Does Medicaid pay for home care in Pennsylvania? A family guide to Community HealthChoices

Does Medicaid pay for home care in Pennsylvania?

Yes, for people who qualify. Pennsylvania's Medicaid program for long-term care at home is called Community HealthChoices, often shortened to CHC. It can pay for help at home with bathing, dressing, using the toilet, meals, housework and other daily tasks, so your parent can keep living at home rather than moving to a nursing home.

CHC is run by the Pennsylvania Department of Human Services through three health plans: AmeriHealth Caritas, PA Health & Wellness and UPMC Community HealthChoices. All three serve every part of the state, including all 16 counties we serve.

A few notes that clear up common confusion:

• CHC replaced several older Pennsylvania waiver programs (the Aging, Attendant Care, Independence and CommCare waivers). If you see those names on a website, the information is out of date.
• People who get services through the Office of Developmental Programs, and residents of state-run nursing homes such as state veterans' homes, are not served through CHC.
• Adults 55 and older who qualify may choose the LIFE program instead. See LIFE vs. home care.
• Medicare, which most older adults have, does not pay for ongoing non-medical home care. CHC is a Medicaid program, and many people have both.

It's Your Home Care is a provider with all three CHC plans. We are glad to explain the steps, even if your parent has not applied yet.

What are the steps, from the first call to the first visit?

Here is the path in order. Some steps happen at the same time, so do not worry if yours overlap.

1. Call the enrollment line. You ask for an application for home care and answer some screening questions.
2. The doctor fills out a form. Your parent's doctor completes a short form about their medical needs.
3. Someone visits to assess daily needs. An assessor meets your parent at home, in the hospital or in a nursing facility to see how much help is needed.
4. The County Assistance Office reviews finances. This is the Medicaid application, which looks at income and savings.
5. You pick a health plan from the three choices.
6. You pick a service coordinator, your main contact at the plan.
7. Together you write a care plan that sets the number of hours of help each week.
8. You choose a home care provider, or choose to direct care yourself.
9. Care begins. The agency visits, writes its own care plan, matches a caregiver and starts.

The rest of this guide explains each step and how to make it go a little more smoothly.

Who do you call to start?

Call the Pennsylvania Independent Enrollment Broker, usually called the IEB, at 1-877-550-4227 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m. The IEB is the state's enrollment service for CHC. You can also start online at paieb.com.

Before you call, have these ready: your parent's Social Security and Medicare numbers, insurance cards, the doctor's name and phone number, and a short description of what help is needed each day.

A family member can make the call, but your parent, or their legal representative, will need to take part and sign forms. If your parent is in the hospital, ask the case manager whether an application has already been started.

How does the state decide if your parent needs enough help?

The state looks at whether your parent needs the kind of daily help and oversight a nursing home provides. The official term is "nursing facility clinically eligible." It does not mean your parent has to move into a nursing home. It simply measures need. Two things go into the decision:

• The doctor's form. The doctor has to complete and send in a certification form before the state can decide. Call the doctor's office early, because this is where many applications get stuck.
• The in-person assessment. An assessor asks about bathing, dressing, eating, using the toilet, getting around, memory and safety. Be specific and honest about the hard days.

A gentle tip: many parents tell a stranger "I manage fine." If your mom actually needs help getting out of the shower every morning, it is okay to say so kindly during the visit. The assessor needs the full picture.

If the state decides your parent does not qualify, the letter must explain your appeal rights. If your parent is 60 or older, the county Area Agency on Aging may still be able to help through the OPTIONS program.

How does the financial part work?

The County Assistance Office handles the money side of Medicaid, separately from the needs assessment. The IEB helps you fill out the Medicaid application and sends it to your parent's county office, for example the Dauphin County Assistance Office for an address in Harrisburg or Hershey.

The office may ask for bank statements, pension and Social Security letters, insurance policies, deeds and proof of identity. Answer every request by the deadline on the letter. Missing paperwork is one of the most common reasons applications stall.

Medicaid's financial rules for long-term care can be complicated, especially for married couples and for anyone who has given away money or property in recent years. If there are savings or property involved, it is wise to talk with an elder law attorney before applying.

You can also apply for Medicaid through COMPASS online, by calling the Consumer Service Center at 1-866-550-4355, or at the County Assistance Office. For long-term care at home, though, going through the IEB keeps both halves of the process together.

How do you choose a health plan?

Pick the plan that works with the doctors, hospital, pharmacy and home care provider your parent already uses. All three plans cover the same CHC services. The differences are in which doctors and providers they work with, their service coordination teams and their extras.

• Check that your parent's doctors are in the plan's network. If your parent also has Medicare, ask how the plan works with it.
• Check that your hospital is in network, whether that is UPMC Harrisburg, Penn State Health Hershey Medical Center, WellSpan York, Lehigh Valley Hospital–Cedar Crest or another.
• Ask whether the home care agency you want works with the plan. It's Your Home Care works with UPMC Community HealthChoices, PA Health & Wellness and AmeriHealth Caritas.

If you do not choose, the state assigns a plan. You can switch later, and the IEB will explain when a change takes effect.

What does the service coordinator do for your family?

The service coordinator is your main person at the health plan. Everyone getting long-term care through CHC has one, and you get to choose them from the plan's list.

The service coordinator sets up a detailed needs assessment, writes the care plan with you, approves the number of hours of help each week, connects the dots between doctors and services, and helps find support the plan does not cover. After a fall, a hospital stay or a new diagnosis, this is the person to call to ask for a new assessment and more hours.

Keep the service coordinator's name, phone number and email on the refrigerator. If you cannot reach them, call the member services number on the back of your parent's insurance card.

What goes into the care plan?

The care plan (the state calls it a "person-centered service plan") lists every service your parent will receive, how many hours, who provides them, and what happens if a caregiver cannot come. Your parent, your family, the service coordinator and the providers all help shape it. The plan is reviewed at least once a year, or sooner if things change.

Before the planning meeting, write down a typical day hour by hour: when your parent gets up, needs the bathroom, eats, takes medications and goes to bed, and when family is and is not around. Plans built on real details tend to match real life much better than plans built on "she needs some help."

Can you get paid to care for a parent in Pennsylvania?

In many cases, yes, through Community HealthChoices. This is one of the most common questions we hear. There are two ways it usually happens:

• Directing care yourself. In what the state calls the "participant-directed" model, your parent (or a representative) becomes the employer and hires their own helpers, often an adult child, another relative or a friend. A payroll organization handles paychecks and taxes.
• Through an agency. In some situations, a home care agency in the plan's network can hire a family member as its own employee to care for their relative.

One firm rule: a spouse cannot be the paid caregiver. The service coordinator can explain which other relatives can be paid in your parent's situation.

If you are caring for a parent without pay and they do not qualify for Medicaid, the Pennsylvania Caregiver Support Program may help. It is a Department of Aging program, not a Medicaid program, and it can reimburse some expenses for unpaid family caregivers. Our article on becoming a paid caregiver for a family member covers more.

Should you use an agency or direct care yourself?

It depends on how much your family wants to manage. This comparison helps many families decide.

Some families combine the two, and you can change later by telling the service coordinator. Our guide to private caregivers vs. agencies covers the trade-offs in more depth.

Can you choose your own home care agency?

Yes. Your parent can choose any willing and qualified provider in the plan's network, and you can ask for an agency by name. A service coordinator may hand you a list, but you do not have to take the first name on it. No provider may offer gifts, cash or other incentives to win your choice, and you can change providers if the care is not working.

Ask each agency the questions in our checklist for choosing a home care agency, especially: can you staff every approved hour, including weekends, and who comes when the regular caregiver is sick?

If you choose It's Your Home Care, we schedule an in-home visit, write a care plan around the approved hours, match a caregiver, and introduce them before the first shift when schedules allow. Our page on home care through Community HealthChoices and other programs explains how we work with service coordinators.

How long does it take, and what can you do while you wait?

Plan for weeks rather than days, and longer if paperwork is missing. Coverage for long-term care begins on the date your parent is found eligible.

While you wait, many families pay privately for the most urgent hours, ask the county Area Agency on Aging about short-term help, or set up a family schedule. Keep a folder with copies of everything you send, and jot down the name of everyone you speak with.

If you get stuck, the CHC Helpline at 1-844-824-3655 (TTY 711) answers questions about applying. People already enrolled can call the Office of Long-Term Living participant line at 1-800-757-5042.

What is a good next step?

If your parent might qualify, make the first call to the IEB this week. It does not commit you to anything.

And if you would like someone to talk it through with first, call us at (717) 695-2704 or request a consultation. We can explain what to expect, help you think about which hours matter most, and talk about care while the application is in process.