Looking for the Physician Certification Form in Pennsylvania as part of the Medicaid waiver and getting home and community based services such as home care? We provide that for you here and also give a complete guide in understanding it.
Just want a copy of the physician certification form? Click here to print or download it now.
The eligibility for home and community-based services (HCBS), either through a Medicaid waiver or a state-funded program, requires an individual to meet certain criteria specific to each waiver or program. Home and community-based services are a variety of services that an individual can receive to help keep them living and residing in the community or in their own home. The most common example of services that these individuals receive is home care services . An individual must meet financial criteria to qualify as well as clinical criteria. As part of the clinical criteria, a physician certification form must be completed and submitted.
Why is the Physician Certification Form required to get home care services in PA under the Medicaid waiver?
In order to qualify for services under the Medicaid waiver, such as home care services, the person applying has to meet specific criteria:
- They have to qualify financially. This means that they have income and asset limits below a certain threshold. In other words, one must be realitively low income to qualify financially for the program.
- Secondly, they also have to qualify medically. That means that they have to meet certain medical criteria. This is determined by a physician as well as through other evaluations and assessements that demonstrates a certain level of need. To put it simply, that would mean a determined level of healthcare needs which includes things such as needed help with daily tasks. This could be, for example, assistance with cooking, bathing, grooming, and other necessities. Other examples could include medication reminders, assistance with walking or transferring, and other items. One does not need to have all the needs listed above to qualify. These are only examples.
- To qualify medically, a doctor has to review the applicant and determine if they have needs that could meet the level of care that a person would receive in a nursing home. These medical needs would be considered long term needs (not short term, such as a surgery in which you will recover soon).
- The goal of the Medicaid waiver program which can lead to home care services is designed to help keep people out of a nursing home. The Medicaid waiver program in PA, also known as Community HealthChoices, is designed to help allow this goal of keeping people in their homes and community a reality.
- That is why a doctor who reviews the Physician Certification form must certify that someone has needs that could also be met through a Nursing Home.
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Qualifying based on clinical criteria
As part of the clinical, or medical, criteria, an individual will need an assessment completed as well as a physician certification. These are done to ensure that the person applying for services has a certain level of care need in which services would help them.
The physician certification form is a state form that must accompany the application for Medicaid waiver services. It is also known as the MA 570 form. It is sent to an applicant’s physician or provider and then they review the information and verify that the applicant meets the clinical criteria portion to receive services.
When is the physician certification form completed?
The physician certification form is completed initially when a participant attempts to sign up with home and community based services (HCBS) as well as the LIFE program. The individual applying for the program must be deemed and certified Nursing Facility Clinically Eligible (NFCE) by the physician. If they are not found to be NFCE then they are considered to be Nursing Facility Ineligible (NFI).
It is done when an individual initially applies to qualify for these services. The physician certification form must also be filled out and submitted to the state of Pennsylvania on a yearly basis as well. This is done to make sure that the individual is still considered NFCE and has not become ineligible (NFI).
PRO TIP: Schedule your doctor’s appointment ASAP when first applying for home care services/ Medicaid waiver in Pennsylvania
When it comes to applying for the Medicaid waiver, the general order of things is to do the following:
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- Call the Independent Enrollment Broker (IEB) and start the process.
- Apply for benefits through COMPASS in Pennsylvania.
- Get the Physician Certification Form completed.
Even though the Physician Cert is done in step 3, we recommend scheduling this appointment right away. This is because of several reasons which we have commonly observed:
- It can take some time to get into the doctor’s office. Getting scheduled to see your doctor may take some time, and to prevent delays down the road, schedule this sooner rather than later so you can get that taken care of.
- Your doctor/physician may not indicate that you are eligible for these services. To help you continue in the process, your doctor must evaluate you on medical criteria. They need to demonstrate that you are Nursing Facility Clinical Eligible (NFCE). If the doctor does not say you qualify, then the process cannot continue. If you start this process early, you can know sooner if you may not qualify, or you can try seeking out another doctor’s opinion.
- The doctor or doctor’s office often takes time to return the completed paperwork. It may take the office days or even weeks to send back the completed paperwork. By expediting this process, you can help prevent delays, even when there are hold ups which prevent you from moving forward.
As you can see above, our pro tip is designed to help do one thing: anticipate and minimize delays. Because this part of the process often leads to delays and frustrations, schedule your doctor’s visit quickly.
Find all of our top Medicaid waiver and home care resources right here!
- Comparing CHC Medicaid Waiver Health Plans in Philadelphia: A Guide
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