Community HealthChoices Pennsylvania Enrollment

The 90-Day Enrollment Process

Enrolling in Community HealthChoices follows a strict six-step sequence managed by the PA Independent Enrollment Broker (IEB, operated by Maximus). The full process runs up to 90 days from the initial referral to active services. Understanding each step — and which one is most likely to stall — helps you plan around the timeline instead of being surprised by it.

Step 1: Referral intake. You or your parent submits a referral through the state's COMPASS portal online, or by calling the PA IEB directly. The referral triggers the enrollment process and assigns a case to an IEB representative.

Step 2: First intake visit and physician certification. An IEB representative conducts an in-person meeting where the applicant lives. Simultaneously, the IEB sends the appropriate Physician Certification Form to the applicant's primary care doctor — MA 570 for home and community-based waiver services, or MA 51 for skilled nursing placement. The physician must complete, sign, and return the applicable form within 86 days. This is the primary driver of enrollment delays — doctors' offices lose forms, delay signing, or return them incomplete. Follow up personally with the physician's office within two weeks of the visit.

Step 3: Functional Eligibility Determination (FED). The IEB requests the local Area Agency on Aging to send a state care manager for an in-person functional evaluation. The assessor evaluates cognitive status, safety risks, and the applicant's capacity to perform ADLs and IADLs. This visit typically happens at the applicant's home.

Step 4: Clinical eligibility review. The IEB reviews both the completed FED and the Physician Certification Form to determine whether the applicant meets the Nursing Facility Clinically Eligible (NFCE) standard. NFCE generally requires the applicant to need hands-on help with at least three ADLs or to have significant cognitive impairment requiring continuous supervision.

Step 5: Financial eligibility determination. If clinically approved, the case transfers to the County Assistance Office (CAO) for a financial audit. The CAO reviews 60 months of bank statements, income documentation, property records, and transfer history to confirm the applicant meets Medicaid financial thresholds. Pennsylvania's 2026 income limit is $2,982 per month, with asset limits of $8,000 (Tier 1) or $2,400 (Tier 2) depending on income level.

Step 6: Notice and MCO selection. The CAO issues a final eligibility notice (Form PA 162), and the applicant chooses one of three Managed Care Organizations to begin services.

Choosing Your MCO

Community HealthChoices operates through three MCOs across five geographic zones:

AmeriHealth Caritas (operates as Keystone First CHC in the Southeast zone covering Philadelphia and surrounding counties). Strong network in the Philadelphia metro area with extensive behavioral health integration.

PA Health & Wellness. Available statewide. Operated by Centene Corporation. Known for broad provider network coverage in rural and suburban areas.

UPMC Community HealthChoices. Strongest network in Western Pennsylvania and the Pittsburgh region. Largest healthcare system in the state, which means direct access to UPMC-affiliated specialists and hospitals.

The right choice depends on which MCO's provider network includes your parent's preferred doctors, home care agencies, and specialists. Once enrolled, changing MCOs is possible but involves a transition period that can disrupt ongoing care. Request provider directories from all three before selecting.

In April 2026, a Pennsylvania appeals court struck down the state's CHC plan reprocurement process, finding that DHS acted arbitrarily by issuing identical scores to applications across different regions. Services continue under the current three MCOs while the state redoes the selection — existing enrollees are unaffected.

What CHC Waiver Services Cover

Once enrolled, CHC covers a comprehensive set of home and community-based services at no copay:

• Personal assistance services (help with ADLs and IADLs)
• Home health aide visits
• Physical, occupational, and speech therapy
• Home modifications (ramps, grab bars, stairlifts, bathroom adaptations)
• Home-delivered meals
• Personal emergency response systems (PERS)
• Adult day health services
• Participant-directed care (where a family member can be hired and paid as a caregiver)
• Durable medical equipment
• Non-emergency medical transportation

The participant-directed care option is particularly important for families. Unlike the LIFE program, CHC allows your parent to hire a family member as their paid caregiver — the MCO processes the employment and payment through the state's fiscal intermediary.

If the Application Is Denied

If the CAO denies the Medicaid application, you have 30 calendar days from the date on the written notice to file an appeal with the DHS Bureau of Hearings and Appeals (BHA) in Harrisburg.

If the denial comes from the MCO (they deny a specific service or reduce authorized hours), you must first file an internal grievance with the MCO. The plan must convene a review panel that includes an independent physician and issue its written decision within 30 calendar days. If the MCO upholds the denial, you can simultaneously request an External Review (conducted by a physician chosen by the Department of Health) and a State Fair Hearing through the BHA. Either one decided in your favor forces the MCO to fund the service immediately.

For urgent situations, expedited appeals are available. If a physician certifies that the standard 30-day review period would seriously jeopardize your parent's health or ability to recover, the MCO must issue a decision within 72 hours (48 hours if a physician's letter is attached).

The Pennsylvania Care Decision Guide includes an enrollment timeline tracker and form checklist that maps each step with deadlines and contact information.

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