Health Coverage Eligibility
Eligibility for Health Coverage Programs
This page explains general eligibility guidelines for public health insurance programs. If you need health insurance, please contact our certified Navigators to determine what programs you qualify for and to receive free enrollment assistance.
This page is intended for people living in Pennsylvania. Since state Medicaid and CHIP rules can vary, you should contact your own state Medicaid program if you live outside of Pennsylvania.
Eligibility for health insurance programs is primarily based on three factors.
1. Income and family size – includes all taxable income for your tax household
2. Citizenship or immigration status – eligibility for programs may relate to this status
3. Disability status – Medicaid has special considerations for people with disabilities
Health Insurance Eligibility and the Affordable Care Act
Most people in the U.S. have insurance through an employer. The Affordable Care Act (ACA) creates a health insurance Marketplace where people who do not have affordable employer-sponsored insurance can compare and enroll in private insurance plans or Medicaid Expansion, based on eligibility.
Health Insurance Options
Click on each title to read more
Health Insurance Marketplace
(Also called Affordable Care Act, ACA, or Obamacare Plans)
The Health Insurance Marketplace is intended for consumers who don’t have another way to access health insurance. It is a place where people can compare and enroll in health insurance from different private insurance companies.
Most people who qualify for Marketplace coverage get financial assistance to make the health insurance more affordable based on their income. People who are are eligible for Medicaid, Medicare, or affordable employer-sponsored insurance are not eligible for financial assistance on the Marketplace.
To learn about consumer protections created by the ACA for all consumers, regardless of how you get your coverage, visit this page.
Who qualifies for a Marketplace plan?
People below age 65. Some people over age 65 may qualify.
Must be a U.S. Citizen or be an immigrant with an eligible status. Click here for more information on eligible immigration status.
Who can enroll on your plan:
Your tax household. This means the family members and dependents listed on the same IRS tax filing.
Most people must enroll in a Marketplace plan during Open Enrollment. The 2017 Open Enrollment period will run from November 1 – December 15 to enroll in a 2018 plan. Some life changes can qualify people for a Special Enrollment Period when it is not Open Enrollment.
How much will health insurance plans cost?
The ACA provides two types of financial assistance to make health insurance more affordable based on income. This means it can cost different amounts for difference people based on what financial help they qualify for.
One kind is called Advanced Payments of the premium Tax Credit (APTC), which gives people monthly discounts on their health insurance premium (monthly payment). These are for people with income between 100-400% of the Federal Poverty Level (FPL).
Another kind of financial help is Cost-Sharing Reductions (CSR), which lower the costs of out-of-pocket expenses, such as deductibles, copays, and coinsurance. These are available to consumers earning between 100-250% FPL. To receive cost-sharing reductions, consumers must enroll in a Silver level plan.
It’s very important to report any income changes as they occur throughout the year. Changes to your income could impact the amount of financial help you receive. If you do not report the change, you may have to pay back part of your tax credit when you file your annual federal tax return.
If your income is below 100% FPL, but you do not qualify for Medicaid due to immigration status, you may still be able to access premium tax credits and enroll on the Marketplace. Contact our Navigators for assistance.
What will the health insurance plans cover?
All plans sold on the Marketplace are required to cover 10 Essential Health Benefits, including maternity coverage, prescriptions, hospital, emergency care, and preventive care like annual exams, birth control, and cancer screenings. Some plans offer additional benefits. All plans cover children’s dental and vision coverage. Adult dental and vision is not required but may be offered with a medical plan.
The Marketplace makes it easy to compare health insurance plans from different private health insurance companies side-by-side. It is not government insurance. Available plans vary based on region. For 2017, there are about 35 plans available in the Pittsburgh area. Plans are divided across five levels:
Bronze: Lowest monthly premium, highest out-of-pocket expenses. The issuer covers 60% of average medical costs. Most plans at this level require the consumer to meet the deductible before the plan pays a portion of the cost for services.
Silver: The most popular level. The issuer covers 70% of average costs. *Consumers eligible for Cost-Sharing Reductions receive additional discounts on Silver plans. For these consumers, issuers pay between 73-94% of plan costs, based on the consumer’s income.
Gold: Higher monthly premium, lower out-of-pocket expenses. The issuer covers 80% of average costs.
Platinum: Highest monthly premium, lowest out-of-pocket expenses. The issuer covers 90% of the average costs, but the consumer pays the majority of their portion up front as their premium.
Catastrophic: Typically available only to consumers under age 30. Low monthly premium, access to free preventive care, protection from catastrophic medical bills. Only three primary care visits per year are covered without meeting the high deductible.
Consumers have the option to purchase a dental plan separately from their Marketplace medical plan. Both low- and high-coverage plans are available, from several well-known companies.
For 2017, a basic dental plan covering routine exam and cleaning starts at about $9 per person per month. Consumers are not required to purchase a dental plan, and will not face any tax penalty for not enrolling in dental coverage. The monthly tax credit cannot be used on a dental plan. Other local options for low-cost dental services may be available.
Stand-alone vision plans are not available on the Marketplace.
Medicaid or Medical Assistance
Medicaid is a state health insurance program that provides free of low-cost health insurance to families and individuals. It is jointly funded by state and federal funds. In Pennsylvania this program is referred to as Medical Assistance(MA). It is granted through the Department of Human Services (previously called the Department of Public Welfare).
There are several categories of eligibility under Medical Assistance.
Both adults and children can qualify for Medical Assistance. There are special eligibility requirements for certain groups of people such as pregnant women, parents & caretakers, former foster youth, seniors, adults with disabilities, and children.
Adult Medicaid Expansion
The Affordable Care Act (ACA) encouraged states to expand adult Medicaid eligibility to all adults based on income. Pennsylvania accepted Medicaid Expansion in 2015. It is available now.
With Medicaid Expansion, eligibility for adults is based solely on income. This does not include savings or resources.
Medicaid Expansion has helped over 700,000 Pennsylvanian adults access medical care!
Who qualifies for Adult Medical Assistance under expansion?
19 to 64.
You must be a resident of Pennsylvania. This means you must physically live in Pennsylvania with plans to continue living there. People without a permanent address can qualify.
Adults must be a U.S. Citizen or have a qualified immigration status. Some of these immigration status require a 5-year waiting period for people to be eligible.
Eligibility is based on current, gross (before taxes) monthly income for the household. Income must be below 138% of the federal poverty level. Use the chart below to see what monthly income amounts are eligible for Medical Assistance. (Amounts are for 2017.)
For example, a single adult with no dependent children, making no more than $1,387 gross (before taxes) per month, should be eligible. Contact our certified Navigators to see if you qualify for this coverage.
Resources are not counted. You do not need to provide information about savings, properties, retirement accounts, or other resources
What do health plans cover?
Medical Assistance offers comprehensive coverage, including routine and specialist doctor visits, prescriptions, hospital and emergency care, mental and behavioral health, treatment for substance use disorders, and basic dental and vision services.
MAWD – Medical Assistance for Workers with Disabilities
MAWD provides Medical Assistance health coverage to adults who make too much money to qualify for other categories of Medical Assistance. To qualify for MAWD, you much be working and have a serious chronic health condition, disability, or take a health-sustaining medication.
Who qualifies for MAWD?
Between age 16 – 65
Less than 250% Federal Poverty Level, with some income not counted. Please contact our Navigators to be screened for eligibility.
Consumers may not have more than $10,000 in countable resources. This includes financial accounts like checking, savings, 401k, IRA, etc. It does not include one vehicle or your home.
- Must be working, which can include self-employment such as babysitting, housecleaning, etc. You can work as little as 2 hours per month, but you will need to show proof, such as paystubs or a letter from the employer.
- Must have a serious chronic health condition, disability, or need a health-sustaining medication, shown either by receiving Social Security Disability or by providing information from your doctor. If you’re not receiving SSD, additional medical records may be requested.
How much does MAWD cost?
There is a monthly premium for MAWD that is 5% of your income only. Some amounts of income might not count toward this amount.
CHIP – Children’s Health Insurance Program
CHIP is a health insurance program specifically for children. It is available to almost all children in Pennsylvania if their household incomes are too high to quality for Medical Assistance.
CHIP is a national program that is funded by both state and federal funding. Unfortunately, federal funding for CHIP is not permanent, and it must be re-authorized periodically. Congress will consider the next CHIP re-authorization in September 2017.
Who is eligible for CHIP?
Children from birth to age 19.
Must be a U.S. Citizen or have an lawful immigration status.
Unfortunately, children who are undocumented are not eligible to enroll in CHIP. Dream Care is an advocacy initiative in Pennsylvania to open CHIP coverage to all children in the Commonwealth.
The monthly premium for CHIP is determined by family income and the child’s age. There are three categories: free, low-cost, and full-cost.
If your child is eligible for full-cost CHIP, it may be less costly to enroll the child in a Health Insurance Marketplace plan. Consult with our certified Navigators to learn about options.
If family income falls below the Free CHIP range, your child should be eligible for Medicaid.
What do CHIP health insurance plans cover?
CHIP offers comprehensive coverage that includes annual exams, vaccinations, prescriptions, medical equipment, hospital and emergency care, dental and vision coverage.