Pennsylvania Medicaid Long Term Care Programs, Benefits & Eligibility Requirements

Summary
Medicaid is a joint federal and state program, so its rules, coverage plans and even its name all vary by state. This article focuses on Pennsylvania Medicaid Long Term Care, which is different from regular Medicaid. In Pennsylvania, Medicaid is also called Medical Assistance (MA). Medicaid will help pay for long term care for Pennsylvania residents in a nursing home, in their home and in other residential settings through one of three programs – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers and Aged Blind and Disabled (ABD) Medicaid.

 

Pennsylvania Medicaid Long Term Care Programs

Nursing Home / Institutional Medicaid

Pennsylvania Medicaid, also known as Medical Assistance (MA), will cover the cost of long term care in a nursing home for eligible Pennsylvania residents through its Nursing Home / Institutional Medicaid. This includes payment for room and board, as well as all necessary medical and non-medical goods and services. These can include skilled nursing care, physician’s visits, prescription medication, medication management, mental health counseling, social activities and assistance with Activities of Daily Living (eating, bathing, moving, dressing and using the bathroom).

Some of the things that Pennsylvania’s Medicaid/MA won’t cover in a nursing home are a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example), personal reading items, plants, flowers, and any care services not considered medically necessary.

Any Pennsylvania MA beneficiary who receives Nursing Home Medicaid coverage must give most of their income to the state to help pay for the cost of the nursing home. They are only allowed to keep a “personal needs allowance” of $45 / month. This can be spent on any personal item – clothes, snacks, books, haircuts, cell phones, etc. It cannot be spent on any item that MA covers, including hygiene basics like toothbrush, soap, deodorant, razors and incontinence supplies, unless the MA beneficiary wants a specific brand that is not covered by Pennsylvania Medicaid. In this case, they could spend their personal needs allowance on the item.

 

Home and Community Based Service (HCBS) Waivers

Home and Community Based Service (HCBS) Waivers will pay for goods and services that help Pennsylvania Medicaid/Medical Assistance (MA) recipients who require a Nursing Facility Level of Care remain living “in the community” instead of moving to a nursing home. Living “in the community” can mean living in their home, the home of a loved one, a personal care home, an adult foster care home or an assisted living residence. The goods and services provided by HCBS Waivers can be medical (skilled nursing care, physical therapy, durable medical equipment or prescription medication) or non-medical (like adult day care, transportation, housekeeping, and personal care assistance with Activities of Daily Living such as getting out of bed, dressing, eating, bathing and toileting). While HCBS Waiver benefits can include nursing home care, the program’s primary purpose is to delay nursing home placement by providing care in the community.

Unlike Nursing Home Medicaid, HCBS Waivers are not an entitlement. This means that even if an applicant is eligible for an HCBS Waiver, they are not guaranteed by law to receive the benefits.

Community HealthChoices (CHC) Program (formerly Department of Aging Waiver)
The Community HealthChoices (CHC) Program is Pennsylvania’s HCBS Waiver for seniors and physically disabled adults who require a Nursing Facility Level of Care but want to remain living “in the community.” The program will provide services in the beneficiary’s home, the home of a loved one, a personal care home, an adult foster care home or an assisted living residence, but it will not pay for room and board in any of these settings.

CHC Program benefits include adult day care, assistive technology, home modifications, meal delivery, medication management, non-medical personal care and transportation, and multiple therapies (physical, cognitive rehabilitation, speech, behavior, occupational). Not all CHC Program benefits are available to everyone who qualifies for the program. Instead, Pennsylvania uses its Functional Eligibility Determination (FED) tool to evaluate each program applicant and decide which benefits are needed and how often they are needed.

The CHC Program delivers its benefits through a single Medicaid plan provided by a managed care organization (MCO), which has a network of care providers. Pennsylvania is divided into five regions for CHC Program purposes, and within each of those regions program members can choose from a variety of plans from the MCO. CHC Program members can go outside of the MCO network using Pennsylvania’s “Services My Way” consumer-directed option. This allows beneficiaries to hire caregivers of their own choosing, including family members except for spouses and legal guardians.

The CHC Program, like all HCBS Waivers, is not an entitlement. This means that even if an applicant is eligible for the program they are not guaranteed to receive the benefits. The CHC Program has approximately 124,000 enrollment spots, and once all of those are full, eligible applicants are placed on a waiting list until there is an open enrollment slot for them.

 

Aged Blind and Disabled / Regular Medicaid

Pennsylvania’s Aged Blind and Disabled (ABD) Medicaid, also known as Regular Medicaid, provides healthcare and personal service benefits to low-income Pennsylvania residents who are aged (65 and older) or disabled and live “in the community.” Living “in the community” can mean living in their home, the home of a loved one, a personal care home, an adult foster care home or an assisted living residence. While ABD Medicaid will cover services in all of those settings, it will not cover room and board costs.

ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits without any wait. This includes a variety of long term care benefits such as adult day care, doctor’s visits, skilled nursing care, in-home personal care, prescription assistance and transportation. ABD Medicaid beneficiaries qualify for these benefits and services one at a time, which is different from Nursing Home Medicaid, which makes all of its services immediately available for anyone who qualifies. Instead, ABD Medicaid recipients will be evaluated by the state to determine what kind of long-term care benefits they need and will receive.

Living Independence for the Elderly (LIFE)
Elderly (age 65 and up) Pennsylvania residents who have Aged Blind and Disabled (ABD) Medicaid can coordinate their medical, social service and non-medical personal needs into one comprehensive plan and delivery system using the Living Independence for the Elderly (LIFE) program. LIFE is intended to help Pennsylvania residents who need a Nursing Facility Level of Care but want to keep residing and receiving care in their home or somewhere else in the community. This program can be used by people who are “dual eligible” for Medicaid and Medicare and will help them coordinate the care from those two programs. Use this Pennsylvania Department of Human Services directory of LIFE offices to find one in your area.

LIFE Programs, in most other states, are referred to as PACE programs. However, Pennsylvania has a medication assistance program by that same name.

 

Eligibility Criteria For Pennsylvania Medicaid’s Long Term Care Programs

To be eligible for Pennsylvania Medicaid/Medical Assistance (MA), a person has to meet certain financial requirements and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid / Regular Medicaid.

  The easiest way to find the most current Pennsylvania Medicaid/Medical Assistance (MA) eligibility criteria for one’s specific situation is to use our Medicaid Eligibility Requirements Finder tool.

 

Pennsylvania Medicaid Nursing Home Medicaid Eligibility Criteria

Financial Requirements
Pennsylvania residents have to meet an asset limit and an income limit in order to be financially eligible for Nursing Home Medicaid. For a single applicant in 2022, the income limit is $2,523 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, Nursing Home Medicaid recipients are only allowed to keep a $45 / month of their income as a “personal needs allowance” and must give the state the rest to help offset nursing home costs. The 2022 asset limit for a single Nursing Home Medicaid applicant in Pennsylvania is $8,000, which means they must have $8,000 or less in countable assets. The only exception to this rule is if the applicant has an income greater than $2,523 / month, in which case the asset limit is $2,400. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities.

For married applicants with both spouses applying, the 2022 income limit for Nursing Home Medicaid through Pennsylvania Medicaid/Medical Assistance (MA) is $2,523 / month per spouse for a total of $5,046 / month combined, and the 2022 income limit is $8,000 per spouse for a total of $16,000 combined. The only exception to this rule is if either applicant has an income greater than $2,523 / month, in which case their asset limit is $2,400. For a married applicant with just one spouse applying, the 2022 income limit is $2,523 / month for the applicant, and the income of the non-applicant spouse is not counted. And the 2022 asset limit is $8,000 for the applicant spouse (as long as their income is less than $2,523 / month, otherwise the asset limit is $2,400) and $143,400 ($137,400 + $6,000 disregard) for the non-applicant spouse.

Pennsylvania MA applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Pennsylvania MA has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Nursing Home Medicaid in Pennsylvania is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals.

 

Pennsylvania Home and Community Based Service (HCBS) Waivers Eligibility Criteria

Financial Requirements
Pennsylvania residents have to meet an an income limit and an asset limit and in order to be financially eligible for Home and Community Based Service (HCBS) Waivers. For a single applicant in 2022, the income limit is $2,523 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. The 2022 asset limit for a single HCBS Waivers Medicaid applicant in Pennsylvania is $8,000, which means they must have $8,000 or less in countable assets. The only exception to this rule is if the applicant has an income greater than $2,523 / month, in which case the asset limit is $2,400. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities.

For married applicants with both spouses applying, the 2022 income limit for HCBS Waivers in Pennsylvania is $2,523 / month per spouse for a total of $5,046 / month combined, and the 2022 income limit is $8,000 per spouse for a total of $16,000 combined. The only exception to this rule is if either applicant has an income greater than $2,523 / month, in which case their asset limit is $2,400. For a married applicant with just one spouse applying, the 2022 income limit is $2,523 / month for the applicant and the income of the non-applicant spouse is not counted. And the 2022 asset limit is $8,000 for the applicant spouse (as long as their income is less than $2,523 / month, otherwise the asset limit is $2,400) and $143,400 ($137,400 + $6,000 disregard) for the non-applicant spouse.

Pennsylvania Medicaid/Medical Assistance (MA) applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Pennsylvania Medicaid has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Home and Community Based Service (HCBS) Waivers in Pennsylvania is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals.

 

Pennsylvania Aged Blind and Disabled Medicaid Eligibility Criteria

Financial Requirements
Pennsylvania residents have to meet an an asset limit and an income limit in order to be financially eligible for Aged Blind and Disabled (ABD) Medicaid / Regular Medicaid. For a single applicant in 2022, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2022 income limit for a single applicant is $863.10 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants, the 2022 asset limit for Pennsylvania ABD Medicaid is $3,000 combined between the two applicants/spouses, and the income limit is a combined $1,294.30 / month. These limits are used for both married couples with both spouses applying for ABD Medicaid and married couples with only one spouse applying.

Pennsylvania Medicaid/Medical Assistance (MA) applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Pennsylvania Medicaid has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional requirements for Pennsylvania Aged Blind and Disabled (ABD) Medicaid are being disabled, blind or aged (65 or over), and needing help with Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Pennsylvania Medicaid will conduct an assessment of ABD Medicaid applicants and their ability to perform Activities of Daily Living to determine the kind of services the beneficiary needs and the state will cover.

 How Pennsylvania Medicaid Counts the Home
One’s home is often their most valuable asset, and if counted towards Pennsylvania’s Medicaid/Medical Assistance (MA) asset limit, it would likely cause them to be over the limit for eligibility. However, in some situations the home is not counted against the asset limit. If the applicant lives in their home and the home equity interest is less than $636,000 (as of 2022), then the home is exempt from the asset limit. Home equity interest is portion of the home’s equity value that the applicant owns, and the home’s equity value is the current value of the home minus any outstanding mortgage / debt against the home. If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives. If none of the above-mentioned people live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $636,000. These rules apply to all three types of Medicaid.

 

Applying For Pennsylvania Medicaid Long Term Care Programs

The first step in applying for a Pennsylvania Medicaid/Medical Assistance (MA) Long Term Care program is deciding which of the three programs discussed above you or your loved one want to apply for – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid / Regular Medicaid.

The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for Pennsylvania MA when not financially eligible will result in the application, and benefits, being denied.

During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Pennsylvania MA applicant. These documents will be needed for the official Pennsylvania Medicaid application. Necessary documents include five years of quarterly bank statements from all accounts; the most recent monthly or quarterly statements from all investments, IRAs, 401Ks, annuities and any other financial accounts; a letter from the Social Security Administration showing the applicant’s gross Social security income and deductions; tax forms to verify income streams including wages, pensions, royalties and interest; lists of items of any trusts; proof life insurance (if the applicant has any) and a list of beneficiaries; Power of Attorney documentation.

After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, Pennsylvania residents can apply for Nursing Home Medicaid or Aged Blind and Disabled Medicaid online through the state’s COMPASS portal. They can also complete this paper application and submit it to their local County Assistance Office.

To apply for home and community based services through the Community HealthChoices (CHC) Program, Pennsylvania residents should fill out this online Department of Human Services form or call 1-877-550-4227 to contact an Independent Enrollment Broker (IEB). The IEB will schedule a face-to-face meeting to determine if the applicant meets the functional eligibility criteria for the program. The IEB can also help in completing the Medicaid application, and after the applicant is found eligible, an “enrollment assister” is available to help them choose a plan.

 

Choosing a Pennsylvania Medicaid Nursing Home

After an applicant has been approved for Nursing Home Medicaid through Pennsylvania Medicaid, they need to choose which Medicaid-approved nursing home they will live in. Even though Nursing Home Medicaid is an entitlement, Pennsylvania Medicaid will only cover stays and care in approved nursing homes. Pennsylvania residents can find and compare nursing homes in the state using the Pennsylvania Department of Health Nursing Care Facility Locator Page. They can also use Nursing Home Compare, which is a federal government website that has information about more than 15,000 nursing homes across the country. All of the nursing homes on this site are either Medicaid- or Medicare-approved.