Pennsylvania’s Medicaid Waiver: The Step by Step Enrollment Guide

Pennsylvania's Medicaid Waiver

Pennsylvania’s Medicaid Waiver: The Step by Step Enrollment Guide

Our comprehensive guide walks you through registering and enrolling into Pennsylvania’s Medicaid waiver program. The program helps cover home health care and senior personal care, among other things for older adults. 

Are you a senior that finds yourself needing a bit more extra assistance in your daily life? Do you find information and the process around Medicaid waivers confusing or lacking? This guide is made to help walk you through the registration process, which can be complicated, confusing, and lengthy. 


Resource Center: Download our printable and handy process guide


What is a Medicaid waiver? 

 

A Home and Community-based Services (HCBS) waiver is a Medicaid program that in provides a variety of assistance to keep seniors independent at home. Services include skills development, respite care for family caregivers, transportation, home modifications, home meal delivery programs, and other services that support the elderly and their family caregivers. 

The waiver can help seniors 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 for seniors and adults 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.

Previously, the CHC waiver was administered under other waiver names. These include the aging waiver, which includes all qualifying individuals over the age of 60. Others include the independence and attendant care waiver, which were intended for physically disabled adults between the ages of 18 and 60. Now, all of these waivers have been combined into one and they fall under the Community HealthChoices waiver. They now fall under a healthcare model of managed care. 

What is managed care and Community HealthChoices?

 

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). 

When a patient qualifies 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. 


Read more resources on Medicaid waivers in Pennsylvania for seniors:


 

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

 

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 Pennsylvania. 

Additionally, 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? 

 

Below, we outline the steps in detail to enroll with the waiver program in detail. Also, be sure to check out our resource guide handout on the process to download here. 

STEP 1: Apply for and get approved for medical assistance through the state of Pennsylvania

 

  • If you have already qualified for Medical Assistance, please proceed to step 2. 

 

  • Go to https://www.compass.state.pa.us/ and register and fill out the registration information for the state of Pennsylvania’s health and human service programs. 
  • After filling out the initial application and information needed, a case worker will be assigned to review your information through a local County Assistance Office near you
  • Timeline: Generally, this process will take up to 60 days in most cases. You can ensure that this process goes smoothly by taking the time to ensure that all information is filled out correctly and accurately. 

STEP 2: Call the PA Independent Enrollment Broker (PA IEB) at 1-877-550-4227.

 

  • The Independent Enrollment Broker can help you learn more about Home and Community Based Waiver Services for you or your loved one. 
  • Inform the PA IEB you want to apply for waiver services and schedule your first in-home visit.
  • Read the list of papers you need for the first in-home visit.
  • PA IEB sends a Physician’s Certification Form to your doctor to fill out and send to PA IEB.
  • Timeline: Normally, between two weeks and two months. The biggest factors in the timeline include how long it takes for your doctor to respond with the Physician’s Certification Form and also the availability of the PA IEB to schedule and complete your first in-home visit. 
  • Helpful Tip: You may want to remind your doctor to fill out and send the form back to the IEB. The IEB cannot proceed without this information. 

STEP 3: Schedule and have your first in-home visit.

 

Seniors Secure And Independent At Home

  • At your first in-home visit, you talk with a person from PA IEB about your needs and abilities to see if waiver services or other programs meet your needs.
  • Complete the Medical Assistance application (PA 600) and other required forms, if applicable. 
  • Helpful Tip: It is important to complete all forms and to make sure that all required forms are sent to the CAO. Otherwise, there may be delays. If there are any missing forms, The County Assistance Office (CAO) will send a letter to tell you how to send the forms.
  • Timeline: Usually within 14 to 45 days.  

STEP 4: Schedule and complete your second in-home assessment visit.

 

  • After your first in-home visit is completed, processed, and approved, the PA IEB sends a request to your local Area Agency on Aging (AAA) to complete .
  • AAA calls you to schedule your second in-home visit.
  • At this visit, a person from AAA does a Functional Eligibility Determination to find out whether you qualify for waiver services under Community HealthChoices based on the care you need. 
  • Once your second in-home visit is completed, the AAA sends the results to PA IEB for review.
  • Timeline: Usually within 14 to 45 days.  

STEP 5: PA IEB reviews your Physician’s Certification Form and Functional Eligibility Determination.

 

  • PA IEB needs your Physician’s Certification Form and Functional Eligibility Determination within 86 days of the first in-home visit.
  • If your doctor has not sent the certification form after your second in-home visit, PA IEB calls your doctor and you.
  • Once PA IEB has your Physician’s Certification Form and Functional Eligibility Determination, they review both to find if you qualify. If both forms meet program eligibility, PA IEB sends your application to the CAO. 
  • Timeline: Usually within 14 to 45 days.  

STEP 6: The CAO reviews your waiver application and makes a decision.

 

  • The CAO reviews your waiver application to see if you qualify financially.
  • If anything is missing, the CAO will send a letter to tell you how to send it to them.
  • Once your application is finalized and complete, the CAO approves or denies it.
  • The CAO sends a notice to you, to PA IEB, and to your chosen Managed Care Organization/Service Coordination Agency.
  • You get the decision about whether you qualify within 90 days after PA IEB starts your waiver application.
  • If you do not get a decision within 90 days, you can ask for a fair hearing.

If your waiver application is approved :

 

  • Congratulations! You are enrolled in Home and Community Based Waiver Services

If your waiver application is denied :

 

  • You are NOT enrolled in Home and Community Based Waiver Services.
  • However, if you disagree with that decision, you have the right to request an appeal hearing

Still Confused or Have Questions? Chosen Family Home Care can help. Call us at 267-457-4122 or email us at info@chosenfamilyhomcare.com with any inquiries you may have. We are glad to help during this process free of charge and without obligation.

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