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Does Medicaid cover home care services?
The short answer is “yes”. However, requirements to receive benefits vary state by state. Each state has its own Medicaid programs, which offer different home care benefits. Below, we discuss Pennsylvania’s Medicaid coverage for home care so you can make the best decisions for yourself or a loved one before working with a home care agency.
What are Pennsylvania’s Home Care and Medicaid Requirements?
Pennsylvania has three Medicaid programs that offer financial assistance for home care: Pennsylvania Department of Aging (PDA) Waiver, the Services My Way Program, and the newly-adopted Pennsylvania Community HealthChoices (CHC) Program.
Pennsylvania Department of Aging Waiver
The PDA Waiver offers an extensive range of home care and community based services to senior individuals who require nursing facility care but prefer to remain in their own homes or in a community living domicile. This waiver is also referred to as the PA Council of Aging Waiver, the PDA Waiver, the Office of Long Term Living (OLTL) Waiver, and the Home and Community-Based Services (HCBS) Waiver for Individuals Aged 60 and Over.
This program covers basic personal care services and support to help family members pay for services such as adult day care and respite care. Additionally, the program pays for home medical equipment as well as home modifications to improve accessibility such as wheelchair ramps and stair glides. Under this waiver, individuals can choose from which vendors they purchase certain goods or self care services.
Services provided under this waiver are determined on a needs basis, and there is no limit on how many can be received by a single beneficiary.
Services include:
- Adult Daily Living Services / Adult Day Care
- Attendant Care (Personal Care)
- Community Transition Services (Moving Assistance)
- Companion Services (Escort)
- Coordination of Services
- Counseling
- Environmental Accessibility Modifications (Home and / or Vehicle)
- Financial Management Services
- Home Health Services
- Home Medical Equipment and Supplies
- Meal Delivery (Hot or Prepared)
- Non-Medical Transportation
- Personal Emergency Response (PER) System
- Respite Care Services (Temporary Caregiver Relief)
- Telecare
Services My Way Program
The Services My Way (SMW) Program is designed for Medicaid eligible, Pennsylvania residents who are elderly and/or disabled. Services are provided on the Cash and Counseling model, also referred to as consumer-direction or participant direction, which means individuals can choose their own care providers as opposed to the state agency making such decisions on their behalf. This method is not necessarily a waiver, but it’s a way that waiver participants can obtain home care services.
SMW Program participants work with a Case Manager from the state to help determine a plan for a level of care and a budget for goods and services. This is known as a participant’s “Individual Service Plan”. Participants can then choose people such as neighbors, friends, and some family members (excluding spouses or legal guardians) to serve as caregivers. An Employer Agent from the SMW Program is responsible for making payments to the care providers to offer care, which participants approve.
To qualify for Medicaid paying for homecare, individuals must be Pennsylvania residents that qualify for either the PA Community HealthChoices Program or the Attendant Care Program through Medicaid. Individuals must require nursing home level care, and financial requirements are dependent on age and marital status. Additionally, there are requirements related to income and asset limits.
Benefits for which a participant is eligible for is determined by a participant’s Individual Service Plan, which may include any of the services listed below. Not all of these services can be self-directed:
- Adult Day Services
- Chore Services
- Community Transition Services
- Companion Services
- Counseling
- Financial Management Services
- Home Delivered Meals
- Home Health Care
- Household Services (light house cleaning, laundry, meal preparation)
- Home Modifications
- Medical Supplies and Equipment
- Personal Assistance Service
- Personal Care
- Personal Emergency Response System (PERS)
- Respite Care
- Transportation
The Pennsylvania Community HealthChoices (CHC) Program
The Pennsylvania CHC Program is for persons who are 21 years of age or older and are eligible for both Medicaid (known as Medicaid Assistance in Pennsylvania) and Medicare (the federal health insurance program) or those who require a nursing home level of care. Participants can receive medical benefits and long-term support services, which includes personal care services.
Enrollment in this program is mandatory for those who meet the eligibility requirements, and individuals who were receiving services via the PDA Waiver were automatically enrolled in the CHC once it became available in their area (it’s now available state-wide, as of January 2020).
Like the SMW Program, there are income and asset limits. For Pennsylvania residents, 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 $2,000, although the state of Pennsylvania allows an additional $6,000 to be disregarded, allowing a total disregard of $8,000. In addition, certain exemptions are allowed, such as one’s home, given the individual lives in the home, or intends to return to the home, and the equity value is under $595,000, household items, and personal effects.”
The CHC Program covers a wide range of services, including:
- Adult Daily Living Services / Adult Day Health
- Assistive Technology / Durable Medical Equipment
- Medical Supplies
- Home Health Aide / Nursing
- Therapies (Physical, Occupational, Language, and Speech)
- Meal Delivery / Nutritional Counseling / Food Supplements
- Respite Care
- Non-Medical Transportation
- Personal Emergency Response Systems
- Home / Vehicle Modifications
- Nursing Home Care
- Hospice Care
- Medical / Dental Services
- Emergency Room Services
- Prescription Drugs
- Personal Assistance Services
- Counseling
- Service Coordination
- TeleCare
- Behavior Therapy
- Cognitive Rehabilitation Therapy
- Community Integration / Community Transition
- Pest Control
- Consumer Direction of Goods / Services (available via Services My Way)
How to Apply for Pennsylvania Medicaid Waiver Services
1) Apply for Medical Assistance
Apply for medical assistance through the state’s health and human services programs. A case worker from your local County Assistance Office will review your information, which can take up to 60 days.
2) Call the PA Independent Enrollment Broker (PA IEB)
Call the PA IEB at 1-877-550-4227 to apply for waiver services and to schedule an in-home visit. The IEB will send a Physician’s Certification Form to your doctor’s office to fill out and return to the IEB. Because this partly depends on your doctor, it’s helpful to remind them to fill out the form and send it back to the IEB.
3) Schedule an In-Home Visit With PA IEB
A representative with PA IEB needs to assess your needs and abilities to determine if Waiver services will fulfill your medical needs. Your local County Assistance Office will detail which forms need to be completed to schedule a visit.
4) Schedule an In-Home Visit with the Area Agency on Aging (AAA)
Once the PA IEB has conducted an in-home visit and determines Waiver services meet your needs, they will send a request to your local AAA. An AAA representative will then call to schedule an in-home visit. During this visit, a representative will perform a Functional Eligibility Determination to assess qualifications based on the services you need. Afterward, the AAA will send their assessment to PA IEB to review.
5) PA IEB Reviews Physician’s Certification Form & Functional Eligibility Determination
PA IEB needs to review your Physician’s Certification Form and Functional Eligibility Determination assessment to see if you qualify for program benefits. If this is the case, PA IEB will send your application to the CAO.
6) The CAO Reviews Your Application
Your local CAO will review your application to see if you qualify financially for program benefits. You will receive a decision within 90 days after PA IEB begins your application. If you don’t receive a decision within this period, you can request for a fair hearing.
If you’re approved, then you’re now enrolled to receive Waiver services. If you’re denied, you have the right to appeal.
For more information about Medicaid for home care services in Pennsylvania, visit the state’s website. To consult a TruCare Home Care Services representative about home care services, please visit our website or call (610)-878-2273.