Pennsylvania Long-Term Services and Supports Benefits
PA Health and Wellness Benefits Overview
PA Health and Wellness offers health insurance plans with comprehensive healthcare services that suit the needs of families and individuals throughout Pennsylvania. We coordinate long-term supports and services (LTSS) to improve the quality of the individual’s healthcare experience.
View some of PA Health and Wellness's long-term care insurance benefits below.
PHW Nursing Facility Ineligible (NFI) and Home and Community Based Services (HCBS) participants can receive coverage for home accessibility durable medical equipment that includes wheelchair lifts, stair glides, ceiling lifts and metal accessibility ramps. These requests can be submitted by a qualified DME provider, a service coordinator, a doctor or the participant. These requests should include a prescription, clinical documentation supporting the need, and proof of home ownership or approval letter from landlord. For more information, please call Participant Services at 1-844-626-6813 (TTY 711).
Participants interested in employment services have access to the following resources; benefits counseling, career assessment, employment skills development, job coaching, and job finding. For more information, please call Participant Services at 1-844-626-6813 (TTY 711).
Care coordination and disease coaching are part of your long-term care insurance benefits and are provided to you at no cost. PA Health and Wellness pays for these services. We provide services for many conditions, such as asthma, diabetes, COPD, high-risk pregnancy and many more. Call Participant Services at 1-844-626-6813 (TTY 711).
PA Health and Wellness will support you in moving from a nursing home back into the community of your choice.
Transition benefit helps qualified participants move from nursing facility back home with up to $5000 for assistance ($1000 more than $4000 state limit)
Certain drugs are considered maintenance medications because they are used to treat Long-Term Services & Supports (LTSS) conditions or illnesses. If the drug you take is part of the Maintenance Drug Program, you may receive up to 90-day supply at specific retail pharmacies.
PA Health and Wellness’s Supportive Solutions Caregiver program offers encouragement and assistance to caregivers. Benefits include:
- Respite
- Caregiver Journal
- Referrals to local resources
- Caregiver Portal Access (with Participant approval)
PA Health & Wellness can work with your Behavioral Health insurer to help you find a provider, find local resources, plan an appointment and find transportation. Call Participant Services at 1-844-626-6813 (TTY 711).
As a PA Health and Wellness Participant, you can choose who you see for your healthcare needs from our network of Providers. We have many for you to choose from. If you need help choosing a doctor, call Participant Services at 1-844-626-6813 (TTY 711).
PA Health and Wellness provides limited dental benefits for Participants through dentists within the PA Health and Wellness network for services. PA Health and Wellness covers the following services for Participants age 21 and older:
- Beyond Medicaid-covered services, participants can request an oral hygiene kit.
- Up to $1000 lifetime benefit for dentures for Nursing Facility Clinically Eligible participants
- All medically necessary dental services.
- Includes teeth cleaning, x-rays, cavity fillings, crowns and other services.
PA Health & Wellness covers the following services for Participants age 21 and older:
- Two periodic oral exams and cleanings per year.
- Includes surgical procedures and emergency services related to treatment for symptoms and pain.
PA Health and Wellness Participants may be eligible for additional benefits for dentures beyond the standard denture benefit.
Preventative care visits are covered by PA Health and Wellness. This means visiting the doctor for a regular check-up, rather than waiting until you are sick.
PA Health and Wellness covers an annual physical for adults.
Our Nurse Advice Line is ready to answer your health questions 24 hours a day – every day of the year. It is staffed with Registered Nurses. These nurses have spent lots of time caring for people. Now they are ready and eager to help you. 1-844-626-6813 (TTY 711).
Start Smart for Your Baby (Start Smart) is our special program for women who are pregnant and for those moms who just had a baby. We want to help you take care of yourself and your baby every step of the way. If you are pregnant, please let us know by completing a Notification of Pregnancy form. After completing this form, you will be enrolled in Start Smart. You will receive information in mail and over the phone.
Tips for Pregnancy
If you are pregnant or want to become pregnant, keep these things in mind:
- Go before you show! Go to the doctor as soon as you think you are pregnant. It is important for you and your baby to see a doctor as early as possible. It will keep both of you healthy. It will also help your baby get off to a good start. It is even better to see a doctor before you are pregnant. This is so you can get your body ready for pregnancy.
- Maintain healthy lifestyle habits. This includes exercising, eating balanced and healthy meals, and resting for 8-10 hours every night.
- Do not use tobacco, alcohol or drugs now or while you’re pregnant.
Breastfeeding
Doctors and health organizations agree that breastfeeding is best. You may already know that breast milk is packed with the perfect mix of nutrients your baby needs. Did you know that it is also more than just food? Breast milk has special ingredients, like antibodies, that only you can provide. Breast pumps are helpful if you are breastfeeding and must be away from your baby. Call us after you deliver to see if breast pumps are offered.
Are You Pregnant? Tell Us Right Away!
Call us. Or, you can login to your PA Health and Wellness account and fill out the Notification of Pregnancy form.
Interpreter services are provided free of charge to you during any service or grievance process. This includes American Sign Language and real-time oral interpretation.
If you need something translated into a language other than English, please call PA Health and Wellness 1-844-626-6813 (TTY 711). We can also provide things in other formats such as Braille, CD or large print.
If you need an interpreter for your medical appointment, contact Pennsylvania Health and Wellness 8 am – 8 pm before your appointment. We will arrange for one to be at your appointment.
PA Health and Wellness covers you for medically necessary transportation
Examples are:
- Transporting you from one hospital to another.
- Transporting you from an emergency room to another hospital because you need services that another hospital must provide.
- Transporting you when you have an unusual non-emergent medically necessary transportation need due to a medical condition.
Your PA Health & Wellness participating provider or behavioral health provider will coordinate this medically necessary transportation for you.
We also offer additional transportation services that allow you greater access to the community!
Emergency transportation
If you have an emergency, go to the nearest emergency room, call 911, or call the local ambulance service. In case of an emergency, PA Health & Wellness covers the ambulance costs.
Routine Transportation
PA Health and Wellness will provide you with transportation to help you meet the goals you have outlined in your Person Centered Service Plan. Also, the Medical Assistance Transportation Program (MATP) can provide routine transportation to and from medical appointments.
MATP has several ways to help you get routine transportation to services. This includes bus fare, paying you or a family participant to drive to your appointment, or sharing a ride with others in a vehicle provided by MATP. MATP may provide door-to-door transportation for individuals who are physically or emotionally unable to use public transportation.
You do not need to pay for MATP transportation to medical offices and providers’ covered services.
MATP services
You must register with the MATP office in your county in order to get transportation. It can take up to 14 days to register, so plan ahead. Call the MATP office in your county to register. Telephone numbers are listed below. You can get more information online by visiting matp.pa.gov
PA Health and Wellness covers examinations and treatment of eye conditions. This includes: preventative eye examinations (including refraction), eyeglasses for participants with a diagnosis of aphakia, low vision aids, eye prostheses, and other medically necessary eye care services.
Beyond Medicaid-covered services, $100 yearly for glasses/contacts for LTSS participants
- After hospital stay: 14 days of home delivered meals
- After hospital stay: 14 days of respite care
- Smart Start for Baby and health library
- PHW Community Connect Online resource site
- 90-day prescription refill for those not on Medicare
- Community support services for participants waiting for LTSS eligibility determination to assist with accessing local resources
- My Health Pays™ card for health items at retailers
- MIND at Home™ for dementia and Alzheimer’s participants
Prior Authorization and Referrals
Some medical services also need approval from PA Health and Wellness. This is called prior authorization. The provider offering you the service will get the approval from PA Health and Wellness. PA Health and Wellness does not require referrals for you to see a specialist. Below is a partial list of services that may require prior authorization from your doctor before you can get them. For more information please contact Customer Service.
Prior Authorization
Non-Participating/Out-of-Network Providers
In most cases you must see a PA Health and Wellness specialist or provider. If the service is available from PA Health and Wellness providers, we will ask that you use a PA Health and Wellness provider. If the service is not available from PA Health and Wellness providers, PA Health and Wellness may approve an out-of-network provider. We only approve out-of-state appointments when the service is not available in Pennsylvania.
| Service | Limit, Copayment, and Prior Authorization/Referral |
|---|---|
| Primary Care Provider | No Limit, $0, No Prior Authorization or referral |
| In-Network Specialist | No Limit, $0, No Prior Authorization or referral |
| Certified Registered Nurse Practitioner | No Limit, $0, No Prior Authorization or referral |
| Federally Qualified Health Center/Rural Health Center | No Limit, $0, No Prior Authorization or referral |
| Outpatient Non-Hospital Clinic | No Limit, $0, No Prior Authorization may apply for some services |
| Podiatrist Services | No Limit, $0, Prior Authorization may apply for some services |
| Chiropractor Services | No Limit, $0, Prior Authorization may apply for some services |
| Optometrist Services | Limits may apply, $0, Prior Authorization may apply for some services |
| Hospice Care | Limits may apply, $0, Prior Authorization may apply for some services |
| Radiology (ex. X-rays, MRIs, CTs) | No Limit, $0, Prior Authorization may apply for some services |
| Outpatient Hospital Short Procedure Unit (SPU) | No Limit, $0, Prior Authorization may apply for some services |
| Outpatient Ambulatory Surgical Center (ASC) | No Limit, $0, Prior Authorization may apply for some services |
| Non-Emergency Medical Transport | Limits may apply, $0, Prior Authorization may apply for some services |
| Family Planning Clinic Services | No Limit, $0, Prior Authorization may apply for some services |
| Renal Dialysis | No Limit, $0, Prior Authorization may apply for some services |
| Emergency Room Services | No Limit, $0, No Prior Authorization or referral required |
| Ambulance Services | No Limit, $0, Prior Authorization may apply for some services; i.e. Air Ambulance |
| Inpatient Hospital | No Limit, $0, Prior Authorization may apply for some services |
| Inpatient Rehab Hospital | No Limit, $0, Prior Authorization may apply for some services |
| Maternity Care | No Limit, $0, Prior Authorization may apply for some services |
| Prescription Drugs | No Limit, No copay for generic prescription drugs $3 copay for brand name prescription drugs, Prior Authorization may apply for some services |
| Nutritional Supplements | No Limit, $0, Prior Authorization may apply for some services |
| Nursing Home | Limits may apply, $0, Prior Authorization may apply for some services |
| Home Health Care Including Nursing, Aide, and Therapy Services | Limits may apply, $0, Prior Authorization may apply for some services |
| Durable Medical Equipment | No Limit, $0, Prior Authorization may apply for some services |
| Prosthetics and Orthotics | Limits may apply, $0, Prior Authorization may apply for some services |
| Eyeglass Lenses | Limits may apply, $0, Prior Authorization may apply for some services |
| Eyeglass Frames | Limits may apply, $0, Prior Authorization may apply for some services |
| Contact Lenses | Annual, Limiits may apply, Prior Authorization may apply for some services |
| Medical Supplies | No Limit, $0, Prior Authorization may apply for some services |
| Therapy (Physical, Occupational, Speech) | Limits may apply, $0, Prior Authorization may apply for some services |
| Laboratory | No Limit, $0, Prior Authorization may apply for some services |
| Tobacco Cessation | Limits may apply, $0, Prior Authorization may apply for some services |
| Dentist Services | Limits may apply, $0, Prior Authorization may apply for some services |