Many families assume that when Medicare doesn’t cover long-term care at home, that Medicaid will step in and fill the financial gap. The answer is not always simple, especially here in Pennsylvania.
As an RN Case Manager in the Philadelphia area, I’ve seen how confusing it can be for families to navigate the differences between Medicare and Medicaid. In addition, many assume that when Medicare doesn’t cover long-term care at home, Medicaid will naturally fill that gap. While Medicaid can certainly offer important support, it has its own set of financial and clinical requirements that are helpful to understand early on. I’ll do my best to explain how it works clearly, even though I know some of these rules can feel frustrating for families.
Medicare typically covers short-term, skilled home health care needs. And, if you’re still unsure what Medicare actually covers, especially when it comes to care at home, it’s helpful to understand the details of skilled-based short-term care before making assumptions.
What Is Medicaid and Who Qualifies?
Medicaid is a needs-based program, which means eligibility is determined by both financial and medical factors. Unlike Medicare, which is largely age-based, Medicaid looks more closely at a person’s income, assets, and level of care needs.
From a financial standpoint, there are specific income and asset limits that must be met in order to qualify. These limits can vary slightly, but in general, Medicaid is designed for individuals who have limited financial resources or who have spent down assets due to ongoing healthcare needs or expenses in general.
Just as important is the clinical side of eligibility. In order to receive home care services through a Waiver program, an individual must meet what is considered a “nursing home level of care.” This doesn’t necessarily mean they need to be in a nursing home, but rather that their care needs are significant enough to require that level of support.
In my experience, this is where many families feel confused. A loved one may clearly need help at home, but not yet meet the strict criteria required for approval, or they may meet the clinical need but not the financial requirements. Understanding how these two pieces work together can help families better prepare and avoid surprises during the application process.
For example, PA Medicaid will take into account is the number of people in the home, and everyone’s income. Say the applicant is 80 years old and demonstrates physical need eligibility (help with ADLs and personal care assistance), but has an adult child living in the household who even brings in a small paycheck, this may disqualify the elderly applicant due to the income that is now combined income at the same residence.
I know…some of the eligibility of rules can be frustrating….
Does Medicaid Pay for Home Care in Pennsylvania?
Yes, indeed, it will pay for personal “non-skilled” Home Care in the home.
But, it is not automatic.
Let’s start with the Waiver Program.
What Is the PA Medicaid Waiver Program and How It Helps in the Home
One of the most important parts of Medicaid to understand, especially for families hoping to keep a loved one at home, is the Waiver Program.
How Community HealthChoices (CHC) Fits In
In Pennsylvania, many of these home care services are provided through a program called Community HealthChoices (CHC).
CHC is Pennsylvania’s managed care program for individuals who have both Medicare and Medicaid. It helps coordinate long-term services and supports (LTSS), including care at home, so individuals can safely remain in their community.
Through CHC, eligible individuals can receive support with daily activities like:
- Bathing and dressing
- Meal preparation
- Mobility and safety at home
Instead of navigating multiple systems, CHC helps bring services together and connects families with approved providers that will service your loved one in the home.
In Pennsylvania, Medicaid offers what are called “waiver programs,” which are designed specifically to provide support outside of a nursing home setting. In simple terms, these programs allow someone who meets nursing home level of care requirements to receive services in their own home instead.
This is often where families feel a sense of relief! The goal of these programs is to help individuals remain safely in their home environment for as long as possible, rather than moving into a facility. Many love this and the continued feeling of independence.
Through a waiver program, Medicaid may help cover services like personal care assistance, help with daily activities, and even coordination of care. These home health aide supports can make a meaningful difference for both the individual and their caregivers, especially when needs start to increase.
That said, it’s important to understand that these programs are not automatic. There is an application process, and eligibility is based on both financial qualifications and clinical need. In my experience, this is where many families feel overwhelmed, because even though the support exists, navigating the system can take time and patience…a lot of patience. But once you get through the initial steps, it really does become more manageable!
And, when it comes together, the Waiver Program can be an incredibly valuable option for families trying to balance safety, independence, and the desire to remain at home.
What Types of Home Care Does Medicaid Cover?
Generally, the type of home care covered is: light housekeeping, meal set-up or prep, light laundry, dressing, bathing, ambulation, and assistance withce with some medical equipment, transfer assistance, and non-skilled help in the home.
How These Services Are Different (In Real Life)
When Medicaid covers care at home, the support usually falls into a few different categories, and it can be helpful to understand what each one really means day to day.
Personal care refers to very hands-on support with basic needs like bathing, dressing, and hygiene. This is the type of care that helps someone maintain dignity and safety when they are no longer able to manage these tasks independently.
Help with daily activities is a bit broader and often includes things like meal preparation, light housekeeping, and reminders throughout the day. This type of support is meant to help someone function safely in their home, even if they are still somewhat independent.
Limited medical support is where some confusion comes in. While Medicaid may include basic health-related tasks, such as monitoring or reminders, it does not replace skilled nursing care. This means more complex medical needs, like wound care or injections, are typically handled separately through skilled services, not through the waiver caregiver.
In my experience, families often expect all of these to blend seamlessly, but in reality, they are provided at different levels and by different types of caregivers. Understanding that distinction early on can help set more realistic expectations and make it easier to plan for additional support if needed.
What Medicaid Typically Does NOT Cover for Home Care
While Medicaid waiver programs can be incredibly helpful, it’s just as important to understand what they typically do not cover so families can plan ahead without surprises.
One of the biggest gaps are around-the-clock care. Medicaid does not usually provide 24/7 in-home support, which means families often still need to fill in those gaps, especially overnight or during longer stretches of time.
Recently, there have been some rollbacks in the number of hours. There is still, at times a need for family pitch-in to fill in the gaps if the person has cognitive or significant physical needs.
Even if someone clearly needs more help, services are often based on assessments and program guidelines, not always on what families feel is needed in real time.
Another area that is not typically covered is companion-based care. While some social support may be included, the Medicaid Waiver is focused more on essential daily care needs rather than ongoing companionship or supervision. Many of these home health aides become like family, but it is not written in the books that this is a requirement of the job.
Medicaid also does not provide the skilled-based care that is serviced by Registered Nurses, or LPNs, Physical Therapists, Occupational Therapists or Speech Language Therapists. This falls under Medicare or commercial insurance as a payer.
It’s also important to know that Medicaid does not cover what they call non-essential or convenience-based services, such as extensive housekeeping, private transportation beyond medical needs, or higher-end, private-duty care options.
In my experience, this is where families start to realize that while Medicaid can provide meaningful support, it often works best when combined with family involvement or additional private care to truly meet a loved one’s needs at home, especially if the goal is to keep the person out of a facility at this time.
How to Apply for Medicaid Home Care in PA
- You can apply directly on the PA COMPASS website: https://paieb.com/en/apply-for-waiver-services.
- PA Pennsylvania’s Department of Human Services at 1-866-550-4355
- Will help you answer general questions, and help you through the process
- Philadelphia Local Area Agency on Aging – Main Phone is 215-765-9000
- Highly recommend that you call the Local office in your county or the catchment for your zip code. They will also walk you through the application process!
- Determine eligibility
- And guide you through the process
This has gotten a bit easier! If you have access to a computer or can access a Public Library, you can apply via the PA Compass website.
There are many Financial Documents you may need to access. In fact, the state will do a deep dive into any assets, annuities, retirement savings, and real estate that your loved one may have – or even forgot to mention to you.
The States will do a look back, sometimes back to 5 years, including bank statements or even longer. Banks are used to this. I tell my family to access support and help wherever it is offered. Take some of the load off your shoulders.
Next, is a Needs Assessment. Each county in the State of PA has its own Area on Aging. Within this Department, you will find the respective unit that will come to the home, hospital, or rehab to begin the physical and cognitive needs assessment that they feel will be needed to keep them safe in the home.
How Long It Takes to Get Approved
- Application: usually 2-4 weeks when one needs to gather all the paperwork requested.
- Approval: often 30–90 days with an in-home or in-person assessment
- Services start after approval
Wait time can vary by your county, the number of case managers they employ, and the load. I usually tell my families, it can take about 1-3 months for a determination of financial and physical need for Philadelphia.
What I Tell Families as a Nurse Case Manager
As a nurse case manager, I always tell families not to wait until a crisis. Like anything with the government, there is a lot of red tape.
- Apply early
- Keep documents ready
- Don’t assume you won’t qualify!
- Get help if overwhelmed – some counties and Area on Aging sites have social workers or case managers who will help you fill these out. Even the County Assistance office can be of assistance.
What Families Should Know Before Relying on Medicaid Home Care
There can be delays. I would expect it, then you are not too disappointed when you run into this.
Expect some back-and-forth phone calls requesting more financial documents.
And expect regular visits from the case manager even after the determination. They are only checking in to ensure that the Home Health Aide and the agency they are deployed from are serving the older person as needed.
Even with the backing and reliability of an agency that schedules the Home Health Aide, expect some gaps. Some last-minute cancellations may happen.
There is also a lot of burnout with this type of work, and there may be frequent turnover of staff.
Always have a backup plan!
There is also an Options Program where a family may be able to supplement the financial cost if not all hours are covered under the Waiver Program.
Final Thoughts
As you start to piece together a plan, it can be helpful to explore local home care options and resources that can support your loved one alongside what Medicaid provides.
You can explore providers and services in the Philadelphia area through our directory.
