What You May Need to Know About Pennsylvania Medicaid
To try to explain Medicaid to the average Pennsylvanian (or resident of any other state for that matter) is like jumping through a minefield of contradictory information. There are, however, a few points that can safely be made, most of them describing the overall complexity of a very complicated system. So here goes the leap forward.
1 st . Medicaid or Medical Assistance as the program is known is not really a single system but a series of many systems and rules describing a program that is funded partially by the federal government and partially by the Commonwealth of Pennsylvania.
2 nd . The rules can be and are different for different age categories and differing disabilities.
3rd. The rules as described in many publications give what appears to be contradictory information. This is because Medicaid may be used to help fund the cost of care in skilled nursing facilities but may also pay for medications and services for disabled or infirm individuals living at home. It might help pay for surgery for infants or could contribute to the cost of what is basically health insurance.
4th. Because of the many uses of Medicaid sometimes we informally or formally describe different types as “nursing home Medicaid” or “Home and Community Based Services” under a program known as Community Health Choices.
5 th . There is MAGI (Modified Adjusted Gross Income) Medicaid which was introduced by the Affordable Care Act and is calculated based on income. Another category is MAWD which is Medicaid for the Working Disabled which allows Medicaid recipients to work based on certain specific rules.
6th. Pennsylvania has broad areas where there are serious needs but no coverage. This especially relates to assistance at home where coverage is especially limited.
7th. Pennsylvania has no Medicaid coverage for assisted living/personal care as such. (Note there are facilities in Pennsylvania that would be considered assisted living in other states but are here referred to as “personal care.”) There are other states including adjoining states of Delaware and New Jersey that do have Medicaid for Assisted Living/Personal Care although on a limited basis.
8th.The income limit for a person living alone for Home and Community Based Care in Pennsylvania is $2,829 monthly in 2024. This is gross income. If the income limit is exceeded there is no HCBS.
9 th . The rules are different in the case of married couples and families which would be too complicated to describe here.
10th. Especially in rural areas a person whose income exceeds the limit and who is not located near to a Medicaid certified nursing home may have very limited options in obtaining care. That can also be true in suburban areas.
11 th . The number of Medicaid certified nursing homes and nursing home beds in Pennsylvania has not kept pace with the increase in population in many years.
12 th . Especially since COVID the needs have been greater and staffing needs are also a serious consideration.
13 th . Under the Deficit Reduction Act of 2005 the rules to qualify for Medicaid in Medicaid certified long term care facilities changed dramatically. As of February 8, 2006 the period of time the government rules relative to gifting changed from 3 years for most transactions to 5 years – the so called “five year lookback.” More significantly, however, the time from which calculations are made changed so that any prohibited gifting transactions conducted within the five years prior to when the individual needs to qualify for the benefit are considered when deciding on a penalty. The penalty can result in a period of time during which the person will not have Medicaid as a source of payment.
14 th . What counts as a “gift” and how planning needs are to be considered in the individual case requires knowledge and assistance from someone who is experienced in the field. There are some exceptions for instance under the Caretaker Child exception an adult child who cares for a parent for at least two years during which her parent would otherwise need to be in a nursing home can, if documented, qualify in some cases to have the home transferred to her without penalty when the parent moves to skilled care. There also can be a written agreement relative to care and services with a parent who needs assistance.
15 th . Since Memory Care and Personal Care/Assisted Living are not considered skilled care in Pennsylvania, therefore, Medicaid is not available in these facilities regardless of planning.
Seek help if needed.
About the Author Janet Colliton
Esquire, Colliton Law Associates, P.C. Janet Colliton has practiced law for over 38 years, 37 of them in Chester County, Pennsylvania, a suburb of Philadelphia. Her practice, Colliton Law Associates, PC, is limited to elder law, Medicaid, including advice, applications and appeals, and other benefits planning including Veterans benefits, life care and special needs planning, guardianships, retirement, and estate planning and administration.