Healthy Horizons is Pennsylvania’s Medical Assistance program for people who have Medicare and are either 65 or older or meet the Social Security Administration’s disability standard. It comes in four tiers. One pays full Medicaid plus every Medicare premium, deductible, and coinsurance charge. The others pay progressively less, down to just the Medicare Part B premium. Which tier you land in depends on your monthly income and your countable resources, both measured against limits that update each year.
The Four Healthy Horizons Tiers
Every tier uses the Federal Poverty Income Guidelines as its yardstick. For a single person in 2026, 100% of the guideline is $1,330 per month ($15,960 per year).1U.S. Department of Health and Human Services. 2026 Poverty Guidelines – 48 Contiguous States
QMB Categorically Needy
Income at or below 100% of the Federal Poverty Level. Countable resources no more than $2,000 for one person or $3,000 for a couple. This is the broadest package: full Medical Assistance benefits plus payment of your Medicare Part A and Part B premiums, deductibles, and coinsurance.2Pennsylvania Code. 55 Pa Code 140.201 – Policy on Healthy Horizons
QMB Medicare Cost-Sharing Only
Same income ceiling (100% of poverty), but the resource limit doubles to $4,000 individual, $6,000 couple. You get help with the Medicare premiums, deductibles, and coinsurance, but not full Medical Assistance benefits.2Pennsylvania Code. 55 Pa Code 140.201 – Policy on Healthy Horizons
SLMB (Specified Low-Income Medicare Beneficiary)
Income between 100% and 120% of poverty. In 2026 the single-person ceiling is $1,616 per month. Resources must stay under $4,000 individual, $6,000 couple. Benefit: payment of the Medicare Part B premium.3Medicare.gov. Medicare Savings Programs
QI-1 (Qualifying Individual)
Income between 120% and 135% of poverty, with a 2026 single-person ceiling of $1,816 per month. Same resource limits as SLMB. Benefit: payment of the Medicare Part B premium.3Medicare.gov. Medicare Savings Programs
What Counts as Income and Resources
Countable resources include cash, bank account balances, stocks, bonds, and life insurance policies with cash surrender value. Your home generally doesn’t count while you live in it, and one vehicle is typically excluded.
If you’re applying based on disability rather than age, you’ll need medical documentation meeting the Social Security Administration’s standard: an impairment that has lasted or is expected to last at least 12 continuous months or result in death.4Social Security Administration. Disability Evaluation Under Social Security – Listing of Impairments
You also need to be a Pennsylvania resident and a U.S. citizen, refugee, or lawfully admitted noncitizen. There’s no minimum length of residency.5Commonwealth of Pennsylvania Department of Human Services. Medicaid General Eligibility
If Your Income Is Over the Limit: NMP Spend-Down
Being a few dollars over the ceiling doesn’t automatically close the door. Pennsylvania’s Non-Money Payment spend-down lets you subtract qualifying medical expenses from your monthly income. When what’s left falls at or below the eligibility limit for your tier, you qualify for that month.6Pennsylvania Department of Human Services. Medical Assistance Eligibility Handbook – 368.4 NMP Spend-Down
The County Assistance Office takes your monthly net income, subtracts a $10 standard deduction, then subtracts your paid or unpaid medical expenses: prescriptions, doctor bills, medical equipment. If the result is within the limit, you’re covered for that month. In months when your medical costs are low, coverage may not kick in. If your income already falls below the limit after the $10 deduction, or if your income and medical expenses are expected to stay stable for 11 months, the office can approve you without recalculating every month.
Protections When One Spouse Needs Long-Term Care
If one spouse enters long-term care through Medicaid and the other stays home, federal law shields the at-home spouse from being drained to zero. The Community Spouse Resource Allowance lets that spouse keep a protected share of the couple’s combined countable resources. For 2026, the protected amount falls between a federal minimum of $32,532 and a maximum of $162,660.7Centers for Medicare and Medicaid Services. 2026 SSI, Spousal Impoverishment, and Medicare Savings Program Resource Standards The at-home spouse also keeps a monthly income allowance for living expenses.
How Healthy Horizons Pairs With Medicare
Medicare pays first for covered services. Medical Assistance fills in behind it. QMB Categorically Needy enrollees see essentially no out-of-pocket costs for Medicare-covered care, because the state covers both Part A and Part B premiums along with deductibles and coinsurance. QMB Medicare Cost-Sharing enrollees get the same relief on costs without the full Medicaid benefit package. SLMB and QI-1 enrollees get only the Part B premium picked up.8Centers for Medicare and Medicaid Services. Qualified Medicare Beneficiary (QMB) Program Group
How to Apply
The fastest route is COMPASS, Pennsylvania’s online benefits portal at compass.dhs.pa.gov. You can create an account, complete the application, upload documents, and track status in one place.9Pennsylvania Department of Human Services. COMPASS Homepage You can also apply by mail, by phone, or in person at your County Assistance Office.
Most applicants use the PA 600 form. If you’re applying for long-term care services, use the PA 600L, which collects the extra financial detail those programs require.10Pennsylvania Department of Human Services. PA 600 L – Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services
Documents to Have Ready
- Social Security numbers for everyone applying, plus proof of your Pennsylvania address (utility bill, lease, or state ID).
- Recent pay stubs, tax returns, or profit-and-loss statements if self-employed.
- Bank statements for all accounts, documentation of stocks or bonds, and life insurance policies showing any cash surrender value. Healthy Horizons is asset-tested, so these matter.
- Medical records supporting a disability claim, if that’s your basis for applying.
The County Assistance Office must decide within 30 calendar days of your filing date. If something’s missing, you’ll get a notice asking for the specific documents. Sending everything upfront avoids the delay.11Pennsylvania Department of Human Services. Cash Assistance Handbook – 104.5 Processing an Application
Keeping Your Coverage
Enrollment runs on annual renewals. The Department of Human Services mails a renewal packet when it’s time to recertify, and you have to return it by the due date even if nothing has changed. You can renew through COMPASS, by mail, by phone at 1-866-550-4355, or in person.12Commonwealth of Pennsylvania Department of Human Services. Medicaid and CHIP Renewals Home
Miss the deadline and coverage ends. You then have a 90-day grace period to send the overdue renewal; if you still qualify, coverage reopens with no gap. After 90 days you have to start over with a fresh application. A lot of people lose coverage they’d still qualify for simply by setting the envelope aside.
If You’re Denied
If the Department denies your application, cuts your benefits, or ends your coverage, you can request a fair hearing. File the appeal in writing with the program office that issued the decision; that office forwards it to the Bureau of Hearings and Appeals within three business days.13Commonwealth of Pennsylvania Department of Human Services. Hearing and Appeals Process Federal regulations give you up to 90 days from the mailing date of the notice to request a hearing.14eCFR. 42 CFR Part 431 Subpart E – Fair Hearings for Applicants and Beneficiaries
An Administrative Law Judge runs the hearing. If you disagree with the decision, you can ask the Secretary of Human Services to reconsider within 15 calendar days, then petition the Commonwealth Court of Pennsylvania within 30 days of the Secretary’s order. If you file an appeal before your existing benefits end, those benefits can sometimes keep running while the appeal is pending.
A Note on Look-Back and Estate Recovery
These two rules often come up alongside Healthy Horizons, but they apply only to long-term care Medicaid, not to Healthy Horizons tiers that cover only Medicare cost-sharing. The 60-month look-back on asset transfers is triggered by applying for nursing facility services or home and community-based services.15Office of the Law Revision Counsel. 42 USC 1396p – Liens, Adjustments and Recoveries, and Transfers of Assets Estate recovery after death also targets long-term care costs; Medicare cost-sharing amounts paid through the SLMB and QI programs are not subject to it.16Commonwealth of Pennsylvania Department of Human Services. Estate Recovery If your Healthy Horizons application is strictly for premium and cost-sharing help, neither rule reaches you.