As a Medicare beneficiary, where you live – meaning your state of residence – can have a significant impact on the care that you receive and how you pay for that care during your “golden years.” This page explains how Pennsylvania’s regulations and policies are likely to affect your bottom line.
Does Pennsylvania help with my Medicare premiums?
Many Medicare beneficiaries who struggle to afford the cost of Medicare coverage are eligible for help through a Medicare Savings Program (MSP). In Pennsylvania, these programs pay for Medicare Part B premiums, Medicare Part A and B cost-sharing, and – in some cases – Part A premiums.
Asset limits: Pennsylvania uses the federal asset limits for QMB, SLMB and QI – which are $9,090 if single and $13,630 if married.
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Who's eligible for Medicaid for the aged, blind and disabled in Pennsylvania?
Medicare covers a great number of services – including hospitalization, physician services, and prescription drugs – but Original Medicare doesn’t cover important services like vision and dental benefits.
Medicare can also leave its beneficiaries with large cost sharing expenses. Some beneficiaries – those whose incomes make them eligible for Medicaid – can receive coverage for Medicare cost sharing and services only Medicaid covers through Medicaid for the aged, blind and disabled (ABD).
In Pennsylvania, Medicaid ABD covers emergency dental procedures (e.g., extractions) and services for pain relief. Some adults may be eligible for non-emergency dental care.
Medicaid ABD also covers an eye exam every two years. Traditional (i.e., fee-for-service) Medicaid only pays for eyeglasses or contacts for adults who have been diagnosed with aphakia. Medicaid managed care organizations (MCOs) (i.e., private insurers with whom the state contracts to administer Medicaid benefits) may cover eyeglasses or contacts for adults without this condition.
Income eligibility: The income limit is $936.10 a month if single and $1,404.30 a month if married.
Asset limits: The asset limit is $2,000 if single and $3,000 if married.
Medicaid spend-down for regular Medicaid for the aged, blind and disabled benefits and LTSS
Individuals with incomes too high to qualify for Medicaid for the aged, blind and disabled can enroll in Pennsylvania’s Medicaid spend-down. This program allows applicants to qualify for Medicaid by subtracting medical and long-term care expenses from their income that is counted toward the Medicaid eligibility limit.
When an applicant enrolls in the Medicaid spend-down, the state determines the amount of their income that is above the income limit; this is known as “excess income”. Enrollees activate their coverage by submitting medical bills equal to this amount.
Pennsylvania usually approves spend-down benefits in 6 month increments – with additional coverage requiring new medical expenses be submitted.
In Pennsylvania, the Medicaid spend-down program covers Long Term Services and Supports.
Income eligibility: The income limit is $425 a month if single and $442 a month if married.
Asset limits: The asset limit is $2,400 if single and $3,200 if married.
How does Pennsylvania regulate long-term services and supports (LTSS)?
Medicare beneficiaries increasingly rely on long-term care, and the portion of seniors needing these services will keep rising as the population ages. However, long-term care is mostly not covered by Medicare. While Medicaid fills the gap in Medicare coverage for long-term care, its complex eligibility rules can make qualifying for benefits difficult. What’s more – eligibility rules vary significantly from state to state.
Medicaid nursing home coverage
Although many Americans prefer to receive long-term care in their homes, their medical conditions or living situation may make nursing home care a better option. Medicare pays for nursing home care for an unlimited number of enrollees in each state.
Income limits: The income limit is $2,742 a month if single and $5,484 a month if married (and both spouses are applying).
This income limit doesn’t mean nursing home enrollees can keep all of their income up to this level. Instead, enrollees have to pay nearly their entire income toward their care, other than a small personal needs allowance (of $45/month) and money to pay for health insurance premiums and Medicare premiums.
Assets limits: The asset limit is $8,000 per applicant (this limit is actually $2,000 but the state doesn’t count the first $6,000 an applicant has saved).
If only one spouse has Medicaid, the other spouse can keep up to $148,620.
Certain assets are never counted, including many household effects, family heirlooms, certain prepaid burial arrangements, and one car. Nursing home enrollees also can’t have more than $688,000 in home equity.
Home and Community Based Services (HCBS) waivers
Every state’s Medicaid program covers community-based long-term care services, which are provided at home or in the community. Medicaid benefits that pay for these services are called Home and Community Based Services (HCBS) waivers. HCBS programs in many states have waiting lists.
Income limits: The income limit is $2,742 a month if single and $5,484 a month if married (and both spouses are applying).
The income limit for single applicants is used – and only the applying spouse’s income is counted – for married couples where only a single spouse needs Medicaid.
Assets limits: The asset limit is $8,000 per applicant (this limit is actually $2,000 but the state doesn’t count the first $6,000 an applicant has saved). If only one spouse has Medicaid, the other spouse can keep up to $148,620.
HCBS enrollees also can’t have more than $688,000 in home equity.
Spousal impoverishment protections in Pennsylvania
Eligibility rules for Medicaid LTSS programs differ from other Medicaid benefits when only one spouse is applying. When this occurs, only income received by the applying spouse is counted toward the eligibility limit. With other Medicaid programs, the income of both spouses is always counted.
Spousal impoverishment rules allow the spouses of Medicaid LTSS recipients (i.e. the non-applying spouses) to keep a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their Medicaid spouse’s monthly income, along with resource and housing allowances. This rule applies when one spouse receives Medicaid coverage for LTSS, and the other spouse doesn’t have Medicaid.
In Pennsylvania as of 2022, these “community spouses” were allowed to keep:
Medicaid home equity limit in Pennsylvania
Federal law requires states to limit eligibility for Medicaid nursing home and HCBS to applicants with a home equity interest below a specific dollar amount. States set these home equity levels based on a federal minimum of $688,000 and maximum of $1,033,000 in 2023.
In 2023, Pennsylvania has chosen to use the federal minimum home equity limit. Applicants with more than $688,000 in home equity will not qualify for LTSS benefits.
Penalties for transferring assets in Pennsylvania
Because long-term care is expensive, individuals can have an incentive to give away or transfer assets to make themselves eligible for Medicaid LTSS. To curb these asset transfers, federal law requires states to institute a penalty period for Medicaid nursing home applicants who give away or transfer assets for less than their value. States can also have a penalty period for HCBS.
Pennsylvania chooses to have an asset transfer penalty for both nursing home care and HCBS. The state uses a 60-month lookback period to calculate this asset transfer penalty during which time asset transfers or gifts made are not allowed. This penalty is calculated by dividing the value of asset transfers and gifts by the monthly cost of nursing home care (which is about $12,870 in 2023).
Estate recovery in Pennsylvania
A state’s Medicaid agency is required to recover what it paid for long-term care related costs for enrollees who were 55 or older. States can choose to also pursue estate recovery for the cost of all other Medicaid benefits, and recover from enrollees who did not receive long-term care.
Pennsylvania has chosen to only pursue estate recovery for enrollees who received LTSS beginning age 55. However, when it does pursue estate recovery, Pennsylvania may attempt to recover its payments for other Medicaid benefits.
When Medicaid coverage was administered by an MCO, the state will attempt to recover what it paid the MCO. That means the estate recovery amount could differ from the actual cost of Medicaid services received.
Pennsylvania chooses not to recover from estates worth less than $2,400.
Here are answers to frequently asked questions about estate recovery in Pennsylvania.
Where can Medicare beneficiaries get help in Pennsylvania?
APPRISE Medicare Counseling Program
You can receive free volunteer Medicare counseling by contacting the APPRISE Medicare Counseling Program at 1-800-783-7067. This program is offered through the Pennsylvania Department of Aging.
APPRISE can help you enroll in Medicare, compare and change Medicare Advantage and Part D plans, and answer questions about state Medigap protections. This website has more information about services APPRISE offers.
Elder law attorneys
Elder law attorneys can help you plan for receiving Medicaid long-term care benefits. Use this search feature from the National Academy of Elder Law Attorneys (NAELA) to find an elder attorney in your area.
Where can I apply for Medicaid in Pennsylvania?
Pennsylvania’s Medicaid program is overseen by the Pennsylvania Health Care Authority. You can apply for Medicaid ABD or an MSP using this website or by visiting a local County Assistance Office.
You’ll have to be interviewed when applying for Long-term Care Medicaid. Some states also require an interview for Medicaid ABD. But an interview is never required when you’re only applying for an MSP.
