In Pennsylvania, almost everyone who has both Medicare and Medicaid, lives in a Medicaid-paid nursing home, or receives Medicaid home care gets that care through Community HealthChoices (CHC). CHC is the Commonwealth's mandatory Medicaid managed care program for dually eligible people and adults with physical disabilities, and the capitated program through which Pennsylvania delivers managed long-term services and supports (MLTSS); enrollment is not optional for the people it covers. It runs through three managed care organizations (MCOs) that each cover all five of the program's zones, and the plan a family chooses decides which case manager, provider network, and extra benefits come with the coverage.

CHC vs. HealthChoices: Telling the Two Programs Apart

Pennsylvania runs two Medicaid managed-care programs with almost the same name. HealthChoices (no leading word) is the physical-health Medicaid managed-care program for most working-age adults, parents and children, and pregnant women. Community HealthChoices is the long-term-services-and-supports program this guide covers. Both are run by PA DHS and mandatory for their populations, so when a hospital social worker says "pick a HealthChoices plan," ask which one they mean; the answer changes which number you call. Behavioral health is a third track, carved out of CHC to a county behavioral-health MCO (BH-MCO), so most CHC members carry two plans at once.

Who Must Enroll in Community HealthChoices (and Who Is Carved Out)

You are in CHC if you are 21 or older and any one of these is true: you receive both Medicare and Medicaid; you get long-term services and supports through the former Attendant Care, Independence, COMMCARE, or Aging waivers; you are in the OBRA waiver and nursing facility clinically eligible; you receive Medicaid-paid nursing-home care; or you are a dually eligible Act 150 participant.

One right rides with the Section 1915(c) authority CHC is built on, and it is easy to be denied in practice: a person determined likely to need the level of care a skilled nursing or intermediate care facility provides must be informed of the feasible alternatives under the waiver, and may choose among them. If nobody has walked you through the home-based options, ask for them.

Several groups are left out, and getting the boundary wrong sends a family to the wrong program:

  • Intellectual-disability and autism waivers (Consolidated, Person/Family Directed Support, Community Living, Adult Autism) run under the Office of Developmental Programs.
  • The LIFE program, Pennsylvania's name for PACE, is a voluntary alternative for people 55 and older who meet nursing-facility level of care, meet the financial requirements or can privately pay, live in a LIFE provider's service area, and can be safely served in the community. It replaces CHC rather than adding to it, and someone already in LIFE stays there unless they ask to change. Enrollment is never locked in: federal PACE rules let a participant disenroll without cause at any time, effective the first day of the month after notice (42 CFR 460.162).
  • Act 150 attendant care is state-funded, so participants are not in CHC unless also dually eligible.
  • Residents of a state-operated nursing facility, including the state veterans' homes, are not eligible. DHS names this explicitly, and it catches families moving a veteran to a community facility.
  • Adults under 21 are outside CHC, which starts at 21.
  • OBRA waiver participants who are not nursing facility clinically eligible are likewise outside it.
  • Behavioral health is a carve-out of the benefit rather than the population.

The Three Community HealthChoices Plans in Pennsylvania

All three CHC-MCOs cover every one of the five CHC zones, so where you live never narrows the list. They differ in supplemental benefits, network depth by region, and service-coordinator practice, so compare on those rather than assuming they are interchangeable.

Plan Member-services line DHS lists Zones covered
AmeriHealth Caritas 1-855-235-5115 (DHS lists a separate Keystone First line, 1-855-332-0729) All five CHC zones
PA Health & Wellness 1-844-626-6813 All five CHC zones
UPMC Community HealthChoices 1-844-833-0523 All five CHC zones

DHS lists AmeriHealth Caritas and Keystone First as separate entries with separate member-services lines, so check which name is on your parent's plan card. What matters is whether your parent's doctors are in network, which plan contracts with the home-care or nursing-facility provider you want, and what supplemental benefits (dental, vision, over-the-counter allowance, transportation) each adds. Call each plan to confirm before you choose.

What Community HealthChoices Covers

Because CHC is capitated, the CHC-MCO is responsible for the Medicaid services a participant qualifies for, and for members who meet nursing-facility level of care that includes the long-term services and supports Medicaid delivers through its home and community-based authorities. For a member in a Medicaid-paid nursing home, the CHC-MCO is the payer. The home and community-based side typically includes personal assistance services (agency- or self-directed), home health, adult day services, home-delivered meals, personal emergency response systems, home modifications, respite, and service coordination; your plan's handbook is the controlling list, so ask for it in writing.

Federal rules set the clock on authorization decisions. For rating periods beginning on or after January 1, 2026, a standard decision is due within 7 calendar days under 42 CFR 438.210, tightened by the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F); the prior 14-day cap still governs earlier rating periods. An expedited decision, used when the standard clock could seriously jeopardize the enrollee's life, health, or ability to regain maximum function, is due within 72 hours. The standard clock extends by up to 14 more days if you or your provider ask, or if the plan justifies needing more information and the delay is in your interest; for the 72-hour clock the regulation names you, not your provider, as the one who may ask. Covered outpatient drug decisions run on a different rule, and an applicable integrated plan follows 42 CFR 422.629 through 422.634 instead.

Getting Paid to Care for a Family Member: Services My Way

Two things often run together are not the same. Participant direction makes the participant the Common Law Employer of their own Direct Care Workers (DCWs), hiring, training, scheduling and supervising them and setting their pay within limits. Services My Way, or Budget Authority, is a distinct option in which the participant manages a budget for their Personal Assistance Services needs and can buy goods and services that may or may not be a covered benefit, so long as they support a goal for the participant's independence. Ask which you are being offered. Tempus Unlimited is the Fiscal/Employer Agent: it processes timesheets, makes payments, withholds employment tax, issues paychecks and W-2s, and files the employer taxes, while the participant stays the employer.

Most relatives can be paid. The CHC waiver lets family members provide Respite, Personal Assistance Services and Participant-Directed Community Supports, with four exclusions: it will not pay a participant's spouse, legal guardian, Representative Payee, or Power of Attorney. So an adult child, parent, sibling, grandchild or in-law who is none of those four can be paid; a spouse cannot. DHS's Tempus handbook states the bar slightly wider, as spouse, power of attorney, legal or designated representative, or guardian, so check both against your paperwork. Three conditions people learn late: a family-member DCW must meet the same provider qualification standards as a worker caring for a stranger, must be 18 or older with a valid Social Security number, and must agree to a criminal record check. And a plan under which one person provides more than 40 hours a week is reviewed and approved by the CHC-MCO, so raise it before anyone quits a job.

The tax break is real but narrower than it sounds. IRS Notice 2014-7 treats qualified Medicaid waiver payments as difficulty-of-care payments excludable from gross income, related provider or not, but the co-residence test runs on where the provider lives: care given outside the provider's home is not excludable, and the exclusion is lost where the provider keeps a separate home. Money paid directly by the care recipient from their own funds cannot be excluded either. The Pennsylvania paid family caregiver guide works through it.

How to Enroll in Community HealthChoices in Pennsylvania

The Pennsylvania Independent Enrollment Broker (PA IEB) is the front door: call 1-877-550-4227 or start at paieb.com. It schedules the in-home assessment, sends the plan-selection packet, and provides Beneficiary Support Services for Office of Long-Term Living programs. Once enrolled, questions go to the CHC participant helpline at 1-844-824-3655; both lines run Monday through Friday, 8:00 a.m. to 6:00 p.m. Eastern. DHS also lists a CHC Participant Call Center at 1-800-757-5042 and PA Relay at 711, and gives the IEB TTY line as 1-877-824-9346 where the IEB's own site gives 711.

1
Step 1

Rule out LIFE first

If your parent is 55 or older, lives in a LIFE provider's service area, and meets nursing-facility level of care, weigh that alternative before choosing CHC.

2
Step 2

Apply for Medicaid

through COMPASS at compass.dhs.pa.gov, by phone at the Consumer Service Center (1-866-550-4355), or at the County Assistance Office.

3
Step 3

Clear the financial test

For 2026 Pennsylvania uses an income limit of $2,982 a month for a single long-term-care applicant, 300 percent of the federal benefit rate. At or below it the countable-resource limit is $2,000 plus a $6,000 disregard; above it, $2,400. Do not read those as your bank balance: they measure nonexcluded resources, and Pennsylvania excludes the home you intend to return to (or where a spouse or dependent lives), one motor vehicle, burial spaces and reserves within set limits, and life insurance under $1,500 face value per person, so a homeowner with a car is not disqualified. The federal home-equity limit for 2026 is $752,000, and a state may elect up to $1,130,000. That cap does not apply at all when the applicant's spouse, a child under 21, or a blind or permanently and totally disabled child lawfully lives in the home, and even without such a relative a reverse mortgage or home equity loan may bring equity below it and the Secretary must maintain a hardship waiver process. Over the income limit, you can still qualify through the medically-needy spend-down over a six-month budget period, but spending down is not enough alone: you must also meet the resource standard ($2,400 for one person), and only the expenses on Pennsylvania's list at 55 Pa. Code 181.14(d), deducted in a set order, count. Full figures: PA Medicaid eligibility and income limits.

4
Step 4

Complete the functional assessment

The IEB arranges an in-home assessment to determine nursing-facility clinical eligibility.

5
Step 5

Choose a plan

The IEB sends a packet listing the three MCOs. If you do not choose, it assigns one, and you can switch at any time.

Continuity of Care in CHC: What Actually Carries Over

Pennsylvania's nursing-facility transition protection is narrower than usually described: it is tied to the CHC Implementation Date in each zone (January 1, 2018 Southwest, 2019 Southeast, 2020 Northwest, Lehigh-Capital and Northeast). A participant already living in a nursing facility on that date keeps receiving services from that facility until the earliest of three things: the stay ends, they are disenrolled from CHC, or the facility stops being enrolled in Medical Assistance. Switching CHC-MCOs, a temporary hospitalization, and therapeutic leave do not cut that short, and being out of network is no reason to refuse payment: the CHC-MCO must contract with the facility to pay for the care.

That is now a closed group. If your parent entered a nursing home after CHC came to their zone, a much shorter rule applies. They must use a facility in their CHC-MCO's network; if it later leaves the network, they may keep receiving care there for up to 60 days, counted from the later of the plan's notice of termination or pending termination and the termination itself, so long as they remain eligible for nursing-facility services. The exception is a facility terminated for cause under 40 P.S. 991.2117(b), and the same 60-day protection covers services that are neither nursing facility nor HCBS.

On the home and community-based side, the 180-day period in which participants kept existing HCBS providers and service coordinators was a rollout-era provision and has run out in every zone, so ask a new plan in writing which providers it will keep and for how long. One question our sources do not settle: whether appealing a proposed transfer or discharge holds the nursing-facility continuity period open. That turns on the Continuity of Care section of the CHC-MCO agreement, so if your parent gets a transfer or discharge notice, ask about appeal rights rather than assuming the protection has ended.

If a Plan Denies or Cuts a Service: Appeals

When a CHC-MCO denies, reduces, or ends a service, the appeal path is layered and the deadlines are federal. Our Pennsylvania Medicaid appeals guide walks the whole process; here is what a CHC family must get right.

  • Appeal to the plan first, within 60 calendar days of the date on the adverse-benefit-determination notice, orally or in writing; the plan offers one level of internal appeal. With your written consent a provider or representative may file it, but a provider cannot request continuation of benefits for you.
  • The plan's clock is a ceiling, not an allowance. A standard appeal must be resolved within 30 calendar days, an expedited one within 72 hours, and the plan must move as fast as your condition requires. Either clock extends by up to 14 calendar days if you ask, or if the plan shows the state it needs more information and the delay is in your interest; extending without your asking obliges it to tell you promptly by phone, give written notice of the reason within 2 calendar days, and note your right to grieve it. If it misses its own notice and timing requirements you are deemed to have exhausted its process and may go straight to a fair hearing.
  • Then request a State fair hearing through the DHS Bureau of Hearings and Appeals, where you have at least 90 calendar days. Federal rules set a 90-to-120-day band and each state picks a number inside it, so treat 90 as the floor and confirm Pennsylvania's exact deadline on the plan's notice of resolution.

The ten-day trap: filing on time and keeping your services are two different clocks. Benefits do not continue automatically. Continued benefits end when you fail to request the fair hearing and continuation within 10 calendar days after the plan sends its notice of adverse resolution, so taking the full 90 days keeps the appeal but loses the coverage meanwhile. Continuation also requires that you filed the plan appeal on time, that it concerns previously authorized services you had not yet received, that an authorized provider ordered them, that the original authorization has not expired, and that you filed for continuation by the later of 10 calendar days after the adverse-benefit-determination notice or the intended effective date. If the final decision upholds the plan, it may recover the cost of what was furnished solely because of the continuation.

Ask for aid pending explicitly, and ask even if you are late. Past the effective date, 42 CFR 431.231(a) still lets the agency reinstate services when you request a hearing no more than 10 days after the date of action. Where the action came without the required advance notice, reinstatement is not discretionary: under 42 CFR 431.231(c) the agency must reinstate and continue services if you request a hearing within 10 days of receiving the notice (receipt presumed 5 days after its date unless you show otherwise) and it determines the action did not result from applying federal or state law or policy. Put the request in writing.

The Pennsylvania Health Law Project (PHLP) at 1-800-274-3258 is the free legal-aid resource for Pennsylvania Medicaid, CHC, and Medicare, independent of DHS and the MCOs. Call it first when something goes wrong with a CHC plan.

Paying for the Nursing Home: What the Family Actually Owes

When a CHC member lives in a nursing facility, the CHC-MCO pays for the facility care and the resident contributes most of their monthly income toward the cost, keeping a Personal Needs Allowance of $60 per month, raised from $45 effective January 1, 2025. If one spouse stays in the community, that spouse's protected share is one-half of the couple's total countable resources, never less than $32,532 and never more than $162,660 for 2026., Read that in both directions: a couple with modest savings protects half of what they have, not $162,660. Our Pennsylvania spousal impoverishment guide works the calculation.

But $162,660 is not a hard ceiling, and this is where families leave money on the table. Pennsylvania's regulation directs the county assistance office to deduct the greater of four amounts, two of which carry no dollar figure: resources transferred to the community spouse under a court support order, and an amount set by a Departmental hearing decision. That hearing route exists where the income the ordinary allowance generates cannot bring the community spouse up to the monthly maintenance need allowance; the hearing officer then sets a resource amount adequate to get them there. Two mandatory conditions bind it: the institutionalized spouse's own income must fund the allowance first, with only the shortfall made up out of resources, and the revision applies only if that spouse actually gives the allowance to the community spouse. You must apply and request a hearing. Two more things DHS states plainly: the community spouse need not pay for the institutionalized spouse's long-term care, and keeps all their own earnings, whatever the amount.

Gifts or transfers in the five years before a long-term-care Medicaid application can trigger a penalty measured in days: Pennsylvania divides the uncompensated value by its average daily private-pay nursing-facility rate, $421.20 per day ($12,811.50 per month) effective January 1, 2026, up from $399.80. A transfer inside the look-back is reviewed, not automatically fatal, and the exceptions are broader than most families are told, but you get only 15 calendar days from the mailing date of the county's notice to rebut. Our Pennsylvania penalty divisor and look-back guide has the full exception and rebuttal lists. The look-back attaches to Medicaid long-term-care eligibility generally, not only nursing-home coverage, so do not assume a gift is safe because the care is delivered at home.

What's Changing in 2026

  • HCBS waivers run on a renewal clock, not an expiration date. Under 42 CFR 441.304 a Section 1915(c) waiver runs in fixed terms, three years for a new waiver (five where it enrolls dually eligible people), extendable for additional five-year periods when the state asks, so a term ending starts a renewal rather than a cutoff. The extension is not automatic: CMS may refuse it where its review shows the required assurances were not met, and where it finds a state substantively out of compliance, after notice and an opportunity for a hearing, it may impose a moratorium on new enrollments, take other corrective steps, withhold part of the federal payment, or terminate the waiver.
  • Faster authorization decisions. The 7-day standard service-authorization clock applies to CHC plans for 2026 rating periods.
  • Medicaid provider-tax changes. Section 71115 of the federal One Big Beautiful Bill Act (P.L. 119-21, enacted July 4, 2025) limits how states use provider taxes to fund the state share of Medicaid for fiscal years starting on or after October 1, 2026, through the hold-harmless safe harbor rather than a ban: no state may put a new provider tax under that waiver, and an existing tax's permissible threshold may not exceed the percentage in place on July 4, 2025. It changes Medicaid financing, not the CHC benefit package.

Frequently Asked Questions

Can I be paid to care for my parent through CHC?

Yes, through Services My Way, with one major exception: a spouse cannot be paid. Adult children, siblings, in-laws, grandchildren, and friends can be paid as Direct Care Workers, but a DCW cannot be the participant's spouse, legal guardian, representative payee, or power of attorney. Tempus Unlimited runs the payroll and tax filings.

How is CHC different from LIFE?

LIFE is Pennsylvania's name for the federal PACE model: voluntary, and requiring age 55 or older, nursing-facility level of care, residence in a LIFE provider's service area, and the ability to live in a community setting safely. LIFE participants get all their care through the LIFE provider and have no CHC-MCO, and someone already in LIFE stays there unless they ask to change. You can leave LIFE without cause at any time, but the disenrollment takes effect the first day of the following month.

Who pays for the nursing home if my parent is on CHC?

The CHC-MCO pays for the facility care, and your parent contributes their income toward the cost, keeping a $60 monthly Personal Needs Allowance. Medicare stays primary for short-stay rehabilitation; CHC pays for long-stay care. The five-year look-back and transfer penalty attach to Medicaid long-term-care eligibility generally, so home-based care does not let a family skip them.

Learn More

MedicaidPennsylvania Medicaid hubPennsylvania Medical Assistance for seniors: 2026 income and two-tier asset limits, a daily penalty divisor, probate-only estate recovery, and how to apply. MedicaidPA Medicaid eligibility and income limitsPennsylvania Medicaid income limits for 2026: the $2,982 long-term-care income cap, the two-tier $2,400/$8,000 asset limit, and how seniors qualify. MedicaidHow to apply for Pennsylvania MedicaidHow to apply for Medicaid in Pennsylvania in 2026: COMPASS online, the County Assistance Office, or the new phone line, plus PA-600/600 LTC forms and timelines.

Find personalized help comparing Pennsylvania's Community HealthChoices plans at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.

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Brevy Care Team

Expert eldercare guidance from Brevy's team of healthcare professionals and researchers.