Summary
Medicaid rules, benefits and name can all vary by state. In Pennsylvania, Medicaid is also called Medical Assistance. This article focuses on Pennsylvania Medicaid Long Term Care for seniors, which will pay for care in a nursing home, a beneficiary’s home and other settings through one of three programs – Nursing Home Medicaid, HCBS Waivers or ABD Medicaid. This is different than regular Medicaid, which is for financially limited people of all ages.
Pennsylvania Nursing Home Medicaid will cover the cost of long-term care in a nursing home for financially limited Pennsylvania seniors who require a Nursing Facility Level of Care. Coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services, such as:
Items not covered include a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example) and any care services not considered medically necessary.
Pennsylvania Nursing Home Medicaid beneficiaries are required to give most of their income to the state to help cover care expenses. They are only allowed to keep a “personal needs allowance” (PNA) of $45/month, which can be spent on personal items such as clothes, snacks, books, haircuts, flowers, etc. They can also keep enough of their income to make Medicare premium payments if they are “dual eligible,” and enough to make any Medicaid-approved spousal income allowance payments to financially needy spouses who are not Medicaid applicants or recipients.
Pennsylvania Nursing Home Medicaid is an entitlement. This means all qualified applicants are guaranteed by law, aka “entitled,” to receive benefits without wait. However, not all nursing homes accept Medicaid, and those that do may not have any available spaces when you or your loved one needs care. So, eligible applicants are guaranteed nursing home coverage without wait, but they are not guaranteed coverage in any facility they choose.
A Nursing Home Alternative – Pennsylvania Nursing Home Medicaid beneficiaries who want to leave their nursing home and return to living “in the community” can receive financial and functional help with that transition through Pennsylvania’s Money Follows the Person program (MFP). This help can include paying for moving expenses, as well as long-term care services and supports in the new residence. MFP beneficiaries must be moving from a Medicaid-approved facility and into their own home, the home of a relative or a small group home with a maximum of four unrelated residents.
Home and Community Based Services (HCBS) Waivers will pay for long-term care services and supports that help financially limited Pennsylvania seniors who require a Nursing Facility Level of Care remain living in the community instead of moving to a nursing home. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long-term care services for Pennsylvania residents who live in their own home, the home of a loved one, a personal care home, an adult foster care home or an assisted living residence. While Pennsylvania’s HCBS Waivers may cover long-term care benefits in those settings, they will not pay for room and board costs such as mortgage payments, rent, utility bills, facility fees and food expenses.
The HCBS Waiver relevant to Pennsylvania seniors is the Community HealthChoices Program.
Community HealthChoices (CHC) Program
Pennsylvania’s Community HealthChoices (CHC) Program, formerly known as the Department of Aging Waiver, provides long-term care services and supports to Pennsylvania Medicaid recipients who require a Nursing Facility Level of Care but live in their own home, the home of a loved one, a personal care home, an adult foster care home or an assisted living residence. The CHC Program may cover some long-term care benefits in those settings, but it will not pay for room and board.
CHC Program benefits include adult day care, home modifications, meal delivery, transportation, medication management and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Pennsylvania uses its Functional Eligibility Determination (FED) tool to evaluate CHC Program applicants and decide which benefits they need and the state will provide.
CHC Program participants receive their medical care and non-medical personal services through a single Medicaid plan provided by a managed care organization (MCO), which has a network of care providers. CHC Program members can choose from a variety of plans, and they can self-direct some of their long term care benefits using Pennsylvania’s “Services My Way” option. This allows program beneficiaries to hire caregivers of their own choosing, including family members, although spouses and legal guardians can not be hired as CHC Program caregivers.
Unlike Nursing Home Medicaid, most HCBS Waivers are not an entitlement. Instead, they have a limited number of enrollment spots, and once those spots are full additional applicants are placed on a waitlist. The CHC Program’s Long-Term Services and Supports division had 140,352 enrollment spots per year as of 2023.
Pennsylvania’s Aged, Blind, and Disabled (ABD) Medicaid covers basic healthcare and long-term care services and supports for financially limited Pennsylvania residents who are aged (65 and older), blind or disabled and live in the community. ABD Medicaid can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for low-income people of all ages. ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive healthcare coverage without wait. Access to long-term care benefits via ABD Medicaid depends on the availability of funds, programs and caregivers in the area where the beneficiary lives.
ABD Long Term Care Benefits
Pennsylvania ABD Medicaid beneficiaries qualify for long-term care benefits and services one at a time and based on their individual needs and circumstances. This is different from Nursing Home Medicaid, which makes all of its services immediately available for anyone who qualifies. Instead, ABD Medicaid recipients will be evaluated by the state to determine what kind of long-term care benefits they need and will receive. These benefits can include in-home personal care, adult day care, home modifications and Personal Emergency Response Systems (PERS).
Living Independence for the Elderly (LIFE)
Pennsylvania residents who are age 55 or older and have ABD Medicaid can cover their medical, social service and non-medical personal needs with one comprehensive plan and delivery system using Living Independence for the Elderly (LIFE). LIFE program participants are required to need a Nursing Facility Level of Care, but they must live in the community. Pennsylvania’s LIFE programs can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. LIFE also administers vision and dental care, and LIFE day centers provide meals, social activities, exercise programs and regular health checkups and services to program participants. Pennsylvania has 18 LIFE centers spread throughout the state. All are listed on this Department of Human Services LIFE directory. LIFE is called PACE (Program of All-Inclusive Care for the Elderly) in other states. To learn more about LIFE/PACE, click here.
Domiciliary Care Program
Although not part of Medicaid, Pennsylvania’s Domiciliary Care Program provides housing for many Medicaid beneficiaries.
The Domiciliary Care Program, often called Dom Care, is for Pennsylvania adults who can not live independently and require assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, cooking, housekeeping, laundry, medication management, etc.). Dom Care program participants can not require a Nursing Facility Level of Care.
Dom Care program participants live in the private homes of Dom Care providers. The Dom Care beneficiaries receive a bedroom with basic furnishings, three nutritious meals a day, laundry service, transportation to medical appointments, medication assistance, and personal care assistance as specified by their care plan. The Pennsylvania Department of Aging sets a standard rate that all Dom Care residents pay, which is usually a portion of their monthly Supplemental Security Income (SSI) and State Supplement budget.
To be eligible for Pennsylvania Medicaid, a person has to meet certain financial requirements and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid.
Just For You: The easiest way to find the most current Pennsylvania Medicaid eligibility criteria for one’s specific situation is to use our Medicaid Eligibility Requirements Finder tool.
Financial Requirements
Pennsylvania residents have to meet an asset limit and an income limit in order to be financially eligible for Nursing Home Medicaid. For a single applicant in 2024, the income limit is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. Holocaust restitution payments are not considered income. However, Pennsylvania Medicaid beneficiaries who reside in nursing homes must give most of their income to the state to help pay for the cost of care. They are only allowed to keep $45/month of their income as a “personal needs allowance,” and they are allowed to make Medicare premium payments if they are “dual eligible,” and they can make any allowable spousal income allowance payments to financially needy, non-applicant spouses.
The 2024 asset limit for a single Nursing Home Medicaid applicant in Pennsylvania is $8,000, which includes an extra $6,000 exemption on top of the base $2,000 limit. This means they must have $8,000 or less in countable assets. The only exception to this rule is if the applicant has an income greater than $2,829/month, in which case the asset limit is $2,400. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
For married applicants with both spouses applying in 2024, the income limit for Pennsylvania Nursing Home Medicaid is $2,829/month per spouse, and the asset limit is a combined $16,000. The only exception to this rule is if either applicant has an income greater than $2,829/month, in which case their asset limit is a combined $4,800. For a married applicant with just one spouse applying, the 2024 income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted. And the 2024 asset limit is $8,000 for the applicant spouse (as long as their income is less than $2,829/month, otherwise the asset limit is $2,400) and $160,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance.
Plan Ahead: There are alternative pathways to eligibility for Pennsylvania Nursing Home Medicaid applicants who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, Pennsylvania has a Look-Back Period of five years. This means the state will look back into the previous five years of the Nursing Home Medicaid applicant’s financial records to make sure they have not given away assets.
Functional Requirements
The functional, or medical, criteria for Nursing Home Medicaid in Pennsylvania is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with a nursing home. To determine level of care need for Medicaid purposes, Pennsylvania uses the Functional Eligibility Determination (FED) tool. The FED tool assesses an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Cognitive abilities and behavioral issues are also considered.
Financial Requirements
Pennsylvania residents have to meet an an income limit and an asset limit and in order to be financially eligible for Home and Community Based Services (HCBS) Waivers. For a single applicant in 2024, the income limit is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.
The 2024 asset limit for a single HCBS Waivers Medicaid applicant in Pennsylvania is $8,000. This means they must have $8,000 or less in countable assets. The only exception to this rule is if the applicant has an income greater than $2,829/month, in which case the asset limit is $2,400. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
For married applicants with both spouses applying in 2024, the income limit for HCBS Waivers in Pennsylvania is $2,829/month per spouse, and the asset limit is a combined $16,000. The only exception to this rule is if either applicant has an income greater than $2,829/month, in which case their asset limit is a combined $4,800. For a married applicant with just one spouse applying, the 2024 income limit is $2,829/month for the applicant and the income of the non-applicant spouse is not counted. And the 2024 asset limit is $8,000 for the applicant spouse (as long as their income is less than $2,829/month, otherwise the asset limit is $2,400) and $160,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance.
Plan Ahead: There are alternative pathways to eligibility for Pennsylvania HCBS Waivers applicants who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, Pennsylvania has a Look-Back Period of five years. This means the state will look back into the previous five years of the Nursing Home Medicaid applicant’s financial records to make sure they have not given away assets.
Functional Requirements
The functional, or medical, criteria for Home and Community Based Services (HCBS) Waivers in Pennsylvania is needing a Nursing Facility Level of Care, which means the applicant requires the kind of full-time care that is normally associated with a nursing home. To determine if they meet that level of care requirement, Pennsylvania Medicaid uses the Functional Eligibility Determination (FED) tool. The FED tool assesses an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Cognitive abilities and behavioral issues are also considered.
Financial Requirements
Pennsylvania residents have to meet an an asset limit and an income limit in order to be financially eligible for Aged, Blind, and Disabled (ABD) Medicaid. For a single applicant in 2024, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The 2024 income limit for a single applicant is $965.10/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.
For married applicants in 2024, the asset limit for Pennsylvania ABD Medicaid is a combined $3,000, and the income limit is a combined $1,448.30/month. These limits are used for both married couples with both spouses applying for ABD Medicaid and married couples with only one spouse applying.
Plan Ahead: There are alternative pathways to eligibility for Pennsylvania ABD Medicaid applicants who are over the asset limit and/or the income limit, such as Medicaid Planning. While Pennsylvania has a Look-Back Period of five years for Nursing Home Medicaid and HCBS Waivers applicants to make sure they don’t give away their assets to get under the limit, the Look-Back Period does not apply to ABD Medicaid applicants. However, ABD applicants should be cautious about giving away their assets. They might eventually need Nursing Home Medicaid or HCBS Waivers, and those programs will deny or penalize the applicant for giving away assets.
Functional Requirements
The only functional requirement to receive basic healthcare coverage through for Pennsylvania ABD Medicaid is being aged (65 and over), blind or disabled. For ABD Medicaid applicants and recipients who need long-term care services and supports, the state will administer an assessment of their ability to perform Activities of Daily Living (mobility, bathing, dressing, eating, toileting) to determine the kind of long-term benefits the state will cover.
One’s home is often their most valuable asset, and if counted toward Medicaid’s asset limit, it would likely cause them to be over the limit. However, in many situations the home is not counted against the asset limit:
These rules apply to all three types of Medicaid, with one important exception – ABD Medicaid applicants can disregard the home equity limit. Value does not matter regarding their home’s exempt status. To learn more about the impact of home ownership on Medicaid eligibility, click here.
Pennsylvania Medicaid applicants and recipients may also want to consider protecting their home (and other assets) from estate recovery. States are required by law to try and collect reimbursement for long-term care after the death of Medicaid recipients. They do this through their Medicaid Estate Recovery Programs (MERPs). The rules and regulations regarding estate recovery can vary greatly by state, but all states have a MERP. To learn more about the MERP in Pennsylvania and how you can protect your home from it, click here.
The first step in applying for a Pennsylvania Medicaid Long Term Care program is deciding which of the three programs discussed above you or your loved one want to apply for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid.
The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that program. Applying for Pennsylvania Medicaid when not financially eligible will result in the application, and benefits, being denied.
During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Pennsylvania Medicaid applicant. These documents will be needed for the official Pennsylvania Medicaid application. Necessary documents may include tax forms, Social Security benefits letters, deeds to the home, proof of life insurance and quarterly statements for all bank accounts, retirement accounts and investments. For a complete list of documents you might need to submit with your Medicaid Long Term Care application, go to our Medicaid Application Documents Checklist.
After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, Pennsylvania residents can apply for Nursing Home Medicaid or ABD Medicaid online through the state’s COMPASS portal. They can also complete this paper application and submit it to their local County Assistance Office.
To apply for home and community based services through the Community HealthChoices (CHC) Program, Pennsylvania residents should call 1-877-550-4227 to contact an Independent Enrollment Broker (IEB). The IEB will schedule a face-to-face meeting to determine if the applicant meets the functional eligibility criteria for the program. The IEB can also help in completing the Medicaid application, and after the applicant is found eligible, an “enrollment assister” is available to help them choose a plan.
For step-by-step guides to applying for each of the three types of Medicaid Long Term Care, just click on the name: 1) Nursing Home Medicaid 2) HCBS Waivers 3) ABD Medicaid.
Professional Help: Many seniors need support when it comes to Medicaid Long Term Care’s rules, benefits and application process. These are all complicated, constantly changing and vary by state. The best place to get help with Medicaid Long Term Care is through a professional like a Certified Medicaid Planner or an Elder Law Attorney.
After being approved for Nursing Home Medicaid through Pennsylvania Medicaid, seniors have to choose which Medicaid-accepting nursing home best meets their needs. Even though Nursing Home Medicaid is an entitlement, not all nursing homes accept Medicaid, and those that do may not have any available beds. Finding the right facility can be difficult, especially if you’re looking in a specific location.
Pennsylvania has about 680 nursing homes, and most of them accept Medicaid. The facilities are spread across the state with clusters of them around the larger cities. There are roughly 130 nursing homes within 25 miles of Philadelphia (and in Pennsylvania) that accept Medicaid. Staying in eastern PA, there are about 50 nursing homes in Allentown and approximately 40 in the Scranton/Wilkes-Barre area. There are another 45 facilities that accept Medicaid within 25 miles of Harrisburg, including York. And Pittsburgh has about 80 nursing homes that accept Medicaid within 25 miles.
Residents in some Pennsylvania communities regularly cross state lines for personal and business reasons, including healthcare. Medicaid coverage, however, does not cross state lines. So, a person with Pennsylvania Medicaid is not covered for long term nursing home care in Youngstown, Ohio, or Wilmington, Delaware, even if facilities in those places are convenient or well-suited for the Pennsylvania Medicaid beneficiary.
TOOLS: Pennsylvania residents can find nursing homes in the state using the Pennsylvania Department of Health Nursing Care Facility Locator, which includes an interactive map. They can also use Nursing Home Compare, which is a search tool administered by the Centers for Medicare & Medicaid Services (CMS) that has information on more than 15,000 nursing homes across the country.
When you’ve found nursing homes that meet your needs and accept Medicaid, you can start comparing them, if you have multiple options. The search on Nursing Home Compare can be filtered by staffing, health inspections, quality measures and overall rating, which can be a good place to start. The healthcare professionals who work with you are another great source of information. And you can contact your local Area Agency on Aging using this Pennsylvania Department of Aging webpage to find out more information about nursing homes in Pennsylvania.
After doing some research, you or someone you trust should visit any nursing homes you’re considering before making a final decision. Call first to make an appointment for the visit, and arrive with a list of questions, like: How does the facility handle dental and vision care? Does it provide transportation? What is the food like? Who are the staff doctors? CMS has a comprehensive “Nursing home checklist” you can use to evaluate a nursing home while visiting.
CMS data collected from 2019-2022 shows that Pennsylvania nursing homes are about averaged compared to the rest of the facilities in the U.S. when it comes to health standards, fire safety and resident-to-staff ratio. There was one area that stood out – the national average during that three-year time period for nursing home residents with depressive symptoms was 8.1%, but in Pennsylvania it was just 2.9%.
If you need Medicaid long term care but do not meet the financial eligibility criteria, consider working with a Medicaid Planning professional. These fee-based experts help families structure their finances to become eligible, while streamlining the application process and preserving assets for spouses and family members.
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