Table of Contents
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.
Our team can help streamline the application process and guide you on the steps to take.
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. Pennsylvania’s Medicaid waiver services include senior home care services, home care for disabled adults, 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.
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. Overall, the waiver program is very relevant to seniors and disabled adults. This is because many seniors and disabled adults 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/ACT 150 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.
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). Around Philadelphia, Amerihealth Caritas is referred to as Keystone First. These companies make up the insurance organizations that are a part of the Community HealthChoices waiver.
When a patient qualifies to receive Pennsylvania’s Medicaid 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.
Family caregivers can get paid to care for loved ones under the 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).
Community HealthChoices waiver program is simply the new waiver program put into place by the state of Pennsylvania. Formerly, it fell under three waiver programs: the independence waiver, attendant care waiver, and the aging waiver. Now, they are all under the umbrella of CHC.
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.
No. CHC Medicaid waiver includes a variety of services an supports available to program participants.
The program includes a large variety of services that are dedicated to keeping disabled and senior adults living independently in the community or their own homes. Our associated guide goes through every possible service that may be available under the CHC Medicaid waiver program.
However, it is important to understand that eligible participants on the Medicaid waiver will not necessarily qualify for all services listed and available. As part of the assessment process for the PA Medicaid waiver program, participants will be assigned the specific services that they need to remain independent in their homes.
As you can imagine, this can vary significantly between individuals. This is because every person’s situation and scenario is unique. Therefore, the CHC waiver program through the health plan (Keystone First, UPMC, or PA Health and Wellness) will provide the appropriate services. One senior could qualify for just caregiver support and service coordination. Another could get a home health aide as well as home delivered meals, a personal emergency response system (PERS), pest eradication, and non-medical transportation provided.
The amount, level, and frequency of services will also vary. For example, one senior adult may have some family support and not have extensive home care needs. They may be assigned 20 hours of home care and caregiver support per week or less.
As another example, a different senior with multiple cognitive and physical impairments could have significantly more hours assigned to them. The program goal of Medicaid waiver is to keep individuals independent in their own homes. However, the health plans work to make sure that plan participants are not dependent either. Therefore, they will work to provide the right mix of services and supports to each individual.
Additionally, it could be determined that it is no longer safe for an individual to remain in their own homes. Those participants could be relocated to a nursing home or long term care facility at that point. They will then no longer be enrolled in the CHC Medicaid waiver program.
Keep in mind that the level of services an individual needs can and will likely change over time. An assigned service coordinator to the participant (by the health plan) will regularly review their participants. They will monitor and assess them for changes. Services will be adjusted as appropriate to those individuals.
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 limited income and resources).
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 or confusing. Generally, they will follow these guidelines:
In order to be eligible for Medicaid, there are income and asset limits. For example, in the state of Pennsylvania, 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.
Plus, 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.
There could be, yes. One option is the ACT 150 program. This is for individuals with a higher income or asset limit and with similar cognitive or physical impairments. Check here for the ACT 150 application. It also provides eligibility information as well on the first page. ACT 150 provides a similar set of services. These are subsidized programs as well but there may be a small c0-pay. It’s also a great option if you qualify for it. Chosen Family Home Care can help you determine if you qualify for Act 150. Please note to apply for ACT 150 you must be denied from Community HealthChoices first.
Elder law attorneys can help you strategize and find ways to gain program approval.
Besides ACT 150, people may still find options for qualifying under CHC Medicaid waiver. If you find yourself or your loved one in a position to need care but are over the financial threshold, you could partner with an elder law attorney to discuss strategies to assist you towards qualifying.
There are different considerations, but one popular alternative 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 Medicaid waiver program. Contact us today so we can learn more about your situation and help advise you.
Yes, it is. Eligible family caregivers can get compensated to provide home care services under the Community Health Choices (CHC) program. This is true if they are disabled adults or seniors and older adults. Read out complete guide for more here.
Below, we outline the step by step guide to sign up and enroll with the waiver program in detail. Also, be sure to check out our printable handout on the process to download here.
