It is critical that seniors have the healthcare coverage and supportive services they need to maintain the highest possible level of health and functioning . There are numerous state and federal healthcare programs available to Pennsylvanians over the age of 65. They include: Medicare, Medicaid, Medicaid Home and Community Based Services Waiver, VA, PACE, OPTIONS and More. Here is some brief information about these programs. For more details, see our recent publications:

Medicare:

Medicare is a federal health insurance program available to eligible individuals age 65 or older. There are three benefit parts to Medicare:

•  Part A (Hospital Insurance)

•  Part B (Medical Insurance)

•  Part D (Prescription Drug Insurance)

There are different ways to get the services covered by Medicare. In most cases, when you first become eligible for Medicare, you receive the Original (also known as traditional) Medicare Plan which includes Medicare Parts A and B. Since Part D became available in 2006, most people will also want to consider joining a Part D Medicare Prescription Drug Plan to add drug coverage. In the alternative, some people may want to consider a Medicare Advantage Plan (which is a health maintenance organization [HMO] or preferred provider organization [PPO]) that provides Part A, Part B, and often Part D coverage. When you become eligible for Medicare, you make a choice of whether to receive your Medicare benefits through the Original Medicare Plan or a Medical Advantage Plan. Each fall you can review your health and prescription needs and decide whether to switch to a different plan for the next year. Click here to go to our webpage on Medicare Part A, B, C, and D.

There is a Medicare Part C, but it is not a separate benefit. Instead, Part C establishes “Medicare Advantage Plans,” an alternative delivery mode for receiving Medicare services. Part C allows beneficiaries to elect to get their care through private managed care organizations.

Medigap:

While Medicare is frequently the primary source of healthcare coverage for people age 65 and over, Medicare provides incomplete healthcare coverage. Under Medicare, not all healthcare services are covered. Additionally, for those services that are covered, you will still have your share of out-of-pocket costs in the form of premiums, co-payments, and deductibles. The amounts of these premiums, co-payments, and deductibles increase each year. Because Medicare does not cover all healthcare services and because there is significant cost sharing for the services that are covered, you may want to supplement your Medicare with other insurance. You may fill these gaps in Medicare coverage with Medicaid (if you qualify), a Medicare Supplemental insurance policy or other insurance coverage.

There are 12 standard Medigap policies a person with Original Medicare can choose from. Click here for Understanding Medigap and Medicare Supplemental Policies.

Medicaid:

Medicaid is a public health insurance program. It is mostly free and is not welfare. In fact, most people on Medicaid receive health insurance coverage only and do not receive welfare in the form of cash benefits. Medicaid in Pennsylvania is also called “Medical Assistance” or “MA.”

To be eligible for Medicaid, you must be a resident of Pennsylvania, meet specific immigration status requirements, fit within a group or category that is covered by Medicaid, and meet the appropriate income and resource requirements. Click here to see our page on Medicaid with more details on Medicaid Eligibility.

There are several categories of Medicaid that cover persons who are age 60 and above. Often, they have different eligibility requirements and different countable income and resource limits. The categories covered on this site include:

These are the most likely categories of coverage for a person age 65 or older. Click here to go to our Medicaid page and get information on all Medicaid categories in Pennsylvania.

Veterans Affairs (VA) Medical Coverage :

The Veteran's Administration provides a standard medical benefits plan which is available to all enrolled veterans. According to the United States Department of Veterans Affairs, in general all veterans who have served on active duty in the armed forces (in war or peacetime) and who received an honorable or general discharge may be eligible to receive medical care through the VA. The medical coverage offered by the VA focuses on preventive as well as primary care and encompasses both inpatient and outpatient services. However, the care/services covered by the VA must be obtained through the VA health system.

While there is no monthly premium for VA care, veterans may have to pay copays. Veterans must complete a means test, which is an annual financial assessment to determine what levels of copays apply to them and to see whether or not they qualify for free services. Free services and/or prescriptions may be offered to veterans who: received a purple heart medal, are former POWs, have compensable service-connected disabilities, or are low income. For a list of the services which are exempt from inpatient and outpatient copays, please contact your local VA office or visit http://www1.va.gov/health/ .

If you cannot afford to pay VA copays, you may request a waiver for the copays you currently owe, request a hardship determination so that copays are not charged, or request a compromise for partial payment.

The VA offers a prescription drug benefit, which is considered creditable coverage. Therefore, if you are enrolled in a VA medical plan with prescription coverage, there will be no penalty if you decline or delay enrollment into a Medicare Part D plan. Please note that an individual can be enrolled in both a Medicare Part D prescription plan and the VA prescription benefit. If an individual has both VA and Medicare prescription coverage, they have to choose what plan to have it written and filled under for every prescription (because a single prescription cannot be covered by both plans). Additionally, VA copays do not count toward Part D true out-of-pocket costs toward catastrophic limit. In other words, expenses incurred because of participation in VA drug coverage do not count towards the donut hole.

PACE, PACENET AND PACE plus MEDICARE

These are programs offered by the Pennsylvania Department of Aging to assist with prescription coverage. PACE and PACENET offer comprehensive prescription coverage to older Pennsylvanians and covers most medications that require prescriptions, including insulin, syringes and insulin needles.  These programs are administered by the Pennsylvania Department of Aging and funded by the Pennsylvania Lottery. 

To be eligible for PACE or PACENET, you must be 65 years of age or older, a Pennsylvania resident for at least 90 days prior to the date of application, and you cannot be enrolled in the Department of Public Welfare's Medicaid prescription benefit.  Eligibility is determined by your previous calendar year's income.  Income limits are different for PACE and for PACENET.

You are eligible for PACE if your total income is $14,500 or less, if you are a single person.  For a married couple, your combined total income must be $17,700 or less. PACENET's income limits are slightly higher than those for PACE. A single person's total income can be between $14,500 and $23,500.  A couple's combined total income can be between $17,700 and $31,500.  Once you are enrolled in either program, a benefit card will be sent to you. 

Resources or assets are not considered for PACE or PACENET eligibility.

PACE and PACENET programs will continue to offer the same prescription benefits that they currently offer. Cardholders will remain enrolled in PACE/PACENET as long as they continue to meet the eligibility guidelines (age, residence & income).
However, effective September 1, 2006 PACE Plus Medicare began to offer a combined prescription benefit with the new Medicare Part D prescription plans and successfully enrolled over 200,000 cardholders into a Part D Partner Plans.

PACENET enrollees who are enrolled in a Part D plan, must pay their Part D Plan Premium. If a PACENET enrollee declines Part D plan enrollment, she must pay the PACENET program a monthly premium of $28.45.

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