Quickscreen Questionnaire

Are You Eligible?

Pennsylvania has many programs that offer free or low cost health care coverage. Answer the questions below to find out if you may be eligible.

Disclaimer: This is a screening tool that the PA Health Law Project has designed, based upon the State’s eligibility rules, to help you to figure out if you may be eligible for free or low-cost health care coverage. These programs are only available to Pennsylvania residents. It is not an official determination of eligibility nor an application for coverage. Only the agencies that administer the programs can make an official determination of eligibility and process applications.

 

Click here to start over at the beginning of the eligibility screening.
Question 1
Please use the grey down arrow to the right to scroll down to and then select the answer that best describes you.
Question 2
Have you been in this immigration status for five years or longer?
Yes:No:
Question 3
Select yes for the answer that best describes your situation. This will determine whether your immigration status affects your eligibility.

Are you pregnant? Yes:
Are you under 21 years of age? Yes:
Are you a veteran or active duty service member? Yes:
Are you a Cuban/Haitian entrant? Yes:
Are you a trafficking victim? Yes:

Question 4
Select yes for the answer that best describes your situation. Please select only one answer. This will determine the category of eligibility for which this tool will screen you. At any time you may return to this page and check your eligibility under another category. To do this, click here.

Are you pregnant? Yes:
Do you have a permanent disability? Yes:
Are you 65 or older? Yes:
Do you have breast or cervical cancer (or a pre-cancerous condition of the breast or cervix)? Yes:

If none of the above choices apply to you, click on the continue button in the bottom right corner of the screen to go on to the next page.
Question 5
Select yes for the answer that best describes your situation. Please select only one answer. This will determine the category of eligibility for which this tool will screen you. At any time you may return to this page and check your eligibility under another category. To do this, click here.

Are you/Is applicant under 21 years old? Yes:
Are you an adult with children under 19 in your household? Yes:

If none of the above choices apply to you, click on the continue button in the bottom right corner of the screen to go on to the next page.
Question 6
Medical Assistance eligibility can be based on a medical condition or on something that is happening in your life, such as domestic violence. The following questions will help to determine if you are eligible for Medical Assistance due to the existence of one of these conditions.
Select yes for the answer that best describes your situation. Please select only one answer. This will determine the category of eligibility for which this tool will screen you. At any time you may return to this page and check your eligibility under another category. To do this, click here.

Do you have a medical condition that keeps you from being able to work? Yes:
Do you take medication without which you would be unable to work? Yes:
Do you have HIV or AIDS? Yes:
Do you care for an unrelated child in your home who is under 13 or for an adult in your home who is disabled? Yes:
Are you in a drug and/or alcohol treatment program? Yes:
Are you a victim of domestic violence in protective services? Yes:

If none of the above choices apply to you, click on the continue button in the bottom right corner of the screen to go on to the next page.
Question 7
Select yes for the answer that best describes your situation. Please select only one answer. This will determine the category of eligibility for which this tool will screen you. At any time you may return to this page and check your eligibility under another category. To do this, click here.

Do you work at least 40 hours per month? Yes:
Are you between 59-64 years old? Yes:

If none of the above choices apply to you, click on the continue button in the bottom right corner of the screen to go on to the next page.
Question 1
Are you married and living with your spouse?
(If you are separated from and no longer living with your spouse, answer "no" here and do not include his or her income information in the upcoming questions about household income.)
Yes:No:
Question 2
How many kids do you have in your household?
Question 3
What are the ages of your kids? (if less than 12 months old, please enter 0)
Question 4
If your monthly income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage you to apply. Click here if you want to apply now on the computer.

If your monthly household income is higher than the amount that you see, you might still be eligible for Medical Assistance. To find out if you are, click here.
Question 5
If you receive child support or alimony each month, enter the total monthly amount that you receive here.
Please enter 0 if you receive nothing.
Question 6
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Question 7
Enter the amount that you and other family members in your household receive each month from:

(Do not include the income of a child who is: 1) A full time student; 2) A part-time student working part-time; 3) In the Job Corps; or 4) Not a student, but age 17 or younger and in the JTPA program.)
Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Question 8
Enter the amount that you pay each month for child care when you are at work for your:
Please enter 0 for each child if you pay nothing.
Question 9
How many, if any, sick or disabled adults are there in your household that you must pay for to be cared for while you are at work? Please enter 0 for none.
Question 10
Enter the amount that you pay each month to have each sick adult member/s of your household cared for while you are at work:
Question 11
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Are one or more of these children related to you and under your care and control?
Yes:No:
Question 2
How many of the children related to you or under your care or control are under 19?
Question 3
What are the ages of the kids? (if less than 12 months old, please enter 0)
Question 4
Are you married and living with your spouse?
(If you are separated from and no longer living with your spouse, answer "no" here and do not include his or her income information in the upcoming questions about household income.)
Yes:No:
Question 5
Do you or your spouse have a disability?
Yes:No:
Question 6
Is the person in your household who usually earns the most money presently unemployed?
Yes:No:
Question 7
If your monthly income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage you to apply. Click here if you want to apply now on the computer.

If your monthly household income is higher the amount that you see, you might still be eligible for Medical Assistance. To find out if you are, click here.
Question 8
If you receive child support or alimony each month, enter the total monthly amount that you receive here.
Please enter 0 if you receive nothing.
Question 9
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Question 10
How many, if any, family members in your household including yourself have any of the following types of income:

(Do not include the income of a child who is: 1) A full time student; 2) A part-time student working part-time; 3) In the Job Corps; or 4) Not a student, but age 17 or younger and in the JTPA program.)
Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Question 11
For each person with one of those types of income, please enter his or her name next to the type of income received by that person.
Question 12
Please enter the monthly amount of money (before taxes) that:

Please enter 0 for none.
Question 13
Please enter the total monthly taxes taken from:

Please enter 0 for none.
Question 14
Please enter monthly work-related transportation costs, if any, for:

Please enter 0 for none.
Question 15
Enter the amount that you pay each month for child care when you are at work for your:
Please enter 0 for each child if you pay nothing.
Question 16
How many, if any, sick or disabled adults are there in your household that you must pay for to be cared for while you are at work? Please enter 0 for none.
Question 17
Enter the amount that you pay each month to have each sick adult member/s of your household cared for while you are at work:
Question 18
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Do you have a severe physical or mental disability?
Yes:No:
Question 2
Is your own income less than $908/month? (Do not count your parents' income. Do not count Social Security Survivor's benefits that are made in your name due to the death of a parent. Do not count support payments made to one parent by the other.)
Yes:No:
Question 3
Are you/applicant 19 or 20 years old?
Yes:No:
Question 4
How many people are in your household? (Include: parents (if you are still financially dependent on them and under their care and control); spouse; children; and siblings.) Make sure to count yourself, the applicant as one member of the household.
Question 5
How many kids, if any, do you have?
Question 6
What are the ages of your kids? (if less than 12 months old, please enter 0)
Question 7
If your monthly income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage you to apply. Click here if you want to apply now on the computer.

If your monthly household income is higher than , you might still be eligible for Medical Assistance. To find out if you are, click here.
Question 8
Enter the total monthly amount (if any) of child support or alimony that you receive each month.
Please enter 0 if you receive nothing.
Question 9
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Question 10
How many, if any, family members in your household including yourself have any of the following types of income:

(Do not include the income of a child who is: 1) A full time student; 2) A part-time student working part-time; 3) In the Job Corps; or 4) Not a student, but age 17 or younger and in the JTPA program.)
Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Question 11
For each person with one of those types of income, please enter his or her name next to the type of income received by that person.
Question 12
Please enter the monthly amount of money (before taxes) that:

Please enter 0 for none.
Question 13
Please enter the total monthly taxes taken from:

Please enter 0 for none.
Question 14
Please enter monthly work-related transportation costs, if any, for:

Please enter 0 for none.
Question 15
Enter the amount that you pay each month for child care when you are at work for your:
Please enter 0 for each child if you pay nothing.
Question 16
How many, if any, sick or disabled adults are there in your household that you must pay for to be cared for while you are at work? Please enter 0 for none.
Question 17
Enter the amount that you pay each month to have each sick adult member/s of your household cared for while you are at work:
Question 18
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Is applicant 18 years or younger?
Yes:No:
Question 2
How many people are in your household? (Include: parents (if applicant is still financially dependent on them and under their care and control), spouse, children, and siblings.)
Question 3
How many kids, if any, do applicant or other household members have?
Question 4
What are the ages of these kids? (if less than 12 months old, please enter 0)
Question 5
If monthly household income* is less than $------, it is very likely that applicant is eligible for free or low-cost health care coverage through Medical Assistance or CHIP, and we encourage you to apply for him/her.
* Include income of the same household members that you included in determining the household number unless any of these household members are children (18 or under) who are full or part time students. Then their earned income should not be included. Also, do not include any SSI or cash benefits received by household members.

Click here if you want to apply now on the computer.

If your monthly household income is higher than the amount that you see, CHIP is still available at cost. To find out more information about at cost CHIP, click here. You might still be eligible for Medical Assistance. To find out if you are, click here.
Question 6
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Child Support:
Alimony:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Question 7
Enter the amount that you and other family members in your household receive each month from:

(Do not include the income of a child who is a full or part time student.)
Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Other:
Question 8
How many people in applicant’s household are working? Please enter 0 for none.
Question 9
Enter the amount that you pay each month for child care when you are at work for your:
Please enter 0 for each child if you pay nothing.
Question 10
How many, if any, sick or disabled adults are there in your household that you must pay for to be cared for while you are at work? Please enter 0 for none.
Question 11
Enter the amount that you pay each month to have each sick adult member/s of your household cared for while you are at work:
Question 12
Program Description
There is a program of coverage for women with breast or cervical cancer in PA called the Breast and Cervical Cancer Prevention and Treatment Program (BCCPT).

If you meet the following requirements, you are eligible for this coverage.

You:
  • are a woman under age 65;
  • are a PA resident;
  • are uninsured (or at least do not have insurance that will pay for your cancer treatment); and
  • have a household income under 250% of the federal poverty level (FPL) (see chart below)
# in HouseholdMonthly Income Limit at 250% FPL
1$2,269
2$3,065
3$3,861
4$4,657
5$5,453
6$6,248
7$7,044
8$7,840

If you meet all of these requirements, please click here to find out how to apply for this coverage.
If you do not meet these criteria, and you want to continue with a screening for eligibility under other categories of Medical Assistance, please click here.
Question 2
To apply for the BCCPT Program, ask your health care provider to complete a BCCPT application (PA 600B). You can find the application, and instructions on completing the application, here.

Your health care provider should fax the completed application to the HWP Case Management Team at Adagio Health (fax: 412-201-4702 / phone: 800-215-7494).

If you have any questions about this program, please call the PA Health Law Project at (800) 274-3258.
Question 1
Are you married and living with your spouse?
(If you are separated from and no longer living with your spouse, answer "no" here and do not include his or her income information in the upcoming questions about household income.)
Yes:No:
Question 2
How many kids under 21 are there in your household who are either related to you or unrelated but under your care and control?
Question 3
What are the ages of your children who are under 21? (if less than 12 months old, please enter 0)
Question 4
Do you have less than the allowable resource limit shown below for the number in your household?
(Resources are things you own. When you count your resources, do not include your home, one car or personal items, such as jewelry or clothes. Do include money, bank accounts, second cars, other real estate, stocks, etc.)
 
# in Household*Resource Limit
1$2,400
2$3,200
3$3,500
4$3,800
5$4,100
6$4,400
7$4,700
8$5,000
*Include yourself, spouse and kids under your care and control for number in household.
Yes:No:
Question 5
If your monthly income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage you to apply. Click here if you want to apply now on the computer.

If your monthly household income is higher than the amount that you see, you might still be eligible for Medical Assistance. To find out if you are, please continue.
Question 6
Enter the total monthly amount (if any) of child support or alimony that you receive each month.
Please enter 0 if you receive nothing.
Question 7
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 8
How many, if any, family members in your household including yourself have any of the following types of income:

(Do not include the income of a child who is: 1) A full time student; 2) A part-time student working part-time; 3) In the Job Corps; or 7) Not a student, but age 17 or younger and in the JTPA program.)
Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Question 9
For each person with one of those types of income, please enter his or her name next to the type of income received by that person.
Question 10
Please enter the monthly amount of money (before taxes) that:

Please enter 0 for none.
Question 11
Please enter the total monthly taxes taken from:

Please enter 0 for none.
Question 12
Please enter monthly work-related transportation costs, if any, for:

Please enter 0 for none.
Question 13
Enter the amount that you pay each month for child care when you are at work for your:
Please enter 0 for each child if you pay nothing.
Question 14
How many, if any, sick or disabled adults are there in your household that you must pay for to be cared for while you are at work? Please enter 0 for none.
Question 15
Enter the amount that you pay each month to have each sick adult member/s of your household cared for while you are at work:
Question 16
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Are you pursuing or receiving protective services because you are a victim of domestic violence? ("Protective services" may include emergency shelter, counseling at an abuse program, filing assault or battery charges at the police department, requesting restraining orders or peace bonds, services to prevent further abuse, services necessary to remain safely at home, or any other government services aimed at counseling or protecting you as a victim of domestic violence.)
Yes:No:
Question 2
Are you married and living with your spouse?
(If you are separated from and no longer living with your spouse, answer "no" here and do not include his or her income information in the upcoming questions about household income.)
Yes:No:
Question 3
How many kids under 21 are there in your household who are either related to you or unrelated but under your care and control?
Question 4
What are the ages of your kids? (if less than 12 months old, please enter 0)
Question 5
Do you have less than $250 in resources (if you live alone) or less than $1,000 in resources (if there is more than one person in your household)?
(Resources are things you own. When counting your resources, do not include your home, one car or personal items, such as jewelry or clothes. Do include money, bank accounts, second cars, other real estate, stocks, etc)
Question 6
What County do you live in?
Question 7
If your monthly household income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage you to apply.

Instructions for How to Apply:
It is important to mention that you are in domestic violence protective services when you apply for benefits, as this will make you categorically eligible. This information is required to be treated with complete confidentiality by the County Assistance Office case workers. They will confirm these protective services once you have submitted your application.

Click here if you want to apply now on the computer. If you do complete a computer application, in the end of the application when it asks for additional information, general comments, or if there are any special circumstances that need to be considered, once again be sure to write that you are in domestic violence protective services as it will make you categorically eligible. They will confirm these protective services once you have submitted your application.

If your monthly household income is higher than the amount that you see, you might still be eligible for Medical Assistance. To find out if you are, please continue.
Question 8
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 9
How many, if any, family members in your household including yourself have any of the following types of income:

Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Question 10
For each person with one of those types of income, please enter his or her name next to the type of income received by that person.
Question 11
Please enter the monthly amount of money (before taxes) that:

Please enter 0 for none.
Question 12
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Do you require health sustaining medications in order to maintain your employment? (Meaning, are you able to work but only with the assistance of health sustaining medications?)
Yes:No:
Question 2
Are you married and living with your spouse?
(If you are separated from and no longer living with your spouse, answer "no" here and do not include his or her income information in the upcoming questions about household income.)
Yes:No:
Question 3
How many kids under 21 are there in your household who are either related to you or unrelated but under your care and control?
Question 4
What are the ages of your kids? (if less than 12 months old, please enter 0)
Question 5
Do you have less than $250 in resources (if you live alone) or less than $1,000 in resources (if there is more than one person in your household)?
(Resources are things you own. When counting your resources, do not include your home, one car or personal items, such as jewelry or clothes. Do include money, bank accounts, second cars, other real estate, stocks, etc)
Question 6
What County do you live in?
Question 7
If your monthly household income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage to you apply.

Instructions for How to Apply:
In order to get approved for Medical Assistance, you will need to have a doctor fill out a form, called a Health Sustaining Medications Form. On this form the doctor must state that you need to take certain medication/s and without this medication you would be unable to work. You do not have to be working at the time of application to be eligible for this coverage. You must then submit this form with your application. To get one of these forms, either go to your local County Assistance Office and request one, or call the PA Health Law Project at (800) 274-3258. Or if you have access to a printer at the present time, click here to print one out.

Click here if you want to apply now on the computer. If you do apply by computer, you must submit your completed Health Sustaining Medications Form with your proof of income and signature sheet that you will be sending in to complete your computer application.

If your monthly household income is higher than the amount that you see, you might still be eligible for Medical Assistance. To find out if you are, please continue.
Question 8
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 9
How many, if any, family members in your household including yourself have any of the following types of income:

Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Question 10
For each person with one of those types of income, please enter his or her name next to the type of income received by that person.
Question 11
Please enter the monthly amount of money (before taxes) that:

Please enter 0 for none.
Question 12
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Are there any kids under 13 in your household who are not your natural or adoptive children but who are under your care and control?
Yes:No:
Question 2
Are there any persons in your household that are ill or disabled and that require your care? (Are you needed in the home to care for an ill or disabled person?)
Yes:No:
Question 3
Are you married and living with your spouse?
(If you are separated from and no longer living with your spouse, answer "no" here and do not include his or her income information in the upcoming questions about household income.)
Yes:No:
Question 4
How many children under 21 in your household who are either related to you or under your care or control?
Question 5
How many persons are there in your household who are ill or disabled (but do not count someone who is already counted as a spouse or child under 21)?
Question 6
Do you have less than $1000 in resources (if you live alone) or less than $1,000 in resources (if there is more than one person in your household)?
(Resources are things you own. When counting your resources, do not include your home, one car or personal items, such as jewelry or clothes. Do include money, bank accounts, second cars, other real estate, stocks, etc)
Question 7
What County do you live in?
Question 8
If your monthly household income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage to you apply.

Instructions on How to Apply:
If you are caring for someone in your home who is ill or disabled, you will need to submit a letter from a doctor along with your application stating that the person who you are caring for is ill or disabled, and stating also the kind of care that you provide to this person. (For example: bathing, feeding, or safety.) You must also be able to show that there is no one else in the house who can provide those services.

Click here if you want to apply now on the computer. If you do apply by computer, you must submit the letter from the doctor with the proof of income and signature page that you send in to complete the application.

If your monthly household income is higher than the amount that you see, you might still be eligible for Medical Assistance. To find out if you are, please continue.
Question 9
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 10
How many, if any, family members in your household including yourself have any of the following types of income:

Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Question 11
For each person with one of those types of income, please enter his or her name next to the type of income received by that person.
Question 12
Please enter the monthly amount of money (before taxes) that:

Please enter 0 for none.
Question 13
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Do you receive or have you received SSI or SSDI from the Social Security Administration? (Or, have you been found permanently and totally disabled by the Social Security Administration?)
Yes:No:
Question 2
Do you have a physical or mental impairment that keeps you from working?
Yes:No:
Question 3
Will this physical or mental impairment keep you from being able to work for at least 12 months?
Yes:No:
Question 4
Are you married and living with your spouse?
(If you are separated from and no longer living with your spouse, answer "no" here and do not include his or her income information in the upcoming questions about household income.)
Yes:No:
Question 5
How many kids under 21 are there in your household who are either related to you or unrelated but under your care and control?
Question 6
What are the ages of your kids? (if less than 12 months old, please enter 0)
Question 7
Do you have less than $250 in resources (if you live alone) or less than $1,000 in resources (if there is more than one person in your household)?
(Resources are things you own. When counting your resources, do not include your home, one car or personal items, such as jewelry or clothes. Do include money, bank accounts, second cars, other real estate, stocks, etc)
Question 8
What County do you live in?
Question 9
If your monthly household income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage to you apply.

Instructions for How to Apply:
In order to get approved for Medical Assistance, you will need to have a doctor fill out a form, called an Employability Assessment Form. On this form the doctor must indicate that you are unable to work due to an illness or condition. You must then submit the form with your application. To get one of these forms, either go to your local County Assistance Office and request one, or call the PA Health Law Project at (800) 274-3258. Or if you have access to a printer at the present time, click here to print one out.

Click here if you want to apply now on the computer. If you do apply by computer, you must submit your completed Employability Assessment Form with your proof of income and signature sheet that you will be sending in to complete your computer application.

If your monthly household income is higher than the amount you see above, you might still be eligible for Medical Assistance. To find out if you are, please continue.
Question 10
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 11
How many, if any, family members in your household including yourself have any of the following types of income:

Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Question 12
For each person with one of those types of income, please enter his or her name next to the type of income received by that person.
Question 13
Please enter the monthly amount of money (before taxes) that:

Please enter 0 for none.
Question 14
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Does your participation in the drug and/or alcohol treatment program prevent or prohibit you from being able to work?
Yes:No:
Question 2
Are you married and living with your spouse?
(If you are separated from and no longer living with your spouse, answer "no" here and do not include his or her income information in the upcoming questions about household income.)
Yes:No:
Question 3
How many kids under 21 are there in your household who are either related to you or unrelated but under your care and control?
Question 4
What are the ages of your kids? (if less than 12 months old, please enter 0)
Question 5
Do you have less than $250 in resources (if you live alone) or less than $1,000 in resources (if there is more than one person in your household)?
(Resources are things you own. When counting your resources, do not include your home, one car or personal items, such as jewelry or clothes. Do include money, bank accounts, second cars, other real estate, stocks, etc)
Question 6
What County do you live in?
Question 7
If your monthly household income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage to you apply.

Instructions for How to Apply:
You should mention that you are in a drug and/or alcohol treatment program when you apply for benefits, as this will make you categorically eligible for coverage. The CAO will give you a form to have filled out by someone in your program, which will confirm your treatment.

Click here if you want to apply now on the computer. If you do complete a computer application, in the end of the application when it asks for additional information, general comments, or if there are any special circumstances that need to be considered, be sure to write that you are in active treatment in a drug and/or alcohol program. The CAO should then provide you with a form to have completed by someone in your drug and/or alcohol treatment program.

If your monthly household income is higher than the amount that you see, you might still be eligible for Medical Assistance. To find out if you are, please continue.
Question 8
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 9
How many, if any, family members in your household including yourself have any of the following types of income:

Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Question 10
For each person with one of those types of income, please enter his or her name next to the type of income received by that person.
Question 11
Please enter the monthly amount of money (before taxes) that:

Please enter 0 for none.
Question 12
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Are you between 19 and 64 years old?
Yes:No:
Question 2
Have you lived in Pennsylvania for the last 90 days?
Yes:No:
Question 3
Have you had insurance coverage within the last 90 days?
Yes:No:
Question 4
Was the insurance that you had within the last 90 days Medical Assistance or CHIP?
Question 5
Did you lose your insurance because you or your spouse lost your job?
Yes:No:
Question 6
Are you married and living with your spouse?
(If you are separated from and no longer living with your spouse, answer "no" here and do not include his or her income information in the upcoming questions about household income.)
Yes:No:
Question 7
How many kids do you have in your household?
Question 8
What are the ages of these kids? (if less than 12 months old, please enter 0)
Question 9
If monthly household income is less than $------, it is very likely that you are eligible for the Adult Basic coverage program and we encourage to you apply. Please note, though, that this program has a limited number of slots. This means that even if you are eligible, you might have to wait for several months on a waiting list before you actually get health care coverage.

Click here if you want to apply now on the computer.

If your monthly household income is higher than the amount that you see, you might still be eligible for ABC. To find out if you are, please click here.
Question 10
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 11
Enter the amount that you and other family members in your household receive each month from:

(Do not include the income of a child who is a full or part time student.)
Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Other:
Question 12
How many people in applicant’s household are working? Please enter 0 for none.
Question 13
Enter the amount that you pay each month for child care when you are at work for your:
Please enter 0 for each child if you pay nothing.
Question 14
How many, if any, sick or disabled adults are there in your household that you must pay for to be cared for while you are at work? Please enter 0 for none.
Question 15
Enter the amount that you pay each month to have each sick adult member/s of your household cared for while you are at work:
Question 16
Question 1
Are you married and living with your spouse?
(If you are separated from and no longer living with your spouse, answer "no" here and do not include his or her income information in the upcoming questions about household income.)
Yes:No:
Question 2
How many kids under 21 are there in your household who are either related to you or unrelated but under your care and control?
Question 3
Do you have symptomatic HIV or AIDS?
Yes:No:
Question 4
Do you have less than $250 in resources (if you live alone) or less than $1,000 in resources (if there is more than one person in your household)?
(Resources are things you own. When counting your resources, do not include your home, one car or personal items, such as jewelry or clothes. Do include money, bank accounts, second cars, other real estate, stocks, etc)
Yes:No:
Question 5
What County do you live in?
Question 6
If your monthly household income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage to you apply.

However, in order to get approved for Medical Assistance, you will need to have a doctor fill out a form, called an Employability Assessment Form, which indicates that you are temporarily unable to work due to an illness or a condition. To get one of those forms, either go to your local County Assistance Office and request one, or call the PA Health Law Project at (800) 274-3258. Or if you have access to a printer at the present time, click here to print one out.

Click here if you want to apply now on the computer. If you do apply by computer, you must submit your completed Employability Assessment Form with your proof of income and signature sheet that you will be sending in to complete your computer application.

If your monthly household income is higher than the amount that you see, you might still be eligible for Medical Assistance because of the way that income is actually counted. To find out if you are, please continue.
Question 7
Enter the amount, if any, that you and other family members in your household receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 8
How many, if any, family members in your household including yourself have any of the following types of income:

Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Question 9
For each person with one of those types of income, please enter his or her name next to the type of income received by that person.
Question 10
Please enter the monthly amount of money (before taxes) that:

Please enter 0 for none.
Question 11
Please enter the amount of medical bills, if any, that you or anyone in your household presently owes.
Please enter 0 for none.
Question 12
Question 13
Are you on SSI?
Yes:No:
Question 14
Do you need supportive services in your home, such as skilled nursing, home health care, or help with dressing, bathing, transferring, walking, or toileting in order to be able to remain in your home?
Yes:No:
Question 15
Do you have any other form of insurance that pays for inpatient benefits?
Yes:No:
Question 16
Does your spouse also have symptomatic HIV or AIDS?
Yes:No:
Question 17
Does your spouse also have a need for some sort of health care in your home, such as skilled nursing or a home health aide, in order to be able to remain in your home?
Yes:No:
Question 18
Yes:No:
Question 19

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 20

Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Other:
Question 21
Special Pharmaceutical Benefits Program
The Special Pharmaceutical Benefits Program (SPBP) is a program by the state that pays for certain HIV/AIDS drug therapies for people with a diagnosis of HIV or AIDS who meet program requirements.

The program requirements are as follows:

Income limits:
# in HouseholdYearly Income Limit
1$30,000
2$32,480
3$34,960
4$37,440
5$39,920
6$42,400
7$44,880
8$47,360

Residence:
You must be a resident of, or live in, Pennsylvania.

Medical Need:
You must have a medical need for HIV/AIDS drug therapies covered by this program, and have a diagnosis of HIV/AIDS.

If you meet the above three qualifications, you should be eligible for this Pharmaceutical Benefits Program. To apply, you can either download an application from here if you have access to a printer, or you can get an application from your local County Assistance Office, community-based AIDS service organizations, Department of Health clinics, hemophilia centers, some doctors' offices, pharmacies, or local mental health providers. You can also call or write to the SPBP Program for an application. The SPBP Program phone number is 1(800) 922-9384 or 1(717) 772-6228 (Harrisburg area). The address is:

Department of Public Welfare
SPBP
P.O. Box 8021
Harrisburg, PA 17105-8021

If you have any questions about this program, please call the PA Health Law Project at (800) 274-3258.
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Are you under 21?
Yes:No:
Question 2
Do you receive or have you received SSI or SSDI from the Social Security Administration? (Or, have you been found permanently and totally disabled by the Social Security Administration?)
Yes:No:
Question 3
Do you have a physical or mental impairment that keeps you from working and will last at least 12 months?
Yes:No:
Question 4
Do you need supportive services in your home, such as skilled nursing, home health aide, or help with dressing, bathing, transferring, walking, or toileting?
Yes:No:
Question 5
Do you work or are you able to work at all (this could be just a few hours a month)?
Yes:No:
Question 6
Are you married and does your spouse live with you?
Yes:No:
Question 7
Is your spouse over 65 OR Does he/she have a permanent disability (such that he/she receives SSI, SSDI, or MA as a person with a permanent disability)?
Question 8
Are you applying for your spouse as well?
Yes:No:
Question 9
Do you have children under 21 who live in your household and are under your care and control?
Yes:No:
Question 10
Yes:No:
Question 11
If your monthly household income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage to you apply.

However, if you have not already been found disabled by the Social Security Administration (meaning you do not or have not recently received SSI or SSDI payments), in order to get approved for Medical Assistance in this category, you will need to have a doctor fill out a form, called an Employability Assessment Form. On this form the doctor must indicate that you are unable to work, due to an illness or condition, either permanently or for 12 months or more. You must then submit the form with your application. To get one of these forms, either go to your local County Assistance Office and request one, or call the PA Health Law Project at (800) 274-3258. Or if you have access to a printer at the present time, click here to print one out.

Click here if you want to apply now on the computer. If you do apply by computer, you must submit your completed Employability Assessment Form with your proof of income and signature sheet that you will be sending in to complete your computer application.

If your monthly household income is higher than , you might still be eligible for Medical Assistance. To find out if you are, please continue.
Question 12
Please enter the amounts, if any, received each month from:

  You Spouse
(if you are married and your spouse lives with you)
Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 13
Please enter the amounts, if any, received each month from:

  You Spouse
(if you are married and your spouse lives with you)
Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Other:
Question 14
Yes:No:
Question 15
Please enter the amount, if any, spent on impairment related work expenses each month.
Please enter 0 for none.

You Spouse
(if you are married and your spouse lives with you)
Question 16
Question 17
Do you and/or your spouse (if applicable) have Medicare?
Yes:No:
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Are you married and living with your spouse?
(If you are separated from and no longer living with your spouse, answer "no" here and do not include his or her income information in the upcoming questions about household income.)
Yes:No:
Question 2
Does your spouse have a disability and need supportive services in the home?
Yes:No:
Question 3
Do you have children under 21 who live in your household and are related to you or are under your care and control?
Yes:No:
Question 4
Yes:No:
Question 5
Question 6
Enter the amount, if any, that you receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 7
Enter the amount, if any, that you receive each month from:

Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Other:
Question 8
Do you have any impairment related work expenses? These include expenses you pay for devices or services that you require because of your disability but that enable you to work, such as an attendant that helps you get ready for work and for bed when you get home or a modification to a work appliance like a typewriter, etc.
Yes:No:
Question 9
How much do you spend on impairment related work expenses each month? Please enter 0 for none.
Question 10
Are you blind?
Yes:No:
Question 11
Do you have any work expenses due to being blind? (For example, do you have a guide dog and upkeep expenses, pay for public transportation to work, require translation of materials into Braille, pay for lunches, have federal, state, local, FICA, and self-employment taxes withheld from your pay?)
Yes:No:
Question 12
Please enter the amount of all of your work expenses due to being blind? Please enter 0 for none.
Question 13
Enter the amount, if any, that your spouse receives each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 14
Enter the amount, if any, that your spouse receives each month from:

Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Other:
Question 15
Does your spouse have any impairment related work expenses? These include expenses you pay for devices or services that you require because of your disability but that enable you to work, such as an attendant that helps you get ready for work and for bed when you get home or a modification to a work appliance like a typewriter, etc.
Yes:No:
Question 16
How much does your spouse spend on impairment related work expenses each month? Please enter 0 for none.
Question 17
Does your spouse have any work expenses due to being blind? (For example, does your spouse have a guide dog and upkeep expenses, pay for public transportation to work, require translation of materials into Braille, pay for lunches, have federal, state, local, FICA, and self-employment taxes withheld from his/her pay?)
Yes:No:
Question 18
Please enter the amount of all of your blind spouse’s expenses? Please enter 0 for none.
Question 19
Question 20
Do you need assistance with the following daily activities (answer yes if you need any assistance, even if not complete assistance but just a little):
  • dressing (enter yes if you need complete assistance or if you can put your shirt and pants on but not your socks and shoes)
  • bathing (enter yes if you need complete assistance or if you can wash yourself once you are in the bathtub but need assistance to get in and out)
  • transferring (enter yes if you need complete assistance or if you need assistance getting in and out of a chair, wheelchair, bed, etc.)
  • walking (enter yes if you need complete assistance or if you need assistance or stand-by support getting around your home or neighborhood, etc.)
  • toileting (e.g. you cannot complete all parts of toileting without some assistance, etc.)
Yes:No:
Question 21
Do you need skilled nursing in your home?
Yes:No:
Question 22
Do you need a home health aide in your home?
Yes:No:
Question 23
How old are you?
Question 24
Are you Deaf?
Yes:No:
Question 25
Are you Blind?
Question 26
Are you technology dependent? (Do you require a technology device to sustain life or replace a vital bodily function? Examples include persons who are ventilator dependent, etc.)
Question 27
Do you have HIV/AIDS?
Yes:No:
Question 28
Are you age 21 or older?
Question 29
Are you a person with a physical disability?
Yes:No:
Question 30
Are you age 18 or older?
Yes:No:
Question 31
Are you mentally alert (or capable of directing your own care?)
Question 32
Do you have Traumatic Brain Injury?
Question 33
Is your physical disability likely to continue indefinitely?
Yes:No:
Question 34
Does your disability (or do your disabilities) result in substantial functional limitations in three or more major life activities?
Question 35
Is your primary diagnosis (from which the need for services arises) a mental health or mental retardation diagnosis?
Question 36
Are you a person with a developmental disability?
Yes:No:
Question 37
Did the disability manifest itself before you turned 22?
Question 38
Do you have a severe disability that is likely to continue indefinitely?
Question 39
Does your disability (or do your disabilities) result in substantial functional limitations in three or more major life activities?
Question 40
Is your primary diagnosis (from which the need for services arises) a mental health or mental retardation diagnosis?
Yes:No:
Question 41
Are you currently in a nursing home?
Yes:No:
Question 42
Have you been found eligible for an ICF/ORC level of care?
Question 43
Are you a person with mental retardation?
Yes:No:
Question 44
Are you age 3 years or older?
Question 45
Are you age 60 or older?
Question 46
Do you have disabilities or have you been found eligible for care in a nursing home (but would rather receive services in your own home)?
Question 1
Are you between the ages of 16 and 64?
Yes:No:
Question 2
Are you married and does your spouse live with you?
Yes:No:
Question 3
Yes:No:
Question 4
If your monthly household income is less than , it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage to you apply.

Click here if you want to apply now on the computer.

If your monthly household income is higher than the amount that you see, you might still be eligible for Medical Assistance for a Workers with Disabilities because of the way that household income is actually counted. To find out if you are, please continue.
Question 5
Enter the total monthly amount (if any) of child support or alimony that you receive each month.
Please enter 0 if you receive nothing.
Question 6
Enter the amount, if any, that you receive each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 7
Enter the amount, if any, that you receive each month from:

Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Other:
Question 8
Do you have any impairment related work expenses? These include expenses you pay for devices or services that you require because of your disability but that enable you to work, such as an attendant that helps you get ready for work and for bed when you get home or a modification to a work appliance like a typewriter, etc.
Yes:No:
Question 9
How much do you spend on impairment related work expenses each month? Please enter 0 for none.
Question 10
Are you blind?
Yes:No:
Question 11
Do you have any work expenses due to being blind? (For example, do you have a guide dog and upkeep expenses, pay for public transportation to work, require translation of materials into Braille, pay for lunches, have federal, state, local, FICA, and self-employment taxes withheld from your pay?)
Yes:No:
Question 12
Please enter the amount of all of your expenses due to being blind? Please enter 0 for none.
Question 13
Enter the amount, if any, that your spouse receives each month from:

Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 14
Enter the amount, if any, that your spouse receives each month from:

Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Other:
Question 15
Does your spouse have any impairment related work expenses? These include expenses you pay for devices or services that you require because of your disability but that enable you to work, such as an attendant that helps you get ready for work and for bed when you get home or a modification to a work appliance like a typewriter, etc.
Yes:No:
Question 16
How much does your spouse spend on impairment related work expenses each month? Please enter 0 for none.
Question 17
Does your spouse have any work expenses due to being blind? (For example, does your spouse have a guide dog and upkeep expenses, pay for public transportation to work, require translation of materials into Braille, pay for lunches, have federal, state, local, FICA, and self-employment taxes withheld from his/her pay?)
Yes:No:
Question 18
Please enter the amount of all of your blind spouse’s expenses? Please enter 0 for none.
Question 19
Question 1
Do you need supportive services in your home, such as skilled nursing, home health aide, or help with dressing, bathing, transferring, walking, or toileting?
Yes:No:
Question 2
Are you married and does your spouse live with you?
Yes:No:
Question 3
Is your spouse over 65 OR Does he/she have a permanent disability (such that he/she receives SSI, SSDI, or MA as a person with a permanent disability) OR is your spouse blind?
Question 4
Are you applying for your spouse as well?
Yes:No:
Question 5
Do you have children under 21 who live in your household and are under your care and control?
Yes:No:
Question 6
Question 7
If your monthly household income is less than $------, it is very likely that you are eligible for free health care coverage through Medical Assistance and we encourage to you apply.

Click here if you want to apply now on the computer.

If your monthly household income is higher than the amount that you see, you might still be eligible for Medical Assistance. To find out if you are, please continue.
Question 8
Please enter the amounts, if any, received each month from:

  You Spouse
(if you are married and your spouse lives with you)
Social Security Benefits (RSDI) (Do not include SSI):
Social Security Disability:
Retirement benefits:
Pension:
Annuities:
Unemployment Compensation:
Workers Compensation:
Veterans Affairs benefits:
Dividends, royalties or interest payments:
Contributions (payments from people other than child support or alimony):
Educational assistance (do not include government loans or grants):
Children's unearned income (such as Survivor's benefits or VA benefits):
Rental income if the rental property is managed by someone else:
Inheritance:
Prizes/awards:
Child Support:
Alimony:
Question 9
Please enter the amounts, if any, received each month from:

  You Spouse
(if you are married and your spouse lives with you)
Income from a job:
Profit from self-employment:
Commissions or bonuses:
Sheltered workshop or work activities center income:
Employee sick benefits (if you plan to return to work):
Earnings from therapeutic activities:
Rental income (unless rental unit managed by someone else. Then count as unearned income.):
Other:
Question 10
Yes:No:
Question 11
Please enter the amount, if any, spent on impairment related work expenses each month.
Please enter 0 for none.

You Spouse
(if you are married and your spouse lives with you)
Question 12
Question 13
Do you and/or your spouse (if applicable) have Medicare?
Yes:No:
Spend-Down to MA Eligibility
A person who would be eligible for Medical Assistance in a given category but has too much monthly income to meet that category’s requirements, may still be eligible for that category of Medical Assistance for a select period of time if
  • they have Medical Expenses that are due, were paid within the past 3 months, or are ongoing (examples include: a $2000 bill from 2 months ago that has not been paid, a $150 bill that was just paid last week, or monthly prescription drug costs of $275) AND
  • these Medical Expenses, when deducted from the individual’s (or household’s) countable income, would reduce that income enough that the final amount of income is less than the income limit for that category.
Persons with large outstanding bills may qualify for several months of Medical Assistance through Spend-Down. Persons with large enough monthly Medical Expenses may qualify for Medical Assistance each month through Spend-Down.

To apply for spend-down, click here. Or, you can apply at your local county assistance office. When you submit your verification, be sure to submit evidence of your Medical Expenses and indicate that if you are not found eligible for ongoing Medical Assistance you are interested in applying for “Spend-Down”.
Question 1
Do you and/or your spouse have a Medicare Part D Prescription plan?
Yes:No:
Question 2
Please click YES if one of the following applies to you.
  • You receive Supplemental Security Income payments AND have Medicare
  • You receive Medical Assistance (ACCESS) and have Medicare
  • Your State pays your Medicare premiums
Yes:No:
Question 3
Is your monthly income less than $1,226/month (for a single person) or less than $1,656/month (for a married couple)?
Yes:No:
Question 4
Are your resources less than $8,180 (if you are single) or less than $13,020 (if you are married)? (Resources are things you own. When you count your resources, do not include your home, cars or personal items, such as jewelry or clothes. Do include money, bank accounts, other real estate, stocks, etc.)
Yes:No:
Question 5
Is your income less than $1,361/month (if you are single) or less than $1,839/month (if you are married)?
Yes:No:
Question 6
Are your resources less than $12,640 (if you are single) or less than $25,260 (if you are married)? (Resources are things you own. When you count your resources, do not include your home, cars, or personal items, such as jewelry or clothes. Do include money, bank accounts, other real estate, stocks, etc.)
Yes:No:

(Click on blue arrow to continue)

If you have questions or problems with this QuickScreen, please call the PA Health Law Project’s toll free Help Line at 1(800)274-3258. The Help Line is open Monday through Friday, from 9am to 5pm.

 

Helpline

Having trouble accessing publicly funded health care coverage or services? Call…

1-800-274-3258

or email us at staff@phlp.org.

Quickscreen Tips

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  • If the tool will not let you advance, this may be because you entered your information in an incorrect format. Where asked to enter an amount of money, please enter the whole number without "$" "," or "." Where asked to enter a number of people, please enter 0 if there are none to enter.
  • Where asked for the age of your children under 21, the tool will not let
    you advance if you enter an age over 21.