Pennsylvania Assisted Living and In Home Care Medicaid Waiver Information and Rules for 2017

Introduction

Pennsylvania provides long-term care resources to seniors throughDepartment of Human Services, Health Care and Medical Assistance Division. The Office of Long Term Living provides information about the state’s Managed Long Term Services and Supports (MTLSS), which includes the new initiative for seniors with physical disabilities, Community HealthChoices (CHC). The CHC programcoordinatesyour health care coverage to improve the quality of your health care experience — serving more people in communities rather than in facilities, giving them the opportunity to work, spend more time with their families, and experience an overall better quality of life. Seniors who are eligible for Medicaid and/or Medicaid and Medicare (dual-eligibles) can participate in this program. Additionally, if you qualify for an aging Medicaid waiver program, you have the option to enroll in CHC.

Pennsylvania also provides the Living Independence for the Elderly (LIFE). The LIFE program is an option that allows the elderly to live independently on their own while receiving services and supports that meet the health and personal needs of the individual. LIFE is a managed care program that provides a comprehensive all-inclusive package of medical and supportive services. The program is known nationally as the Program of All-Inclusive Care for the Elderly (PACE). These are the followingeligibility requirements for the LIFE program: 1) Be age 55 or older 2) Meet the level of care needs for a skilled nursing facility or a special rehabilitation facility 3) Meet the financial requirements as determined by your local County Assistance Office or be able to privately pay 4) Reside in an area served by a LIFE provider and 5) Be able to be safely served in the community as determined by a LIFE provider. You can locate a LIFE program provider here, or by calling the toll free Long-Term Living Helpline at 1-800-753-8827.

Additionally, Pennsylvania administers many Medicaid waivers under the 1915(c) program for specific target populations needing long-term care, including a waiver for seniors for assisted living and in-home care services, known as theAging Waiver.

Medicaid Waiver Programs for Assisted Living and In-Home Care

Pennsylvania's Home and Community-Based Medicaid Waiver for Individuals Aged 60 and Over (HCBS Aging Waiver)

Pennsylvania’s Home and Community-Based Waiver for Individuals Aged 60 and Over (Aging Waiver) has been developed to emphasize deinstitutionalization, prevent or minimize institutionalization and provide an array of services and supports in community-integrated settings. The Aging waiver provides home and community-based services to persons 60 and over who meet the Nursing Facility level of careand is designed to support individuals to live more independently in their homes and communities and to provide a variety of services that promote community living, including participant directed service models and traditional agency-based service models

The Office of Long-Term Living, (OLTL) is responsible for ensuring that the Aging Waiver operates in accordance with applicable Federal laws and regulations. OLTL delegates the following responsibilities to52 local Area Agencies on Aging (AAAs): 1) Facilitate eligibility determinations for potential waiver enrollees (waiver related enrollment activities); 2) Perform the initial level of care determinations for potential Aging Waiver enrollees; and 3) Perform annual level of care reevaluations for Aging Waiver participants.

Services

Services include: Accessibility Adaptations, Equipment, Technology and Medical Supplies, Adult Daily Living Services, Community Transition Services, Home Delivered Meals, Home Health Services, Non-Medical Transportation Services, Participant-Directed Community Supports, Participant-Directed Goods and Services, Personal Assistance Services, Personal Emergency Response System (PERS), Respite, Service Coordination, TeleCare, and Therapeutic and Counseling Services

Eligibility

  1. Health: An applicant must require a Nursing Home Level of Care.
  2. Financial: Pennsylvania allows an applicant to qualify for Medicaid long-term care benefits through two pathways. As a special income limit state, an individual can qualify for benefits by meetingcertain income and asset limits. For 2017, an individual may earn up to $2,205 in income monthly (300% of the Federal Benefit Rate, or FBR), and retain $2,000 in assets. However, the use of a Miller Trust, also known as a Qualified Income Trust, is notpermitted if an applicant’s income is too high.

An additional way to qualify for Medicaid long-term care benefits is through the “medically-needy” provision, which allows the applicant to spend down their income to become eligible for benefits. If the applicant has too much income to meet the special income limit above, the medically needy spend down provision allows the applicant to deduct from their countable income any money spent on medical or remedial care. If an applicant is spending all of their monthly income on medical care already, this is a good option.

Practical Considerations

Generally, applying for a waiver is a two-step process. First, an assessment is completed to determine if someone meets the functional criteria. Second, there is a review of income and resources to see if someone meets thefinancial criteria. Call the Office of Long-Term Living (OLTL) Helpline at 1-866-286-3636 for a referral to the appropriate agency to call to start the application process. Please note that entry into a waiver program is not guaranteed. There are limited funds available, and depending on the waiver, consumers may be placed on a waiting list before they can receive services. There is no cap on the services that Aging Waiver participants receive, no cost sharing and no contributions allowed.

Conclusion

Pennsylvania has a robust Medicaid waiver program to assist seniors over age 60 receive long-term care in their own home or a community setting. However, the special income limit without the ability to use a Miller Trust means that it is a hard income cap, and planning is more difficult if the applicant makes too much income. Although, the state does offer a “medically-needy” pathway, however, the income limit for that option is significantly lower ($735) and would only practically be available to people who are already spending almost their entire income on medical care. Medicaid Planning would be very helpful for seniors who have significant medical costs and want to avoid living in a nursing home, but the strict income cap and medically-needy options make less accessible than some other state programs.