How to Get In-Home Care for an Aging Parent in Pennsylvania

Applying for Medicaid-funded long-term care in Pennsylvania involves two separate determinations: whether the applicant needs a nursing-facility level of care and whether the applicant meets Medicaid’s financial requirements. Although many families still call the program the “Pennsylvania Aging Waiver,” qualifying in-home services are now delivered through Community HealthChoices.

Understanding the PA Aging Waiver and Community HealthChoices

“Pennsylvania Aging Waiver” is an older term that families commonly use when searching for help for an aging parent. Today, Pennsylvania provides these Medicaid-funded home and community-based services through the Community HealthChoices program, commonly called CHC.

The CHC Waiver serves people age 21 or older who are financially eligible for Medicaid long-term services and supports and are determined to be Nursing Facility Clinically Eligible. CHC also provides managed Medicaid coverage to certain people who have both Medicare and Medicaid, even when they do not receive waiver-funded long-term services.

The purpose of home and community-based services is to help eligible participants receive support in their homes or communities instead of entering a nursing facility.

Depending on the participant’s assessed needs and authorized service plan, services may include:

• Personal assistance with bathing, dressing and other daily activities
• Adult daily living services
• Home-delivered meals
• Respite services
• Assistive technology or specialized medical equipment
• Home accessibility modifications
• Transportation for certain covered needs
• Service coordination

These services are not automatically provided to every participant. Each service must be based on the person’s assessed needs, authorized by the CHC managed care organization and included in the person-centered service plan.

You can learn more about available programs in our guide to Pennsylvania waiver programs for seniors.

Financial and Functional Eligibility Requirements

An applicant seeking CHC Waiver services must meet both clinical and financial eligibility requirements.

Functional eligibility

The applicant must be determined Nursing Facility Clinically Eligible, commonly abbreviated as NFCE. This does not mean the person must enter a nursing facility. It means the person has needs that meet Pennsylvania’s clinical standard for that level of care.

A trained assessor completes a Functional Eligibility Determination. The assessment considers the person’s health, safety, mobility and ability to perform daily activities, such as:

• Bathing and dressing
• Getting in and out of bed or a chair
• Walking or moving safely around the home
• Eating and preparing meals
• Using the bathroom
• Managing health-related daily needs

Medical records, physician information or physician certification may also be required as part of the clinical eligibility process.

Financial eligibility

Financial eligibility is reviewed separately under Pennsylvania Medicaid rules. The County Assistance Office may consider:

• Income
• Bank and investment accounts
• Real estate and other property
• Life insurance with a cash value
• Marital status
• Financial transfers or gifts
• Other countable resources

A primary residence, one vehicle and certain personal property may be excluded under applicable Medicaid rules, but the treatment of any asset depends on the applicant’s circumstances. Families should not transfer, give away or retitle assets solely to qualify without first obtaining appropriate legal advice.

Current application information is available through the Pennsylvania Department of Human Services long-term-care portal.

Steps to Apply for In-Home Care

The clinical and financial reviews are separate and may move at different speeds. Receiving one approval does not necessarily mean the entire enrollment process is complete.

1. Start the application

Applicants can begin the process in any of the following ways:

• Call the Pennsylvania Consumer Service Center at 1-866-550-4355
• Call the Pennsylvania Independent Enrollment Broker at 1-877-550-4227
• Apply online through Pennsylvania COMPASS
• Call Alenta Service Coordination at (484) 843-1816 for help understanding the application process, organizing required documents and preparing for enrollment-related calls and assessments

Alenta can guide applicants and families through the steps, and assist with application preparation. The official application must be processed through Pennsylvania’s designated agencies. Alenta does not make eligibility decisions or guarantee approval.

Our guide to the Pennsylvania Independent Enrollment Broker process explains what families can expect during the initial intake process.

2. Provide the requested information

During intake, the applicant or authorized representative will answer questions about the applicant’s living situation, health conditions, daily needs and safety concerns.

The applicant may also be asked to complete authorization forms and provide personal, medical and financial information needed to process the application.

3. Complete the Functional Eligibility Determination

A trained assessor will arrange a Functional Eligibility Determination. The assessment may be completed in the applicant’s home, hospital, nursing facility or another appropriate location.

Describe the applicant’s actual needs, including difficult days and the assistance currently provided by relatives or friends. Do not minimize a need merely because a family caregiver is presently handling it.

4. Complete the Medicaid financial review

The applicant must complete the Medicaid financial application and provide the records requested by the County Assistance Office.

The office may request additional verification. Respond by the deadline shown in the request and retain proof of everything submitted.

5. Review the written decisions

The applicant will receive written notices concerning clinical and financial eligibility. Because these reviews are separate, one decision may arrive before the other.

Read every notice carefully and confirm whether additional information or action is required.

6. Enroll in a Community HealthChoices plan

After eligibility is confirmed, the applicant will enroll in or select a CHC managed care organization as applicable. Someone already enrolled in CHC may remain with the current plan or receive information about available plan choices.

7. Develop the person-centered service plan

After enrollment, the CHC plan completes or coordinates a comprehensive needs assessment. The participant then works with a service coordinator to develop a person-centered service plan.

The planning process identifies the participant’s goals, risks, daily needs and appropriate supports. Personal-assistance hours, equipment, home modifications and other services must be assessed and authorized before they begin.

Documents to Prepare

The County Assistance Office and enrollment representatives will identify the exact documents required for each application. Preparing commonly requested records in advance can help prevent avoidable delays.

Personal and residency records

• Government-issued identification
• Social Security card or Social Security number
• Medicare and other health insurance cards
• Proof of Pennsylvania residency
• Legal representative or power-of-attorney documents, if applicable

Financial records

• Social Security, pension and other income verification
• Bank, savings and investment account statements
• Property deeds, mortgage statements and real estate information
• Life insurance information, including cash surrender value when applicable
• Documentation concerning significant gifts, transfers or property sales
• Other records requested by the County Assistance Office

Pennsylvania’s Medicaid long-term-care rules may include review of financial transactions during a five-year look-back period. The County Assistance Office will specify the period and documents required for the individual application.

Medical and care information

• Current diagnoses and relevant medical records
• Medication list
• Names and contact information for physicians and specialists
• Information about hospitalizations or rehabilitation stays
• A description of assistance needed with daily activities
• Clinical forms or physician information requested during the process

Send copies rather than original documents unless an agency specifically requires an original. Keep copies of every submission, mailing receipt, confirmation number and written notice. Record the date, time, representative’s name and substance of important telephone conversations.

Setting Up the Service Plan and Choosing Providers

The service coordinator works with the participant and, when authorized, the participant’s family or representative to develop and monitor the person-centered service plan.

The plan may address:

• Personal-assistance needs
• Mobility and transfer assistance
• Meal-related support
• Home and community safety
• Equipment or accessibility needs
• Transportation
• Respite and caregiver support
• The participant’s personal goals and preferences

The CHC managed care organization determines which services are authorized based on the participant’s assessed needs, applicable coverage requirements and medical necessity when required. A specific service or number of personal-assistance hours is not guaranteed.

Participants generally have choices among qualified providers that participate in their CHC plan’s network.

Participants who choose Alenta Service Coordination as their service coordination provider work with an Alenta service coordinator to develop develop and monitor the person-centered service plan, coordinate authorized services and respond when the participant’s needs change.

Alenta does not determine Medicaid eligibility, make enrollment decisions or guarantee approval of a program, service or number of care hours.

What to Do If an Application Is Delayed or Denied

If an application appears delayed, contact the Independent Enrollment Broker or County Assistance Office and ask:

• Is the application complete?
• Is any verification missing?
• Has the functional assessment been completed?
• Has the physician provided all requested information?
• Is a response required by a particular deadline?
• Which agency currently has responsibility for the application?

Document every contact and keep copies of all correspondence.

If eligibility is denied, the applicant should receive a written notice explaining the decision, the reason and the applicable appeal rights. Medicaid eligibility appeals generally must be requested within 30 days, but applicants must follow the deadline and instructions printed on their individual notices.

The process may differ depending on the type of decision:

• Financial or program eligibility decisions may involve DHS or the County Assistance Office.
• Clinical eligibility decisions involve the entities responsible for the Functional Eligibility Determination.
• Denials, reductions or terminations of services after CHC enrollment are issued through the CHC managed care organization and may follow a separate grievance, appeal or fair-hearing process.

This article provides general information and is not legal advice. Families who need independent help with an appeal may contact a Pennsylvania legal-aid organization or the Pennsylvania Health Law Project.

If you are enrolled in Community HealthChoices and need service coordination, contact Alenta Service Coordination to learn whether Alenta is available through your CHC plan. When selected or assigned as the service coordination provider, our service coordinators help participants understand their plans and coordinate authorized services.