Understanding Pennsylvania’s Community HealthChoices (CHC) Medicaid Waiver

Navigating long-term care options can be overwhelming, but Pennsylvania’s Community HealthChoices (CHC) program offers an essential lifeline for seniors and individuals with physical disabilities who wish to remain in their homes or communities rather than moving into a nursing facility. Whether you’re a caregiver or exploring care options for yourself or a loved one, this guide breaks down what you need to know about CHC: from eligibility to benefits and how to apply.

Program Description

Community HealthChoices (CHC) is a Medicaid managed long-term services and supports (MLTSS) program designed for adults in Pennsylvania who are 65 or older, or 21+ with physical disabilities. The goal? To help people live independently at home or in their communities instead of entering institutional care settings.

CHC participants receive both their physical health services and long-term support services through one of several Managed Care Organizations (MCOs) that contract with the state. These MCOs coordinate a variety of medical and non-medical services, offering a streamlined and person-centered approach to care.

For a deeper dive into the CHC program, visit the official Pennsylvania Department of Human Services CHC page.

Eligibility Guidelines

General Requirements:

To qualify for CHC, applicants must:

Be a Pennsylvania resident
Be 21 years of age or older
Be eligible for Medicaid
Meet the level of care typically provided in a nursing home (for long-term services)
Be either dually eligible for Medicare and Medicaid or receive long-term care services through Medicaid

Financial Requirements:

Financial eligibility for CHC is based on income and asset limits. As of 2024:

Individuals must typically have monthly income below $2,829 (300% of the Federal Benefit Rate)
Countable assets must generally be under $2,000 for a single applicant

Over the Financial Limits?

An option for persons over these limits is to work with a Medicaid planner, who can help families to gain Medicaid eligibility for their loved one. Read more about Medicaid planning here.

Benefits and Services

CHC offers comprehensive health coverage and long-term support services tailored to each individual’s needs. Services may include:

Personal care assistance (help with bathing, dressing, meal prep, etc.)
Skilled nursing and home health care
Adult day services
Respite care for family caregivers
Transportation to medical appointments
Medical equipment and supplies
Behavioral health services
Home modifications and accessibility aids

Managed Care Organizations like UPMC Community HealthChoices, Keystone First CHC, and PA Health & Wellness coordinate these services. Participants choose the MCO that best fits their needs.

More details on services can be found on the CHC Participant Handbook.

How to Apply or Learn More

Applying for CHC is a multi-step process:

Apply for Medicaid (if not already enrolled):
- Use COMPASS to apply online
- Or apply in person through your local County Assistance Office (CAO)
Undergo a Level of Care Determination:
- This is done by the Independent Enrollment Broker (IEB), who will evaluate whether you meet the medical necessity for nursing home level care.
Choose a Managed Care Organization (MCO):
- Once approved, you can select an MCO that will coordinate your care and services.

To begin the enrollment process or ask questions, contact the Independent Enrollment Broker (PA IEB):
📞 1-877-550-4227
🖥️ Visit the PA CHC Enrollment Website

What to Expect When Applying for a CHC Waiver

Once you initiate the CHC waiver process, here’s what you can typically expect:

Initial Contact and Intake: After applying through COMPASS or contacting PA IEB, an intake specialist will collect basic eligibility information.
Level of Care Assessment: A nurse or other clinical assessor will visit your home to determine if you meet the medical criteria for needing a nursing home level of care.
Financial Eligibility Review: Your income and resources will be reviewed through the County Assistance Office to determine if you qualify for Medicaid.
Service Plan Development: If approved, you’ll work with your chosen MCO to develop a care plan that meets your needs.
Service Coordination Begins: You’ll be assigned a service coordinator who helps arrange supports such as personal assistance services, home modifications, or respite.

The process can take several weeks, so it’s important to stay in contact with the IEB and provide any required documents promptly.

Additional Tips and Documentation to Prepare

To avoid delays and ensure a smooth application process, be prepared to gather and submit:

Medical Documentation: You do not necessarily need to contact your doctor directly to begin, but having recent medical records or treatment notes that reflect the individual’s condition can speed up the Level of Care determination. If the IEB needs more details, they may request a physician’s statement or updated medical evaluations.
Proof of Income and Resources: Be ready to submit pay stubs, Social Security award letters, pension statements, or bank account summaries. Generally, you should be prepared to provide the last 2 to 5 years of financial records, particularly for any asset transfers.
Proof of Residency: Utility bills, lease agreements, or ID with your current address.
Identification: Government-issued ID for the applicant, and Social Security numbers for all household members may be required.
Power of Attorney (if applicable): If someone is helping the applicant apply, documentation confirming their legal authority should be included.