Pennsylvania Medicaid Waivers, Explained Plainly
Community HealthChoices is how most long-term home care actually gets paid for in Pennsylvania. What it is, and how the process really works.
Most families paying privately for home care assume that is simply how it works. For long-term care at home in Pennsylvania, the largest source of funding is Medicaid, and it reaches people through a program most have never heard of until somebody mentions it in passing.
This is a plain description of the shape of it. Eligibility rules, income limits and asset thresholds change, and they are specific to individual circumstances, so treat everything here as orientation and verify the current detail with the Department of Human Services or your Area Agency on Aging before making decisions.
The thing you are actually applying for
Community HealthChoices, usually shortened to CHC, is Pennsylvania’s managed long-term services and supports program. It covers adults aged 21 and over who need long-term care, and it operates statewide.
It consolidated several older waiver programs that families may still hear referred to by name, including the Aging waiver, Attendant Care, Independence and CommCare. If somebody mentions one of those, they are usually talking about something now delivered through CHC.
The word “waiver” causes confusion. It refers to federal rules being waived so that Medicaid can pay for care in somebody’s home rather than only in a nursing facility. That is the entire point of it: keeping people at home who would otherwise qualify for institutional care.
The central idea is worth stating plainly, because it is the argument that persuades reluctant families to apply: this is money that would otherwise pay for a nursing home, being used instead to keep somebody in their own house.
Two separate tests
Almost every confused conversation about this comes from not realizing there are two independent assessments, and you need both.
The financial test. Income and assets, assessed against Medicaid limits. The rules are detailed, they treat a married couple differently from a single person, and there are protections intended to prevent a spouse still living at home from being impoverished.
The functional test. Whether the person needs the level of care that would otherwise be provided in a nursing facility. This is assessed by looking at what they can and cannot do for themselves: bathing, dressing, transferring, toileting, eating, and how much cognitive supervision they need.
People fail on one and assume they have failed on both. Somebody clinically eligible but over the financial limit is a completely different situation from somebody financially eligible who was assessed as not needing that level of care, and the routes forward differ.
How the process actually runs
Broadly: contact the Independent Enrollment Broker or your local Area Agency on Aging to start; a functional assessment is arranged; a financial application goes to the County Assistance Office; and if both are met, you enroll with one of the managed care organizations that deliver CHC.
Currently those are AmeriHealth Caritas Pennsylvania, PA Health & Wellness, and UPMC Community HealthChoices. You choose between them, and you can change later.
After enrollment a service coordinator is assigned. This person matters more than any other individual in the process, because they assess how many hours are authorized and they are the one who can change it. They work for the managed care organization, not for your home care agency, which is a distinction families frequently miss when asking the wrong party for more hours.
Things worth knowing before you start
It takes time. Apply before it is urgent. The commonest mistake is starting the process during a crisis, when the family needs care next week.
Do not spend down blindly. There are look-back rules on transferring assets, and giving money away to qualify can create a penalty period. If there are significant assets, this is genuinely worth advice from an elder law attorney rather than advice from a relative who did it once.
Being denied is not the end. Denials happen, appeal rights exist, and appeals are frequently successful, particularly where the functional assessment did not capture how somebody actually manages on a bad day.
Assessments catch people out. Many people minimize their difficulties in front of a stranger, out of pride. If your mother tells the assessor she manages the stairs fine, that is what gets recorded. Be present if you can, and be honest about the worst days rather than the best ones.
Describe the bad week, not the good day. Assessments are supposed to capture what somebody genuinely needs, and an assessment based on a proud performance produces too few hours.
Directing your own care
Pennsylvania offers participant-directed options, under which the person receiving care has more control over who provides it, in some cases including family members. Programs such as Act 150 and the OBRA waiver also exist for particular circumstances.
If you are considering being paid to provide care for a relative, this is the area to ask about. The rules are specific about who qualifies and in what circumstances, so ask the Independent Enrollment Broker or the service coordinator directly.
If you do not qualify
Plenty of families are over the financial limit and cannot comfortably pay privately either. Things worth checking: veterans’ benefits if there is any service history, long-term care insurance policies that may have been forgotten, Area Agency on Aging programs that are not means-tested in the same way, and whether a smaller number of well-placed paid hours would bridge the gap.
Our guides to veterans benefits for home care in Pennsylvania and budgeting for home care cover those routes, and how to actually use your Area Agency on Aging explains the most useful phone call most families never make.
