A Beginner’s Guide to Using Pennsylvania’s Medicaid Waiver for Home Care

Help decode the process for getting set up with PA Medicaid waiver services. This includes for home care, home health aides, and a variety of other benefits available. Learn about whether you are eligible for the PA Medicaid waiver. Plus, find out what steps you need to take to sign up.

Looking for help in your home and with community events or outings for a loved one with mental illnesses, intellectual disabilities, and/or physical disabilities?  Do you find information and the process around Medicaid waivers confusing or lacking?

This guide is made to help you understand the process of signing up for the PA Medicaid waiver. The waiver enrollment can be complicated and ambiguous. Plus, we help you understand what services and supports are available, especially for seniors and disabled adults. 

What is the PA Medicaid waiver? 

A Home and Community-based Services (HCBS) waiver is a Medicaid program. It generally helps provides assistance with skill development, respite, transportation, and other services. The goal is to help support the individual and their caregiver.

As it relates to aiding members of the community in staying in their homes, the waiver can help elders and disabled individuals to receive a variety of services (including home care). This support will foster one’s independence at home and keep them out of institutional care (such as nursing homes, for example). Not only can the waiver provide home care services, but it allows family members to take care of the individuals in need. They can get paid compensation to do so. 

What is the Pennsylvania waiver program all about?

The Pennsylvania Medicaid waiver can provide senior home care services and other supports to help you remain in your own home.

The Pennsylvania waiver is the umbrella term for the 10 support service waivers. In this guide, we will refer specifically to the Community HealthChoices waiver, known as CHC. This is a new program and is the combination of three former waiver programs: aging waiver,  attendant care/ act 150 waiver, and independence waiver.

CHC is a Medicaid managed care program for persons who are 21 years of age or older and are eligible for both Medicaid and Medicare. Plus, these individuals require a nursing home level of care.

The program as a whole is very relevant to seniors and disabled adults. This is because many individuals are dually eligible for Medicaid and Medicare and / or require a level of care consistent to that provided by a nursing home.

What is managed care?

Managed care in Community HealthChoices was recently implemented by the state of Pennsylvania. Managed care is basically intended to reduce the cost of providing health care. At the same time, it improves the overall quality of that care.

In Philadelphia and the Delaware valley, managed care Medicaid is administered by one of three private companies contracted by the state of Pennsylvania.  These include Amerihealth Caritas (called Keystone First around Philadelphia), UPMC, and PA Health and Wellness. 

Should a patient qualify to receive waiver services, they will ultimately be responsible for selecting one of the three managed care plans. If they don’t they will be randomly assigned one. The Community HealthChoices health plans will coordinate and oversee services. There are some differences between the plans so be sure to compare options. Overall though, they provide a very similar set of services under comparable protocols. 

What is the goal of the Pennsylvania waiver program with Community HealthChoices? 

The Medicaid waiver can not only help you receive home care services, but it can even pay your family member to be your caregiver.

The CHC waiver program provides seniors and physically disabled individuals with medical benefits. These are long-term support services to promote independent living and prevent unnecessary nursing home placements. To sum it up, the CHC waiver program’s goals include helping individuals in need remain safely in their own home (or another home such as that of a family or friend). It also aims to help its members be both independent, active, and integrated within the community that they reside. 

The most common benefit is personal care services. Personal care services include assistance with activities of daily living (ADLs) like bathing, meal preparation, and medication management. This is provided by caregivers and home health aides employed by a home care agency. 

A variety of other benefits exist under the Medicaid waiver program. For Long Term Services and Supports and Home and Community Based Services, we outline the benefits in detail here.

Am I eligible for the Community HealthChoices waiver program? 

In order to be eligible for CHC waiver services, one must be 21 years of age or older and a resident of Pennsylvania. Additionally, one must be both clinically eligible and financially eligible. Clinically eligible means that the person is determined to be eligible through evaluation of one’s needs from a medical perspective. Financially eligible means having very limited income and resources. 

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Clinical eligibility for CHC medicaid waiver

Applicants must require a nursing home level of care or be eligible for both Medicaid and Medicare to be deemed eligible for the program. In medical terms of the program that means the person gets a formal assessment and is nursing facility clinically eligible (NFCE). 

The process for determining if someone is clinically eligible can be somewhat complex. However, it follows these general guidelines:

1. 1. The individual has an illness, injury, disability, or medical condition diagnosed by a physician and
   2. As a result of that diagnosed illness, injury, disability or medical condition, the individual requires care and services above the level of room and board, and
   3. A physician certifies that the individual is NFCE, and
   4. The care and services are either Skilled Nursing or Rehabilitation Services (For example, a nursing home) or health-related care and services that may not be as complex as Skilled Nursing or Rehabilitation Services, but which are needed and provided on a regular basis through medical and technical personnel. 

Financial eligibility for Community HealthChoices

In order to be eligible for Medicaid, there are income and asset limits.

• For the state of Pennsylvania, as a general rule of thumb, seniors must have income no greater than 300% of the Federal Benefit Rate (FBR).
• As of 2020, this means a single elderly individual cannot have income in excess of $2,349 / month.
• The asset limit for a single senior is $8,000 after allowances (including savings accounts and investments). In addition, certain exemptions are allowed. This includes one’s own home that they reside in or intends to return to. It needs to be valued at $585,000 or less along with household items, and personal effects.

Once again, besides financial eligibility, to be eligible for Long-Term Services and Supports (LTSS), an individual must also require a level of care consistent with a nursing home.

What if I exceed the financial eligibility for the program?

There may still be options for getting CHC Medicaid waiver. If you find yourself or your loved one in a position to need care but are over the financial threshold, you should contact an elder law attorney to discuss strategies to assist you in your goal.

At Chosen Family Home Care, we can discuss some of these strategies with interested individuals and help make referrals to elder law attorneys as needed. There are different considerations, but one of them includes a “spend down” option. This is basically a way to spend one’s income or assets to the point that they eventually fall within the financial criteria of the program. Contact us today so we can learn more about your situation and help advise you.

Read more of our Medicaid waiver resources for home care:

• Pennsylvania’s CHC Medicaid Waiver: A Guide to Services at Home
• Get Paid to Care For A Loved One in Pennsylvania: A Guide
• Pennsylvania’s Medicaid Waiver: The Step by Step Enrollment Guide

How do I enroll in the waiver program? 

This handy guide outlines the steps in detail in enrolling with the waiver program. Step one starts with a phone call to the Pennsylvania enrollment broker, also known as the PA IEB, at 877-550-4227. The Independent Enrollment Broker is contracted by the state of Pennsylvania. They are an intermediary that facilitates enrollment and eligibility for individuals seeking services under the Community HealthChoices Pennsylvania waiver programs.

What benefits and services are available under Medicaid waiver?

Home and Community Based (HCBS) Waivers provide long term care services in home and community based settings under Pennsylvania’s state Medicaid Program.

The Pennsylvania CHC waiver program can provide a combination of standard medical services and non-medical services. These offerings will be the same regardless of the CHC health plan (Keystone First, UPMC, or PA Health and Wellness). Standard services include but are not limited to:

– case management (i.e., supports and service coordination), helps with assessing services and providers.

– homemaker personal care services that supports an individual to develop skills and assistance in the home and community.

– home health aide, services that supports the medical needs of the individual

– personal care, similar to homemaker care at home but more focused on daily living skills and in home services.

– adult day health services, habilitation (both day and residential), day programs individuals can attend once they graduate from schooling.

– respite care, provides assistance and supervision in the home.

What home care agencies accept the Medicaid waiver? 

Be sure to work with a home care agency that accepts the PA Medicaid waiver.

It is important to note that not all home care agencies can and will accept medicaid waivers. Chosen Family Home Care is proud to accept the medicaid waiver for personal assistance services, home health aides, and personal care in Philadelphia, Delaware, Bucks, Montgomery, and Chester counties of Pennsylvania.

Contact us now for a free consultation or with other questions. We can assist with any questions about the medicaid waiver, home and community based services, and the best home care service option that meets your needs. Follow us on Facebook and Instagram as well for regularly updated content.