it’s likely that those figures will be used to establish your eligibility.

It should be said that it’s important to be completely honest and forthright at all times when applying for Medicaid benefits. Although it may be tempting to present your information in a manner that will make it as likely as possible for you to be approved, that is not a good idea. The only way to approach this process is to be completely honest and transparent. Attempting to get Medicaid benefits by falsely representing your income or other information on application form is a crime, plain and simple.

What is Medicaid Used For?

Earlier in this article, we touched on some of the many benefits that are available when you qualify for Medicaid. This included some of the basics such as hospital visits, physician services, and more. However, Medicaid is used for more than just those basic services, and many who receive benefits are able to get other types of care that are necessary for them to continue living a safe and comfortable life. Let’s take a look at some important Medicaid uses.

Long-term care. There is no way around it – long-term care is expensive. For those who qualify, Medicaid can pay for a nursing home stay that would not be affordable to you otherwise. It should be noted that your state will determine whether or not you qualify for that level of care, based on their established guidelines and criteria.
CDPAP. This is an important program that stands for Consumer Directed Personal Assistance Program. If an individual needs home care, that individual is able to pick the person they would like to provide that care to them – and it can even be a friend or family member. The person hired under CDPAP does not have to be a friend or family member, but that is often the case as it is one of the benefits of using this plan. Of course, before you can utilize this benefit, you must qualify for Medicaid.
Eye examinations. In some states, eye exams and glasses are an included benefit as part of the Medicaid program. That’s not the case in all states, so you’ll want to check your coverage before making any appointments. If you are one of the millions of people who require some form of eyesight correction, you may be able to have those costs covered by your Medicaid benefits.

Of course, the three points above represent just a small portion of what Medicaid can be used for by the individuals who qualify. Everyone’s health circumstances are unique, and Medicaid is a wide-ranging program so it can care for as many people as possible.

Is Medicaid Welfare?

By most definitions, Medicaid would be considered a welfare program. While the answer to this question depends to some degree on who you ask and how you define ‘welfare’, the general idea of a welfare program fits with what it is that Medicaid provides. In other words, Medicaid offers financial assistance to low-income individuals that allows them to acquire services they need – in this case, health care.

With all of that said, don’t let any negative association you have in your mind with welfare keep you from pursuing benefits. If you qualify by the standards set forth by your state, you should absolutely look into the possibility of being approved. Getting benefits through this program can go a long way toward helping you secure your financial life in both the short- and long-term. Health care can be expensive, and you don’t want to have to skip out on important care just because of the high costs. If you fit into the categories defined for Medicaid qualification, don’t think twice about pursuing those benefits.

What are the Issues with Medicaid?

With any governmental program, there will be plenty of debate regarding how the program works, who it should benefit, how big it should be, etc. With that said, Medicaid is a rather popular and successful program that is utilized by tens of millions of Americans. Nothing will ever have complete support and agreement in the political world, but all things considered, Medicaid has been an enormous success.

So, what are the issues that come up with the program which give people problems and lead to debates? Let’s take a quick look at a few points.

Complexity of qualification process. While the basics of the guidelines for who qualifies for benefits are relatively straightforward, things start to get messy when you get down into the details. Of course, this isn’t so much a failure of the system as it is a simple fact of life when trying to legislate a program that serves millions. The real world is a messy and complicated place, and a program like this has to try and account for as many variables as possible. Also, there are always people who try to cheat the system, so the qualification process needs to weed out as many of them as it can.
State inconsistencies. The basic benefits provided by Medicaid are offered in all 50 states, but the optional coverages vary from state to state – and that can lead to hardships for certain individuals. As we have said previously, states have some latitude in how they administer their programs, so you need to hope that what your state offers lines up nicely with the services you need.
Access to the right providers. Again, this is an issue that is seen more on an individual level. For the most part, those who use Medicaid are able to get the access they need to the right health care professionals. But that isn’t always the case, and an individual who needs to see a certain specialist may not have access to that kind of provider in their area.

Share This Article