A new managed care waiver program, Community HealthChoices (CHC), will impact individuals who are currently enrolled in the Pennsylvania Department of Aging (PDA) Medicaid Waiver. This program, which began in January 2018, is rolling out in three phases, and includes mandatory enrollment from PDA to CHC. The first phase (Southwestern PA) has already been completed, the second phase (Southeastern PA) began in January 2019, and the third phase (the rest of the state) will begin in January 2020. However, the same long-term care services provided by PDA will be provided by CHC. To learn more about CHC, click here.
The Pennsylvania Department of Aging (PDA) Medicaid Waiver provides home and community based services (HCBS) to seniors who require nursing facility care, but elect to live and receive care in their own homes or in other community living arrangements, such as a Domiciliary Care Home. 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 Waiver for Individuals Aged 60 and Over. The program’s objective is not just to reduce nursing home admissions, but also to help seniors to function independently in their homes.
As such, several services are covered in addition to the basic personal care services. Support is available to help family members caring for loved ones, such as adult day care and respite care. The program also pays for home medical equipment and minor home modifications to improve home access (wheelchair ramps, stair glides) and home safety (walk-in bathtubs, safety bars).
Under the PDA Waiver, certain goods, supports, and services can be participant-directed, or said another way, self-directed. This means the individual chooses from whom they purchase goods or care services. Participants in this waiver can elect to have even greater control of their care providers by requesting their services through the Services My Way Program.
In addition to living in PA, residents must be at least 60 years old and require the level of care typically provided in a nursing home. If between the ages of 60 and 64, applicants must be physically disabled, while those 65 and over need only require nursing home level of care. Applicants must also qualify financially for Medicaid in Pennsylvania, which is sometimes called “Medical Assistance” or abbreviated MA. Financial eligibility is determined at the county level, but the following information is sufficiently accurate for planning purposes.
PA Medicaid Eligibility Requirements for 2019
The income limit for an individual applying for a PA Medicaid waiver is $2,313 per month. If one spouse is applying for Medicaid and the other is not, only the applicant’s income counts towards the limit, following the ‘name on the check’ rule. The asset limit for the PDA waiver is $2,000, although the state of PA allows an extra $6,000 disregard, meaning $8,000 in total is considered exempt (non-countable). Resources more than this amount must be spent down or re-allocated into exempt assets. In the situation previously described, where only one spouse of a married couple is applying for benefits, resources greater than $8,000 are permitted. Half of the total countable net worth of the couple can be exempted, up to a maximum of $126,420. This is referred to as the Community Spouse Resource Allowance. Also, important to note, several other assets are considered exempt, including a single vehicle, personal belongings, and one’s primary home, given the applicant or spouse lives in the home or the applicant intends to return to the home, and it is valued under $585,000.
Applicants Who Exceed These Limits
PA has a Medically Needy Medicaid program that enables residents with unusually high care costs to qualify for the program when their income is over the income limit. In brief, Medically Needy programs work by looking at the difference between a candidate’s monthly care expenses and their monthly income. Should their expenses be so high that their remaining “disposable income” is less than $430 per month (this is an approximate amount for 2019), they can then gain eligibility. Alternatively, Medicaid planning professionals can work with a family to arrange their assets and income into annuities and trusts so that they meet the eligibility requirements. For example, by pre-funding a funeral using an irrevocable funeral trust, one can reduce their countable assets by up to $15,000. Couples can exempt two funeral trusts. Learn more about Medicaid planning.
The services provided under this waiver are determined on a needs basis. Individuals can be approved for any of the following and there is no limit on how many of these can be received by any single beneficiary.