How to get PA Medicaid MCO's to Pay for In-home Care

Pennsylvania Medicaid completely covers the cost of personal in-home care for eligible seniors and adults with physical disabilities through Managed Care Organizations (MCOs). Specifically, this specialized long-term support is delivered through a state program called Community Health Choices (CHC). Consequently, instead of moving into a nursing home, qualifying residents receive funding to hire professional caregivers or even pay family members for daily care right at home.

However, navigating the application steps, meeting precise medical or financial requirements, and selecting the correct MCO can seem overwhelming. To simplify this, this complete guide outlines exactly how the process works and how to secure covered care in Pennsylvania:

1. What is Community Health Choices (CHC)?

Community Health Choices is Pennsylvania’s mandatory managed care program for individuals who are dually eligible for Medicare and Medicaid, or who require an institutional level of care.

Under this system, the state partners with private insurance companies—known as Managed Care Organizations (MCOs)—to coordinate and pay for your medical needs and Home and Community-Based Services (HCBS). Therefore, rather than paying a doctor or home care agency directly, the state routes your Medicaid waiver funds through your chosen MCO to cover personal care.

2. Who Qualifies for Covered In-Home Care?

To have an MCO pay for your in-home care services, you must satisfy three primary requirements:

General Requirements

You must be a Pennsylvania resident.
Additionally, you must be at least 21 years old.

Clinical Requirements

You must require a Nursing Facility Level of Care (NFLOC). In practice, this means you need substantial, daily assistance with Activities of Daily Living (ADLs). These activities include bathing, dressing, eating, safely moving around, or managing medications.
Furthermore, you must be able to live safely at home with the assistance of a home care plan.

Financial Requirements (2026 Limits)

Finally, Medicaid rules set specific limits on income and resources:

Income Limit: Gross monthly income must typically be below $2,982 for a single applicant.
Asset Limit: Countable resources (such as cash, savings, or investments) must be below $2,2. Who Qualifies for Covered In-Home Care?
To have an MCO pay for your in-home care services, you must satisfy three primary requirements:
General Requirements
You must be a Pennsylvania resident.
Additionally, you must be at least 21 years old.
Clinical Requirements
You must require a Nursing Facility Level of Care (NFLOC). In practice, this means you need substantial, daily assistance with Activities of Daily Living (ADLs). These activities include bathing, dressing, eating, safely moving around, or managing medications.
Furthermore, you must be able to live safely at home with the assistance of a home care plan.
Financial Requirements (2026 Limits)
Finally, Medicaid rules set specific limits on income and resources:
Income Limit: Gross monthly income must typically be below $2,982 for a single applicant.
Asset Limit: Countable resources (such as cash, savings, or investments) must be below $2,000.
Note: Essential assets like your primary home and one vehicle are usually excluded from this asset calculation.

3. Step-by-Step Guide to Enrolling and Getting Care3. Step-by-Step Guide to Enrolling and Getting Care

[1. Apply to Medicaid] ➔ [2. Contact PA IEB] ➔ [3. Clinical Assessment] ➔ [4. CAO Approval] ➔ [5. Choose MCO & Plan Care]

Step 1: Apply for Pennsylvania Medical Assistance
As a first step, unenrolled individuals must apply for standard Medicaid online through the official Pennsylvania COMPASS Portal. Alternatively, you can call the Statewide Customer Service Center at 1-877-395-8930 (or 215-560-7226 if you reside in Philadelphia) to locate and visit your neighborhood County Assistance Office (CAO).
Step 2: Contact the PA Independent Enrollment Broker (PA IEB)
Once that is underway, an independent agency called Maximus, known formally as the PA Independent Enrollment Broker (PA IEB), manages the enrollment process for long-term home care. Call the PA IEB Helpline at 1-877-550-4227 (TTY: 711) to formally initiate your home care waiver application or visit the PA IEB Website to submit a digital referral.
Step 3: Schedule the In-Home Assessments
Next, the PA IEB will schedule an in-home visit to complete a Functional Eligibility Determination (FED). This assessment determines whether your physical or cognitive needs meet the required nursing home level of care. At the same time, a physician must sign a certification form confirming your medical need for in-home assistance.
Step 4: CAO Final Financial Review
Following the assessments, the County Assistance Office reviews your financial records to confirm you meet the income and asset rules for long-term care. Once both financial and clinical eligibility are verified, you will receive a formal approval notice.
Step 5: Choose Your MCO and Select an Agency
Once approved, you will select one of Pennsylvania’s active CHC-MCOs (such as PA Health & Wellness, AmeriHealth Caritas, or UPMC Community Health Choices) to manage your benefits. Your MCO will then assign a Service Coordinator to evaluate your routine and authorize a set number of care hours per week.

Finally, you select an approved, licensed provider—like Lehigh Care at Home—to send qualified caregivers to your home.

Frequently Asked Questions (FAQ)

Can I choose my own home care agency under Community Health Choices?

Yes. Once your Managed Care Organization (MCO) approves your care hours, you have the right to select your preferred licensed home care provider. For example, Lehigh Care at Home is fully credentialed and proudly accepts all three major Pennsylvania Community Health Choices (CHC) plans: AmeriHealth Caritas, PA Health & Wellness, and UPMC Community Health Choices.

Can Pennsylvania pay a family member to be my caregiver?

Yes. Under the CHC waiver program’s participant-directed care model, family members (including adult children) can often work and earn money as personal caregivers. If you choose a plan through AmeriHealth Caritas, PA Health & Wellness, or UPMC, our team can help coordinate the paperwork required to transition your loved one into a paid caregiver role.

How long does the PA Medicaid waiver enrollment process take?

The entire application process—from your initial phone call to the PA Independent Enrollment Broker (PA IEB) to your final approval notice—typically takes between 60 to 90 days. Because of this timeline, you should start the paperwork early since the program requires both independent physical assessments and a county financial review.

What happens to my benefits if my income or assets go over the 2026 limits?

If your gross monthly income exceeds $2,982 or your countable resources top $2,000, you may temporarily lose eligibility or face a penalty period. To prevent this, families often utilize legally sound financial strategies, such as setting up a Medicaid Asset Protection Trust or a Pooled Income Trust, to legally protect resources and maintain their care coverage.

Does Medicare pay for daily personal in-home care?

No. Traditional Medicare and standard Medicare Advantage plans only cover short-term, medically necessary “skilled” care, such as physical therapy or wound care following a hospital discharge. In contrast, Medicare does not cover long-term, non-medical personal care like bathing, dressing, or meal preparation.

Ready to Secure Care for Your Loved One?

Don’t navigate the complex Pennsylvania Medicaid waiver system alone. Contact Lehigh Care at Home today at (484) 221-8148. Our local care experts are ready to help you complete your application paperwork, coordinate with the PA IEB, and smoothly transition your family member into a paid caregiver role. Our local care experts are ready to help you complete your application paperwork, coordinate with the PA IEB, and smoothly transition your family member into a paid caregiver role.