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 in Pennsylvania confusing ?

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. This guide is useful for both senior and disabled individuals who need care for themselves. It’s also valuable for family members and loved ones. Plus, if your loved one is approved, you could be a paid caregiver!

What is the Pennsylvania (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 Community Health Choices managed care?

Managed care in Community Health Choices 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 Health Choices 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 Health Choices? 

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 and caregiving. 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. This also includes family caregivers who can be paid to care for their family members and loved ones.

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 Health Choices 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 has medical needs which limited income and resources which qualifies someone for Medicaid.

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.
   5. A physician determines eligibility for this through reviewing and signing off on a Physician Certification Form. You can find that form here.

Financial eligibility for Community Health Choices

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 2024, this means a single elderly individual cannot have income in excess of $2,829 / 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.