Medicaid Resources

What is the PA Medicaid waiver or Community HealthChoices?

A Home and Community-based Services (HCBS) waiver is a Medicaid program. It generally helps provides assistance with companionship, personal care, 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 CHC waiver can help aging adults to receive a variety of services (including home care). The purpose of the service is to allow the individual to remain independent in their home and avoiding institutional care such as a nursing home. Not only can CHC waiver provide home care services, but it allows family members to take care of the individuals as well.

What is the Community HealthChoices program all about?

The Community Health Choice waiver can provide senior home care services and other supports to help you remain in your own home.

The Pennsylvania waiver is the umbrella term for the 10 support service waivers. On this page, we will refer specifically to the Community HealthChoices waiver, known as CHC. This is a new program and is the combination of three former waiver programs: aging waiver,  attendant care/ act 150 waiver, and independence waiver.

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. In addition, these individuals require a nursing home level of care.

What is managed care?

Managed care in Community HealthChoices was recently implemented by the state of Pennsylvania. Managed care is intended to reduce the cost of providing health care. At the same time there is a value based component which fosters overall quality care and a much lower cost.  In Uniontown, Connellsville, Brownsville, and Waynesburg (to include all of Fayette and Greene County) managed care Medicaid is administered by one of three private companies contracted by the state of Pennsylvania.  These include Amerihealth Caritas, UPMC, and PA Health and Wellness. The most predominant provider in Fayette and Greene County is UPMC.

Should a Client qualify to receive waiver services, they will be responsible for selecting one of the three managed care plans noted above. The Community HealthChoices health plans will supervise all services and manage your individualized care plan.  There are some differences between the plans so be sure to compare options. In general, each managed care organization provides comparable services with similar governing protocols.

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

The Medicaid waiver can not only help you receive home care services, but it can even pay your family member to be your caregiver.

The CHC waiver program provides aging adults and seniors with medical benefits. These are long-term support services to promote independent living as long as possible, and prevent unnecessary placements to nursing homes. CHC waiver program’s goals include helping individuals in need remain safely in their setting of choice, typically the home.  It also aims to help its members be safe, independent, effective, and integrated within the community.

The most common benefit is personal care services. Personal care services include assistance with activities of daily living (ADLs) like bathing, dressing, meal preparation, and medication management. This is provided by caregivers and home health aides employed by a home care agency like Home Instead.

How do I become eligible for the Community HealthChoices 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. In addition, the patient must be both clinically and financially eligible. Clinically eligible means that the person is determined to be eligible through evaluation of one’s needs from a medical perspective. Financially eligible means having very limited income and resources.

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, the person must be considered nursing facility clinically eligible (NFCE). 

The process for determining if someone is clinically eligible is summed up below.   Follow these guidelines to navigate eligibility:

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 for Community HealthChoices

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. 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.

It is important to note: to be eligible for Long-Term Services and Supports (LTSS), an individual must also require a level of care consistent with a nursing home or be nursing home eligible.

What if I exceed the financial eligibility for the program?

There may still be options for getting CHC Medicaid waiver. If you are in need of care but are over the financial threshold, you should contact an elder law attorney to discuss strategies to assist you in your goal.

At Home Instead, we can discuss some of these strategies with you and also refer you to elder law attorneys that can assist with this process. There are different considerations, but one of them 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 program. Contact us today so we can learn more about your situation and help advise you.

How do I enroll in the waiver program? 

Step one starts with a phone call to the Pennsylvania enrollment broker, also known as the PA IEB, at 877-550-4227. The Independent Enrollment Broker is contracted by the state of Pennsylvania. They are an intermediary that facilitates enrollment and eligibility for individuals seeking services under the Community HealthChoices Pennsylvania waiver programs.

What benefits and services are available under Medicaid waiver?

The Pennsylvania CHC waiver program can provide a combination of standard medical services and non-medical services. These offerings will be the same regardless of the CHC health plan (Keystone First, UPMC, or PA Health and Wellness). 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 homemaker care at home 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?

Be sure to work with a home care agency that accepts the PA Medicaid waiver. It is important to note that not all home care agencies can and will accept medicaid waivers. Home Instead is proud to accept the Medicaid waiver for personal assistance services, home health aides, and personal care in Fayette and Greene Counties:

Belle Vernon, Brownsville, Carmichaels, Connellsville, Cumberland Village, Dunbar, Dunkard, Fairchance, Fairdale, Hatfield, Hiller, Hopwood, Jefferson, Lemont Furnace, Masontown, McClellandtown, Morrisville, Morgantown (W.V.), Nemacolin, New Salem, Normalville, Oliver, Redstone, Perryopolis, Point Marion, Republic, South Connellsville, South Uniontown, Smithfield, Somerset, Springhill, Uniontown, Waynesburg, Wharton Furnace.

Contact us now for a no obligation care consultation.