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

Pennsylvania's Medicaid Waiver

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

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 decode the process, which can be complicated and ambiguous. 

What is a Medicaid waiver? 

A Home and Community-based Services (HCBS) waiver is a Medicaid program that in general provides assistance with skill development, respite, transportation, and other services 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) that 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 while receiving compensation to do so. 

What is the Pennsylvania waiver program all about?

The Pennsylvania waiver is administered by the Community HealthChoices (CHC) program. 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 or those who require a nursing home level of care. The program as a whole is very relevant to seniors and disabled adults, as many 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 was recently implemented by the state of Pennsylvania. Managed care is basically intended to reduce the cost of providing health care while improving 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 (Amerihealth Caritas, 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 (or be randomly assigned one) that will coordinate and oversee services. There are some differences between the plans so be sure to compare options, but overall they provide a very similar set of services under comparable protocols. 

What is the goal of the Pennsylvania waiver program? 

The waiver program provides seniors and physically disabled individuals with medical benefits, as well as long-term support services to promote independent living and prevent unnecessary nursing home placements. To sum it up, the waiver program aims to help individuals in need remain safely in their own home (or another home such as that of a family or friend).

Benefits include personal care services, such as assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADL), like bathing, meal preparation, and medication management.

Am I eligible? 

In order to be eligible for waiver services, one must be 21 years of age or older and a resident of PennsylvaniaAdditionally, one must be both clinically eligible (that is, determined eligible through evaluation of one’s needs from a medical perspective) and financially eligible (have very limited income and resources). 

Clinical eligibility

Applicants must also require a nursing home level of care or be eligible for both Medicaid and Medicare. In medical terms and in terms of the program, that means being deemed nursing facility clinically eligible (NFCE). 

The process for determining if someone is clinically eligible can be somewhat complex, but generally follows these guidelines:

    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

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, such as one’s home that they reside in or intends to return to, and it is valued under $585,000, 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.

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 at 877-550-4227. 

What benefits and services are available?

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 program can provide a combination of standard medical services and non-medical services:  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 HPC 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? 

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. Call us now for a free consultation and assessment at 267-457-4122, and 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. 

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