Author Topic: Pennsylvania medicaid  (Read 1663 times)


  • 5 O'Clock Shadow
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  • Posts: 60
Pennsylvania medicaid
« on: February 24, 2019, 01:01:55 PM »
A few weeks ago, my son's physical therapist mentioned that my son should qualify for the "loophole" provision of Pennsylvania medicaid.  My son has a genetic disorder and if he meets the states guidelines on disability (does not need to be federal guidelines), he should qualify for medicaid regardless of household income.  While we have good income and health insurance through our employers, we still had 18k in healthcare costs for him last year, including out of pocket max and things not covered by insurance (certain genetics tests, therapies, etc).

Well I got a phone call on Friday saying my son had been approved and asking me to pick a plan among three.  I had received no literature on these plans at all and the person I spoke with couldn't tell me either, just said I can switch at any point.  So I chose the one my son's doctors accept without really being able to weigh any options.

I am having trouble finding information on what will be covered and how I go about getting things covered.  I understand that my insurance will be primary and medicaid should then pickup anything that my primary does not include.  However, I am assuming my son's PCP needs to send referrals for everything before any covering will occur (at this point, my insurance lets me go to any doctor without referrals). 

Has anyone used Pennsylvania's medicaid? 
If yes, where do I find a list of providers that take it?
How do I submit claims?
How difficult is it to get them to cover things.
Is there a good resource where I can learn about the benefits?
Does being on medicaid give my son any other benefits besides medical coverage?  I'm thrilled that we were approved and just medical benefits are wonderful but if there's anything else I can do to set my son up for success, I am willing to look into it.  At this point, we are unsure how his genetic disorder will affect his future as he is only an infant.

If anyone has any insight, I would appreciate it!


  • Handlebar Stache
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  • Posts: 1896
  • Location: SE PA
Re: Pennsylvania medicaid
« Reply #1 on: February 24, 2019, 06:54:29 PM »
I used PA Medicaid for my DD from ages 2 months to 15 months.  I was a SAHP during that time, and our income was low enough for her to qualify.  (But not me.  But thatís a different story.). 

Anyway, this was in 2009, and Medicaid was her primary.  I donít remember being offered a choice of plans at all.  We were issued a yellow Medicaid card and I just showed it when I took her to the doctor for well visits.  No big deal.  The office took care of everything and I never paid out of pocket for anything.  Although your case may be different, because all we ever needed was preventative care.  This was pre-ACA, also, so you may be even better off with what is available through Medicaid now.

I had a case manager through the state that was responsible for helping me through the application process.  Do you have one?  If so, I would start there with any questions.  Good luck, I hope your little guy manages his disorder well and the Medicaid provides some financial relief to you.