Pa medicaid eligibility handbook. 70(b)(3), to include items that are primarily and customarily used to serve a B Category – State Blind Pension – receives a limited Health Care Package Note: Unless designated with (S), the category/program status code receives Federal funding for Medicaid services. GHP Family is an insurance plan that provides health coverage to Pennsylvania residents eligible for Medicaid. Comprehensive handbook on long-term care policies and procedures in Pennsylvania. This takes the place of all previous print or website versions of the handbook. Payment of the Medicare Part A premium, if the individual is enrolled in and paying Part A. If you’re 21 or older and have both Medicare and Medicaid, or receive long-term supports through Medicaid because you need help with everyday personal tasks, you may be eligible for enrollment in Community HealthChoices • Children’s Health Insurance Program (CHIP) link redirects the user to the PA DHS CHIP enrollment webpage. The Department of Human Services (DHS) is committed to increasing opportunities for older Pennsylvanians and individuals with physical disabilities to remain in their homes. The Office of Medical Assistance Programs (OMAP) in Pennsylvania’s Department of Human Services (DHS) oversees the physical health portion of HealthChoices. Out-of-state providers must submit proof of participation in that state’s Medicaid program. Medicaid is a government-run health insurance program that provides health insurance to lower-income Americans. applicable . The SNAP Handbook provides guidelines and policies for the Supplemental Nutrition Assistance Program. NOTE: The PA PROMISeTM Provider Handbooks have been designed to be fully functional as paper-based documents PROMISe™ Internet Portal > Home PROMISe™ Internet Portal Children’s Health Insurance Program (CHIP)- The Pennsylvania program that provides free, low-Cost or full-cost health care services to children in accordance with 40 P. The law makes changes to Medicaid (Medical Assistance) and the Supplemental Nutrition Assistance Program (SNAP). Feb 13, 2025 · Information from the Pennsylvania Health Law Project on the eligibility requirements for Medical Assistance benefits and how to establish eligibility for the benefits. Medicaid is a joint federal-state program that offers affordable health insurance at little to no cost for those who qualify. For example, the PA PROMISeTM Provider Handbook for the ADA Claim Form – Version 2012 will contain a link to the Pennsylvania Code, which houses Department of Human Services (DHS) regulations. See page 8 of this Handbook for more information. County where the enrollee’s Primary Care Provider is located. to 6 p. 0/Pharmacy Billing. If you have questions about your benefits, please call Member Services at 1-888-991-7200 or TTY 1-888-987-5704. S. The Vaccines for Children (VFC) Program provides vaccines to children who do not have health insurance. Pennsylvania adopted Medicaid Expansion, the new adult group created by the Affordable C PA PROMISeTM Provider Handbook for NCPDP 5. On February 2, 2016, The Centers for Medicare & Medicaid Services (CMS) issued the final rule, titled “Medicaid Program; Face-to-Face Requirements for Home Health Services; Policy Changes and Clarifications Related to Home Health. To participate in the SPBP 1, providers located in Pennsylvania must be enrolled in the Pennsylvania Medicaid program and the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE) program. ) The CHIP Eligibility Handbook serves to provide contractors with a comprehensive guide that will ensure proper implementation of statutory requirements, pursuant to Title XXI of the Social Security Act, the Children’s Health Care Act, and the Patient Protection and Affordable Care Act (PPACA or more commonly referred to as ACA). Medicaid / Medical Assistance General Eligibility Requirements You must meet income, resources (in some cases), and other eligibility requirements in order to be eligible for Medical Assistance. IMPORTANT NOTES: Applications must be typed or completed by hand using black ink. Physical health services are provided through the physical health managed care organizations (PH-MCOs). Medical Assistance Eligibility HandbookMedical Assistance Eligibility Handbook Moved PermanentlyThe document has moved here. compass. Whether you're a child, parent, pregnant woman, or adult, this guide will help you understand if you qualify for Medical Assistance coverage and how to apply. Income Most income is counted, including: Social security Pensions Interest and dividends from savings and Learn who’s eligible to enroll in Pennsylvania's Medicaid program, how to apply, the status of Medicaid expansion and the effects of Medicaid disenrollment. It is a pu of Human blic health insurance (DHS). 11 55 Pa. Help is available Monday, Tuesday, Thursday, and Friday from 8 a. General Provisions In Pennsylvania, the Department of Human Services (Department) is the State Medicaid Agency and provides benefits for those individuals eligible for Medicaid under the Pennsylvania Medicaid State Plan. 300 Forms, Operations Memoranda, and Policy Clarifications 310 Applicant And Recipient Groups Standard Filing Unit 312 Affordable Care Act/Modified Adjusted Gross Income - MAGI 316 MAWD-Medical Assistance for Workers with Disabilities 317 BCCPT-Breast and Cervical Cancer Prevention and Treatment 379 Reconsidering Denied Applications and Reopening Closed Benefits If the consumer's eligibility shows two categories and at least one of the codes show eligible, then the consumer is eligible for MATP services. For some SNAP recipients, these changes will begin September 1 Apr 19, 2018 · The Buy-In program transfers medical costs from the Medical Assistance (MA) program to the federally funded Medicare program; and helps with Medicare costs for individuals who are above the eligibility limits for MA. Parents and caretaker relatives with income over the income standard for coverage under this group may be eligible for coverage in the adult group in states that have expanded to cover the adult group. Marcia Mikos Department of Human Services Sep 10, 2025 · Everything you need to know to receive free or low-cost health services from Pennsylvania Medicaid, including how to apply, eligibility, restrictions, coverage, and more. Why Medical Assistance? Medical Assistance (also known as Medicaid) has the broadest coverage of medical and mental/behavioral health services for kids under 18 of any insurance plan. . County where the CHIP-eligible service was provided. The Medical Assistance Eligibility Handbook provides comprehensive guidelines on eligibility criteria and procedures for medical assistance in Pennsylvania. Benefit Limits and Benefit Limit Exceptions (BLEs Eligibility for Payment of Long-Term Care (LTC) and Home and Community-Based Services (HCBS) Presented by: Ms. Need this information in print? We’ll mail it to you. Medical Assistance Eligibility Handbook Click here to see this page in full context Oct 17, 2025 · Keystones of Health 1115 DHS seeks to use PA's Medicaid program to offer targeted supports and services to help people live healthier lives. President Trump signed that bill into law. If a dentist needs to access Medical Assistance (MA) policies specific to dental services, a link to 55 Pa. 0/Pharmacy Billing, a general overview of each section of the handbook, and how to obtain a hardcopy PA PROMISeTM Provider Handbook for NCPDP D. Depending on the information you need, it may take up to 5 business days for PHW to send Mar 31, 2025 · An overview of Pennsylvania Medicaid’s long term care programs and eligibility requirements including nursing home care, assisted living and in-home care. Community HealthChoices is a new program designed to coordinate physical healthcare and long-term services and supports (LTSS) for older persons, persons with disabilities, and Pennsylvanians who are dually eligible for Medicare and Medicaid (dual eligible). For MA eligibility questions, call the DHS Provider Helpline at 1-800-766-5387. •HealthChoices Expansion Provider Training Guidesredirects the user the the PA DHS healthchoices publications webpage. PA Medicaid Eligibility Handbook & Benefit Guide The Pennsylvania Medicaid program, often called the Pennsylvania Medical Assistance (MA) program, covers about 20% of the Pennsylvania population. , shall maintain active enrollment in the Pennsylvania Medicaid Mar 10, 2016 · Effective January 1, 2014, the Affordable Care Act (ACA) changed Medical Assistance (MA) rules in Pennsylvania. The following PA PROMISeTM providers should access the PA PROMISeTM Handbook for the 837 Institutional/UB-04 Claim Form to obtain general information, provider specific policies, eligibility information, and billing instructions: Sep 19, 2024 · Medical Assistance Eligibility Handbook Policy ClarificationsUpdated October 27, 2025, Replacing July 9, 2025 What is Medical Assistance? Medical Assistance (also known as Medicaid or MA) is Pennsylvania’s health insurance safety net. To view the Help system without frames click on thishyperlink. Some sections of these handbooks are currently under development and will be updated as additional content becomes available. MAGI Adult Category at a glance rwise qualify for Medical Assistance. 2301-A – 991. o designated requirements in detail in this ma We to category, MA eligibility We would like to show you a description here but the site won’t allow us. But in 2015 Jan 1, 2025 · HealthChoices is Pennsylvania’s Medical Assistance managed care program. gov). See full list on medicaidplanningassistance. Choose from our comprehensive health insurance plans for reliable care. Please choose the appropriate provider type or specialty below to view the PROMISe™ handbook and billing guide appropriate for you. Historically, Medicaid was only available to narrow groups, such as low-income children and adults with disabilities. Explore Pennsylvania's Medical Assistance Eligibility Handbook for comprehensive guidelines on eligibility criteria and procedures. School-Based ACCESS Program (SBAP) Local education agencies must first enroll as a provider in the Medical Assistance program through the Pennsylvania Department of Human Services (DHS) in order to participate in the School-Based ACCESS Program, also known as SBAP. Our Pennsylvania provider resources includes the tools and support you need to deliver the best quality of care. Find your Medicaid and Medicare solution in Pennsylvania with Highmark Wholecare. Use this manual as an extension of your participating Provider Agreement, a communication tool and reference guide. By following the links below, you can find Medical Assistance regulations in currently in use by the Department of Human Services (DHS). Understanding Highmark Wholecare’s policies and procedures is essential. Medicaid for Children with Special Needs (PH95) provides full and free Medical Assistance (MA) coverage to children up to age 18 with disabilities whose parents make too much money to qualify for trad The following sections detail the PA PROMISeTM, providers who should access the PA PROMISeTM, Provider Handbook for NCPDP D. Agencies Department of Human Services Resources & Information For Providers Medical Assistance for Providers Billing Information Medicaid Information for Providers Billing Information We work with our Pennsylvania (PA) state partners at OMHSAS. 13 The Physical HealthChoices program is the name of Pennsylvania's mandatory managed care programs for Medicaid (Medical Assistance) recipients. Medicaid has not changed at this time. The category for which the applicant or recipient is qualified affects how income and resources are treated. For more information regarding PA’s VFC NOTE: Any transfer of assets (income and resources) for less than fair market value in a 5-year period prior to applying for Medicaid LTC services could affect eligibility. Policy Handbooks and Manuals Policy Handbooks and Manuals Cash Assistance Supplemental Nutrition Program (SNAP) Medical Assistance/Medicaid LIHEAP Long-Term Care Supplemental Handbook Water Assistance (LIHWAP) CHIP Handbook Archived Policy Handbooks and Memos A comprehensive guide to eligibility requirements and application process for Medical Assistance (Medicaid) in Pennsylvania. When an applicant/recipient group's net income is more than the eligibility limit for continuing NMP, the CAO will apply the NMP spend-down rules. Jan 31, 2020 · A Pennsylvania ACCESS card to show to medical providers when obtaining medical services. pa. Oct 1, 2021 · Medicaid Regulations, Handbooks, Guides, & Manuals If you are having difficulty finding the document or information you need, please contact the Department of Human Services. Comprehensive guide on policies and procedures for long-term care facilities in Pennsylvania. (April 2020) Feb 27, 2025 · The DHS Provider Helpline can assist LEAs with questions relating to the “Eligibility Verification System” and can provide verification of MA eligibility and plan information. Information for VFC providers. ) Oct 25, 2008 · NMP spend-down makes it possible to deduct medical expenses from net income to become eligible for NMP. CHECKING ELIGIBILITY The PROMISeTM Eligibility Verification System (EVS) enables you to determine a participant’s Medical Assistance eligibility, as well as the participant’s scope of coverage. Medical Assistance Transportation Program Appendix E – FQHC/RHC HANDBOOK This handbook includes the Guidelines and Requirements for Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) for services rendered to Medical Assistance beneficiaries. CHIP Application Processing System (CAPS)- Automated system used by CHIP to capture application information and process eligibility Include all words in search %End of search results. Nursing Facility Services . Medical Assistance - HealthChoices The Office of Medical Assistance Programs administers the joint state/federal Medical Assistance (also known as Medicaid) program that purchases health care for over 2. 1/Pharmacy Billing The following sections detail the PA PROMISeTM providers who should access the PA PROMISeTM Provider Handbook for the 837 Professional/CMS-1500 Claim Form, a general overview of each section of the handbook, and how to obtain a hardcopy PA PROMISeTM Provider Handbook for the CMS-1500 Claim Form. 8 million Pennsylvania residents. Medical Assistance Eligibility Handbook MATP Quick Reference Guide In July 2025, Republicans in Congress passed a bill that will change programs run by the Pennsylvania Department of Human Services (DHS). Please contact Participant Services at 1-844-626-6813 or 711 (TTY) to ask for any help you need. Address any comments concerning the contents of this manual to: DXC Technology Attention: Documentation Unit Apr 8, 2025 · 1 2 Next LastLast revised October 25, 2025 Checkout Highmark Wholecare’s Member Resources available to support our members, including out of network reimbursement, Medicaid guidelines and more! Chapter 2 -- State Organization Chapter 3 -- Eligibility Chapter 4 -- Services Chapter 5 -- Early and Periodic Screening Chapter 6 -- Payments for Services Chapter 7 -- Quality Control Chapter 8 -- Program Integrity Chapter 9 -- Utilization Control Chapter 11 -- Medicaid Management Information System Chapter 13 -- State Plan Procedures and Medicaid Eligibility PA Health Law Project offers an article that begins with “Pennsylvania's Medicaid program, also known as "Medical Assistance", provides comprehensive health care coverage for vulnerable populations and people with limited incomes. and Wednesday from 8 a. , Ohio, New York, etc. m. CBH does not directly provide services. Children who are insured but whose insurance does not cover immunizations are also eligible to receive federally funded vaccines at public sites, including Federally Qualified Health Centers and Rural Health Clinics. Code Chapters 1101 (General Provisions), 1149 (Dentists’ Services) and 1150 (MA Program The most current and approved Medicaid State Plan is now available in a searchable text PDF format. CBH is the only BH-MCO for Philadelphia County. PHW can provide vital documents and other information you need in other formats such as compact disc, Braille, large print, DVD, electronic communication and other formats if you need them, at no cost to you. Code § 178. The CAO will make the following deductions, as needed, to try to make the applicant/recipient group income-eligible: 55 Pa. It covers services rarely covered by employer-based insurance such as Behavioral Health Rehabilitation Services (“Wraparound”), in-home shift nursing or personal care services, diapers, nutritional PA Health & Wellness will serve Participants in the Community HealthChoices program. The entire Highmark Wholecare team is Jun 16, 2025 · The name waiver comes from the fact that the federal government "waives" medical assistance rules for institutional care in order for Pennsylvania to use the funds for HCBS. Providers cannot deny services or discriminate in any way against an MA recipient on the grounds of race, color, national origin, or disability. Over 75 million adults and children are enrolled in Medicaid. The DHS Provider Helpline can assist LEAs with questions relating to the “Eligibility Verification System” and can provide verification of Medical Assistance eligibility and plan information. While the provider manual contains basic information about the Commonwealth of Pennsylvania Department of Human Services (DHS) and the Centers for Medicare and Medicaid Services (CMS), make sure you fully understand and apply DHS and CMS requirements when administering covered Pennsylvania Medicaid PROMISe™ Eligibility Verification System (EVS)The Relevance Inspector will open in the Coveo Administration Console. 55 Pa. Access Pennsylvania's Medical Assistance Eligibility Handbook for guidelines on eligibility criteria and procedures. HealthChoices is Pennsylvania’s Medical Assistance managed care program. The program is based on the individual’s income and resources. To learn more about Medicaid eligibility in Pennsylvania, including how to apply, view our Medical Assistance (Medicaid) Eligibility Manual. Learn about categories, income and resource limits, immigration status, and how to find in-person help. Will My Child Qualify for Medical Assistance? To qualify for Medical Assistance, your family income must 5. Do not assume that a participant is eligible for Medical Assistance because he/she has an ACCESS or CHC health plan ID card. The Pennsylvania Code is the official codification of rules and regulations issued by Commonwealth agencies and other statutorily authorized documents. The Pennsylvania Department of Human Service’s offices located in each county where Medicaid eligibility is determined. §§ 991. program MA provides income and in resource to meeting and disability Assistance, all eligibility requirements applicable. A waiver is when the federal government “waives” the Medicaid rules for institutional care in order for Pennsylvania to use the same funds to provide supports and services for people in their own communities. 55 18. usor myCOMPASS PA mobile app for smart phones Change your personal information for Medical Assistance eligibility. to 8 p. PROMISe™ Internet Portal > Home PROMISe™ Internet Portal The PA School-Based ACCESS Program (SBAP) Handbook is intended to be used by Local Education Agencies (LEA) who are enrolled in Pennsylvania’s Medical Assistance (MA) Program as school-based service providers through the Pennsylvania Department of Human Services (DHS). This page has eligibility information for the most common Pennsylvania Medical Assistance (Pennsylvania Medicaid) eligibility pathways for children and adults up to 65 who do not have a disability (in other words, for Remember to refer to specific Medical Assistance (MA) regulations, bulletins, provider handbooks and the MA Program fee schedule for more detailed information on the limitations and exclusions for your provider type. org Pennsylvania Medicaid (Medical Assistance) Eligibility Guide This guide provides comprehensive information about Medicaid eligibility in Pennsylvania, known as Medical Assistance. If you require an alternative format or would like printed copies instead, please call a Health Care Concierge team at 1-800-286-4242 (TTY: 711). When you see the term “Medicaid” or “Title XIX” in this training, it is being used intentionally to refer to the cooperative federal/state program that provides healthcare to qualifying indigent persons (which does not include PA’s general assistance program. Spanish (PDF) Vietnamese (PDF) The member handbook on this website is the most up-to-date version. May 2, 2025 · Learn more about Pennsylvania Medicaid, available programs and benefits and view important updates about the health plan. state. Modified Adjusted Gross Income (MAGI) is the income methodology used for determining MA eligibility for children through age 18, parents (biological, adoptive or step), caretakers, pregnant women and adults ages 19-64. 12 The following categories are not Medical We would like to show you a description here but the site won’t allow us. 7 MA Providers To be eligible for participation in the MA program, a provider must enroll and sign a provider agreement. In addition to providing health care coverage, Medicaid is the only program that covers Long-Term Services and Supports (LTSS) at home or in a nursing facility or group home. Feb 14, 2012 · 338. ” The final rule revised the definition of equipment and appliances at 42 CFR 440. DHS pays the monthly Medicare premiums and Medicare becomes the primary payer for medical bills. The Medicaid Eligibility Handbook provides guidelines and policies for determining eligibility for Wisconsin's Medicaid programs, including those for individuals with disabilities. See additional information under "Transfer of Assets" below. 300 Forms, Operations Memoranda, and Policy Clarifications 303 General Information 304 Application 305 Category 309 Health Care Services Benefits for Children 310 Applicant And Recipient Groups Standard Filing Unit 311 RESERVED 312 Affordable Care Act/Modified Adjusted Gross Income - MAGI 314 Students 315 Children with Special Needs 316 MAWD What is Medical Assistance? s Medicaid) Department little cost- . Pennsylvania Department of Human Services Phone Numbers County Assistance Office/COMPASS 1-877-395-8930 or 1-800-451-5886 (TTY/TTD) or www. Those Providers permitted by SPBP to enroll, and whose place of business is in a contiguous state, e. Health insurance coverage that meets a minimum set of qualifications established by ACA. About This Manual Highmark Wholecare’s successes, measured by member and provider satisfaction and assessments by the Centers for Medicare and Medicaid Services (CMS), and the Pennsylvania Department of Human Services (DHS) are dependent upon strong educational processes. Code 178. Providers may request enrollment information by visiting PROMISe Enrollment (pa. g. PA Health and Wellness equips each of our Medicaid and Medicare providers with the most up-to-date provider resources available in the State . 2309-A. Together, we manage behavioral health benefits for Philadelphia residents who receive Medical Assistance (MA), also known as Medicaid, through the PA Medicaid program called HealthChoices. A provider who is enrolled in the MA Dec 9, 2024 · Long-Term Care Handbook FormsUpdated June 9, 2025, Replacing December 9, 2024 PURPOSE: The purpose of this bulletin is to advise providers that the Department of Human Services (Department) has updated The PROMISeTM Provider Handbook 837 Professional/CMS-1500 Claim Form, Appendix E – Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC) Handbook (Appendix E). On this page you can find electronic copies of many UPMC for You resources, including documents, forms, and more. Administered by the Department of Public Welfare (DPW), MA provides the broadest coverage of any insurance plan of physical and mental health services for children. A participant’s eligibility is subject to change; therefore, it is Mar 14, 2016 · Medical Assistance Cascade Table 17. Code § 181. Reflects Medicaid state plan coverage of the eligibility group for parents and other caretaker relatives. HCBS provides for supports and services beyond those covered by the Medical Assistance (also referred to as Medicaid) program that enables a person to remain in a community setting rather than being admitted to a Long Term Aug 19, 2019 · The County Assistance Office (CAO) must determine which category and program each Medical Assistance (MA)applicant or recipient belongs in. w0nr mz9 picxk ay82l sx6xrkry 1l nh cghh13ge chc qwt