Understanding Pennsylvania Medicaid Waivers for Home and Community-Based Services

In Pennsylvania, Medicaid waivers play a critical role in providing home and community-based services (HCBS) to individuals who require long-term care but wish to remain in their homes or community settings. These waivers offer an alternative to institutional care by enabling individuals to receive necessary services while staying in a more familiar and supportive environment. Here’s an in-depth look at what Medicaid waivers are, how they work in Pennsylvania, and their significance for home and community-based services.

What is a Medicaid Waiver?

A Medicaid waiver is a special program that allows states to waive certain federal Medicaid requirements to provide more flexible and personalized care options for individuals with specific needs. In essence, these waivers give states the flexibility to use Medicaid funds in ways that might not be covered under the standard Medicaid program, focusing on services that support individuals living in the community rather than institutions.

Types of Medicaid Waivers in Pennsylvania

Pennsylvania offers several Medicaid waivers tailored to different populations and needs. These waivers are managed by the Pennsylvania Department of Human Services (DHS), but different waivers are overseen by specific offices within the department. Here’s a breakdown of the current waivers, the managing offices, and the services they provide.

Community HealthChoices (CHC) Waiver

Managed By: Office of Long-Term Living (OLTL)
Purpose: Assists adults with physical disabilities who need long-term services and supports and prefer to live in a home or community setting rather than a nursing facility.
Eligibility: Age 21 or older; must meet nursing facility level of care criteria.
Services Covered:

Daily Living Services
Assistive Technology
Environmental Adaptations
Cognitive Rehabilitation Therapy Services
Employment Services
Home Delivered Meals
Transportation Services
Personal Assistance Services
Pest Eradication
Respite Care

3. Act 150 (State-Funded Program)

Managed By: Office of Long-Term Living (OLTL)
Purpose: Provides services for individuals who do not qualify for Medicaid but need long-term care, including those with a medically determinable physical impairment expected to last at least 12 months or result in death.
Eligibility: Age 18 through 59 (conditional eligibility over age 59); requires Skilled Nursing Facility level of care; not financially eligible for Medicaid.
Services Covered:

Personal Assistance Services
Personal Emergency Response System (PERS)
Service Coordination

9. OBRA Waiver

Managed By: Office of Long-Term Living (OLTL)
Purpose: Provides services to support individuals with developmental physical disabilities, helping them live as independently as possible within their communities.
Eligibility: Age 18 or older; disability manifested prior to age 22; requires ICF/ORC level of care.
Services Covered:

Daily Living Services
Environmental Adaptations
Assistive Technology
Community Integration Services
Respite Services
Transportation
Supported Employment Services
Prevocational and Educational Services

10. LIFE (Living Independence for the Elderly) Program

Managed By: Office of Long-Term Living (OLTL)
Purpose: Provides comprehensive services to elderly individuals who need nursing facility-level care but wish to remain in the community.
Eligibility: Age 55 or older; meets eligibility requirements for nursing facility level of care; able to live safely in the community with available services.
Services Covered:

Adult Day Health Services
Transportation/Escort Services
Primary Medical Specialist Care
Nursing Care/Skilled Nursing
Dental, Vision, Podiatry, Audiology Care
Social Services/Case Management
Therapies (Physical, Occupational, Speech)
Recreational Therapy
Nutritional Counseling/Education
Laboratory/Diagnostic Tests
Pharmaceuticals
Prosthetics, Orthotics, Durable Medical Equipment and Supplies
Psychiatric Services
Personal Care
Homemaker Chore Services
Home Delivered Meals
Hospital Care/Hospice Services
Services for Hearing/Speech Impairments
Translation Services

5. Adult Autism Waiver (AAW)
Managed By: Office of Developmental Programs (ODP)
Purpose: Provides support for adults with Autism Spectrum Disorder who need assistance with daily living and community integration.
Eligibility: Age 21 or older; diagnosis of Autism Spectrum Disorder; meets ICF level of care.
Services Covered:

Assistive Technology
Behavioral Health Services
Community Inclusion
Community Transition Services
Counseling
Day & Residential Habilitation
Environmental Modifications
Family Counseling & Training
Job Assessment and Finding
Nutritional Consultation
Occupational Therapy
Respite Care
Speech/Language Therapy
Supported Employment
Supports Coordination
Temporary Crisis Services
Transitional Work Services

7. Person/Family-Directed Support (P/FDS) Waiver

Managed By: Office of Developmental Programs (ODP)
Purpose: Allows individuals with intellectual disabilities or autism to receive tailored support while managing their services more directly.
Eligibility: No age limit for intellectual disabilities or autism; from age 0 through 8 for developmental disabilities with high probability. Requires ICF/ID or ICF/ORC level of care.
Services Covered:

Employment Services
In-Home and Community Support
Companion Services
Community Participation Support
Respite Care
Shift Nursing
Therapies
Behavioral Support
Assistive Technology
Home and Vehicle Accessibility Adaptations
Transportation

Individual Cost Limit:
$33,000 per person per fiscal year (Supports Coordination and Supports Broker are excluded).

8. Consolidated Waiver

Managed By: Office of Developmental Programs (ODP)
Purpose: Provides a broad range of services to support individuals with intellectual disabilities or autism, with no annual cost limit on services.
Eligibility: No age limit for intellectual disabilities or autism; from age 0 through 8 for developmental disabilities with high probability. Requires ICF/ID or ICF/ORC level of care.
Services Covered:

Residential Habilitation
Employment Services
In-Home and Community Support
Companion Services
Community Participation Support
Respite Care
Shift Nursing
Therapies
Behavioral Support
Assistive Technology
Home and Vehicle Accessibility Adaptations
Transportation
Life Sharing
Supported Living

Conclusion

In Pennsylvania, Medicaid waivers are essential for delivering home and community-based services, ensuring individuals receive the care they need while staying in their preferred environment. The Pennsylvania Department of Human Services oversees these waivers, with specific offices managing different programs. Understanding the roles of the Office of Long-Term Living (OLTL) and the Office of Developmental Programs (ODP) helps in navigating the services and eligibility requirements for each waiver. For more detailed information and assistance, visit the Pennsylvania Department of Human Services website or contact your local Area Agency on Aging.