Pennsylvania Medicaid Community HealthChoices (CHC) Program: Benefits & Eligibility

Last updated: April 21, 2021

 

Overview of PA’s Community HealthChoices Program

Pennsylvania’s Community HealthChoices (CHC) Program is a Medicaid managed care program for PA seniors and physically disabled adults. In addition to medical benefits, long-term services and supports are available via CHC for persons who require a nursing home level of care. While nursing home care is an available benefit, a variety of home and community-based services (HCBS) are also available to program beneficiaries in their home, the home of a loved one, a personal care home, a domiciliary care home (adult foster care home), or an assisted living residence to prevent and delay the need for nursing home admission. The benefits received vary based on the needs and circumstances of the program participant. Benefits might include personal care assistance, meal delivery, home modifications, and personal emergency response systems.

CHC is a statewide program in which participants receive their long-term care benefits via a single Medicaid plan provided by a managed care organization (MCO). A MCO is essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. Pennsylvania is divided into 5 regions, and within each region, CHC program participants have several managed care plans from which to choose.

There is some flexibility of providers for persons receiving long-term care services via CHC, as some benefits, such as personal care assistance, may be participant directed through “Services My Way”. This means that rather than receive services by the MCO’s network of licensed care providers, a program participant can hire their own caregiver. Some relatives can be hired, but spouses and legal guardians cannot. A financial management services agency handles the financial aspects of employment responsibilities such as background checks, tax withholding, and caregiver payments.

Pennsylvania’s CHC Program is made up of two parts: Physical Health (medical) Services and Long-Term Services and Supports (LTSS). Persons eligible for LTSS are also eligible for medical services. LTSS is not an entitlement, which means meeting eligibility requirements does not equate to immediate receipt of home and community based services. Instead, there are a limited number of participant enrollment slots, and when these slots are full, a waitlist for program participation forms.

In PA, the Medicaid program is also called Medical Assistance. The Community HealthChoices Program is a Medicaid program. CHC LTSS is authorized under a 1915(c) and 1915(b) Medicaid Waiver. Via the 1915(c) Waiver, home and community based services (HCBS) are provided. The 1915(b) Waiver requires the program’s services and supports be delivered via a managed care model. The former Pennsylvania Department of Aging Medicaid Waiver was absorbed by CHC LTSS.

 What are 1915(c) HCBS Medicaid Waivers?
Historically Medicaid only paid for long-term care in nursing homes. 1915(c) HCBS Medicaid Waivers allow states to offer benefits outside of these institutions. “HCBS” stands for Home and Community Based Services. The goal of HCBS is to delay or prevent institutionalization, and to that end, care may be provided in one’s home, the home of a relative, an assisted living residence, or adult foster care / adult family living home. Waivers can target specific groups who require a nursing home level of care and are at risk of institutionalization, such as the elderly, disabled, or persons with Alzheimer’s. Waivers are not entitlements. This means that meeting eligibility criteria does not guarantee receipt of benefits, as there are a limited number of slots for program participants.

 

Benefits of the Community HealthChoices Program

In addition to medical benefits, such as hospice care, physician visits, lab work, and hospitalization, long-term services and supports are available via the CHC Program. A service care plan will determine which benefits a program participant will receive. Follows is a list of potential LTSS benefits.

– Adult Day Health Care / Adult Daily Living – provides daytime supervision and personal care assistance in a group setting
– Assistive Technology – devices & services to improve functioning
– Benefits Counseling
– Career Assessment
– Community Integration – skills training for community living
– Counseling Services
– Day Habilitation / Residential Habilitation
– Home Health Aides
– Home Modifications – wheelchair ramps, outside railings, and widening of doorways, etc.
– Home Meal Delivery
– Homemaker Services – assistance with housecleaning and preparing meals
– Job Finding
– Medication Administration & Management
– Nursing Home Care
– Nutritional Consultation
– Participant-Directed Goods and Services / Community Supports
– Personal Care – non-medical assistance with eating, bathing, toileting, meal preparation, etc.
– Pest Control
– Personal Emergency Response System (PERS)
– Prevocational Services – also called employment skills development
– Respite Care – in-home and out-of-home short-term care to alleviate a primary caregiver
– Specialized Medical Equipment / Supplies
– Supported Employment – job coaching services
– TeleCare
– Therapies – behavior, cognitive rehabilitation, occupational, physical, speech)
– Transitional Services – i.e., security deposit payment and utility set-up fees to assist one in transitioning from a nursing home to a private home
– Transportation – non-medical
– Vehicle Modifications

While services can be provided in assisted living residences, personal care homes, and domiciliary care homes, CHC will not cover the cost of room and board.

 

Eligibility Requirements for Community HealthChoices Program

 The American Council on Aging now offers a quick and easy PA Medicaid eligibility test for seniors. Start here.

The CHC Program is a mandatory managed care program for Pennsylvania residents who are 21+ years old and meet one of the following criteria:

– “Dual eligible”, meaning eligible for both Medicaid and Medicare. While Medicaid benefits are received via CHC, Medicare benefits continue to be provided via Medicare.
– Eligible for Medicaid long-term services and supports. One exception is persons who are enrolled in the Living Independence for the Elderly (LIFE) Program.
– Residing in a Medicaid-funded nursing home.

Additional eligibility criteria are as follows:

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2021, an applicant, regardless of marital status, can have a monthly income up to $2,382. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. There is a minimum income allowance, set at $2,155 / month (effective July 2020 – June 2021), which is intended to bring a non-applicant spouse’s monthly income up to this amount. There is also a maximum income allowance, which is $3,259.50 / month (effective January 2021 – December 2021), and is dependent on the non-applicant spouse’s shelter and utility costs. This monthly maintenance needs allowance is intended to ensure the non-applicant spouse does not become impoverished.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $4,000. Furthermore, PA allows an additional $6,000 exemption per applicant. This means each applicant can have up to $8,000 in countable assets and still meet Medicaid’s asset limit. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $8,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our free spend down calculator

Home Ownership
The home is often the highest valued asset a Pennsylvania Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A non-applicant spouse lives in the home.
– The applicant has a dependent residing in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

An applicant must require a nursing facility level of care (NFLOC). For the CHC Program, the Functional Eligibility Determination (FED) tool is used to determine if this level of care need is met. The ability / inability to complete activities of daily living (i.e., bathing, personal hygiene, dressing, walking, toileting, eating) independently is considered. Relevant to some persons with Alzheimer’s disease or a related dementia, cognitive issues, such as disorientation and memory issues, or behavioral problems, like wandering and removing clothing in public, are also considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.

 For more information about long-term care Medicaid in Pennsylvania, click here

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

Persons who have income over the limit, but have high medical bills, can become income eligible via PA’s Medically Needy Only Medical Assistance (MNO-MA) spend-down program. This program permits applicants to spend their “excess” income on medical expenses in order to meet Medicaid’s MNO-MA income limit. The amount that must be paid each month can be thought of as a deductible. Once one’s “deductible” has been met for the month, the CHC Program will pay for services and supports. With this option, both the income and asset limit is lower than the limits mentioned above. The income limit is $425 for an individual and $442 for a couple and the asset limit is $2,400 and $3,200 with no additional asset disregard.

When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option are annuities that turns countable assets into a stream of income. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of Pennsylvania to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria, but can also protect assets from Medicaid’s estate recovery program, preserving them for family as inheritance. Lady bird deeds is one strategy that specifically protects one’s home from estate recovery. Some planning techniques violate Medicaid’s 60-month look back rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, of which Medicaid planners are aware. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for the Community HealthChoices Program

Before You Apply

Prior to applying for the CHC Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

Since the CHC Long-Term Services and Supports Program is not an entitlement, there may be a waitlist for program participation. This program is approved for approximately 124,000 beneficiaries per year. In the case of a waitlist, persons who reside in a nursing home and wish to transition back to community living or those who have an immediate risk of nursing home placement are given priority when a participant slot becomes available.

 

Application Process

To apply for long-term services and supports via CHC, one should call 1-877-550-4227 to reach the Independent Enrollment Broker (IEB). Persons can also fill out and submit a contact information form here. A face-to-face assessment will be scheduled by IEB to determine if the functional need is met. Financial need for Medicaid is determined by one’s county assistance office (CAO). IEB can assist persons in completing the Medicaid application. Once found eligible for CHC, an “enrollment assister” is available to help persons choose and enroll in a CHC plan. Persons who do not choose a plan will automatically be enrolled in one. A needs assessment will determine which LTSS are received.

Additional information about the CHC Program can be found on the DHS website. Persons can also call 1-833-735-4416 to reach the CHC participant hotline. The Pennsylvania Department of Human Services (DHS) administers the Community HealthChoices Waiver Program.

 

Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further. Furthermore, as wait-lists may exist, approved applicants may spend many months waiting to receive benefits.

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