Does Pennsylvania Medicaid Pay for In-Home Care?

Yes. Pennsylvania Medicaid covers in-home personal care through the Community HealthChoices (CHC) program — and it's an entitlement, meaning the state must provide services if your parent qualifies clinically and financially. There's no waitlist for CHC, unlike many other state programs.

Here's how it works, who qualifies, and the exact steps to apply.

What Medicaid Home Care Covers

Through CHC, Medicaid covers non-medical personal assistance services delivered in your parent's home:

• Help with bathing, dressing, grooming, and toileting
• Meal preparation and feeding assistance
• Light housekeeping and laundry
• Mobility assistance and transfers
• Medication reminders
• Accompaniment to medical appointments

The number of weekly hours depends on a clinical assessment — there's no fixed cap. A parent with moderate needs might receive 15 to 20 hours per week. Someone with severe functional limitations could receive 40 or more hours.

CHC is managed through three private insurance plans (Managed Care Organizations): AmeriHealth Caritas, PA Health & Wellness, and UPMC Community HealthChoices. All three operate statewide. After approval, a Service Coordinator from your chosen plan develops a Person-Centered Service Plan based on your parent's specific needs.

Who Qualifies

Two tests must be met simultaneously:

Clinical eligibility: Your parent must need nursing facility level of care (NFLOC) — meaning their physical or cognitive limitations require the kind of hands-on help that a nursing home provides. The Independent Enrollment Broker (currently Maximus) conducts an in-home Functional Eligibility Determination (FED) to assess this.

Financial eligibility: The 2026 thresholds are strict:

• Gross monthly income at or below $2,982 (300% of the SSI Federal Benefit Rate)
• Countable assets at or below $8,000 if income is at or below the $2,982 limit
• Countable assets at or below $2,400 if income exceeds $2,982

That second asset threshold creates a cliff. If your parent's Social Security plus pension equals $2,990 per month — just $8 over the limit — their allowable assets drop from $8,000 to $2,400. A $5,600 swing from a few dollars of income.

How to Apply: Step by Step

Step 1: Call the Independent Enrollment Broker. Contact Maximus at 1-877-550-4227 or submit a referral at paieb.com. This starts both the clinical and financial review processes.

Step 2: Get the physician certification. The MA 51 form must be completed and signed by your parent's doctor, documenting the medical necessity for long-term care. Submit it to both the County Assistance Office and the IEB.

Step 3: File the financial application. Submit the PA 600L through COMPASS (compass.state.pa.us) or deliver it in person to your local County Assistance Office. Keep a date-stamped copy. If your parent has a spouse, attach the PA 1572 Resource Assessment Form to protect the community spouse's assets.

Step 4: Complete the in-home assessment. A Maximus assessor will visit your parent at home to evaluate their functional abilities. Be present for this — the assessor needs to understand your parent's worst days, not just how they present during a 45-minute visit.

Step 5: Choose a managed care plan. Once approved, select one of the three CHC plans. Compare their provider networks in your county — the plan with the best local home care agency coverage matters more than marketing materials.

Step 6: Set up services. Your plan's Service Coordinator develops the care plan and arranges providers. If you want a family member to provide the care, request the Services My Way participant-directed option during this step.

The County Assistance Office has 45 days from the PA 600L submission to make a financial determination. The full process — from initial call to services starting — typically takes 45 to 60 days.

If Your Parent's Income Is Too High

Pennsylvania doesn't use Miller Trusts. Instead, seniors whose income exceeds $2,982 qualify through the Medically Needy (MNO-MA) spend-down pathway. Under this approach, your parent must show medical expenses (private-pay home care bills, prescriptions, doctor visits) that reduce their remaining monthly income to $425.

This calculation uses a rolling six-month budget period. Keep every medical bill, pharmacy receipt, and home care invoice — the County Assistance Office will need all of it.

How to Appeal a Denial

If the County Assistance Office denies the application, you have 30 days from the date of the written notice to file an appeal with the DHS Bureau of Hearings and Appeals.

File the appeal in writing with your parent's signature. If you need benefits to continue while the appeal is pending (called "aid paid pending"), you must file within 15 days of the denial notice — the clock is tight.

For managed care disputes — the CHC plan reducing hours or denying a service — file an internal appeal with the plan's grievance department within 60 days. If the plan upholds the denial, you can escalate to an external review through DHS.

The Pennsylvania Home Care Navigator includes the complete document checklist, a financial eligibility calculator, and appeal letter templates to keep the process moving without hiring an attorney for routine applications.

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