Nursing homes and assisted living facilities in Pennsylvania are expensive, and even alternative long-term care like home health care can be costly. In 2017, the median annual cost of a private room in a nursing home in Pennsylvania was $120,085. Private health insurance policies generally don't cover long term care, very few people purchase private long-term care insurance policies, and Medicare coverage for long-term care services is limited.
When people can't afford to pay the $5,000 to $8,000 per month of long-term care, they often turn to Medicaid, which has become a very common source of funding for long-term care. In 2017, approximately 60% of nursing home residents in Pennsylvania used Medicaid to pay for their nursing home care.
There are many different ways to become eligible for Medicaid in Pennsylvania, and there are specific eligibility rules for long-term care services like nursing homes, assisted living facilities, and home health care services.
If you receive SSI, you are already eligible for Medicaid. People who don't receive SSI but are sixty-five or older, disabled, or blind can qualify for Medicaid if they meet certain income and asset limits.
Pennsylvania’s Medicaid benefit for elderly, disabled, and blind individuals is called Non Money Payment (NMP) Medicaid. You may be eligible for NMP Medicaid if your income is equal to or less than 300% of the monthly SSI benefit amount (also known as the federal benefit rate, or FBR). In 2019, the FBR is $771, and the individual NMP income limit is $2,250/month.
If your income is above the 300% FBR limit, you may still be able to qualify for Medicaid. First, you can put your extra income each month into a special bank account that is set up under the terms of a special needs trust, or qualified income trust. For help with an income trust, consult an attorney.
You may also qualify for Medicaid through Pennsylvania’s Medically Needy Program. In the Medically Needy Program, you can use medical bills, including nursing facility bills, that you incur each month to “spend down” your income and qualify for Medicaid Needy Only (MNO) Medicaid.
The MNO income limit is $425/month, meaning that you must show that you have incurred medical expenses each month that would leave you with no more than $425. When you apply, your county assistance office will estimate your income and expenses for six months and see whether your adjusted income is less than $2550 ($425/month for six months). The actual or anticipated cost of a long-term care facility for a six-month period is an allowable expense to qualify for MNO Medicaid.
For example, Mrs. Smith is 70 years old. Her income is $3,500/month, but she lives in a nursing home that charges $7500/month. She is not eligible for NMP Medicaid because she is over the income limit of $2,250/month, but she is eligible for MNO Medicaid because her medical expenses exceed her income. She will be allowed to keep a monthly personal needs allowance of $45, but she will have to contribute all of her other income to the cost of the nursing home. Medicaid will pay the remaining balance. If she has a dependent or a spouse remaining in the community, the state will allow her to set aside some income for their support.
To qualify for Medicaid in Pennsylvania, you must also have few resources, or assets. The resource limit for individuals whose income is below 300% of the FBR ($2,313/month in 2019) is $2,000 for an individual, but the program also “disregards” $6,000 in assets, so you can actually have up to $8,500 in resources and still qualify. The resource limit for an individual whose income is above 300% of the FBR is $2,400.
Some property does not count toward the resource limit. In Pennsylvania, your home is exempt up to an equity value of $572,000, so long as you live in it, intend to return to it, or if your spouse or dependent lives in it. One vehicle is also excluded from the resource calculation.
Medicaid will pay for a nursing home only when it is medically necessary, meaning that a doctor has said you need a nursing home because you have a condition that requires more care than just room and board. This is called meeting the "nursing home level of care." In Pennsylvania, to meet the nursing home level of care, you must show that either you need skilled nursing or rehabilitation services or that you need some kind of health-related care to be provided to you on a regular basis. You must show that you cannot provide the care yourself and that you need some type of licensed staff to provide services for you.
In Pennsylvania, before you are admitted to a nursing home, you will get a Pre-Admission Screening and Resident Review (PASRR). PASRR screening is intended to assess whether you meet the nursing home level of care and also whether a particular facility can meet your needs.
Assisted living facilities, called “personal care homes” (PCHs) in Pennsylvania, are generally less expensive and less medically intensive than nursing homes. PCHs are licensed by the state, but in general, Pennsylvania’s Medicaid programs do not cover the costs of PCHs. However, if you receive SSI and need to live in a PCH, the state can pay a supplement to the facility to help you afford the cost with your SSI benefit. In addition, Medicaid might pay for some services you receive while you are living in a PCH, even though it would not pay your room or board fees.
Home health care can include skilled nursing or therapy services, home health aide services like medication management or bathing assistance, and personal care aide services like meal preparation or cleaning. Pennsylvania has several programs that offer payment for home care services.
First, if you receive Medicaid, the program will pay for some limited home care services. The services must be prescribed by your doctor as part of a plan of care for a particular problem, and the services must be directed at curing or rehabilitating you.
Pennsylvania also operates several Medicaid Waiver programs that provide home health care services to low-income Pennsylvanians.
To qualify for any of Pennsylvania’s Waiver programs, you must meet the nursing home level of care. In addition, you must have income less than $2,163/month and fewer than $8,000 in resources. To apply for waiver programs, contact the Office of Long-Term Living (OLTL) Helpline at 866-286-3636.
If you are 60 or older, you may qualify for Pennsylvania’s Aging Waiver. The program offers home-delivered meals, home health services, transportation, personal assistance, emergency response systems, and accessibility modifications to your home.
If you are younger than 60 and have a physical disability, you may qualify for Pennsylvania’s Attendant Care Waiver. Depending on your income, you may be required to contribute to the cost of your services. If you qualify, the Attendant Care Waiver can provide you with personal support, home health services, emergency response services, and specialized equipment and supplies to help you live independently. Pennsylvania has similar waiver programs for other specific populations, like people with developmental disabilities, people with AIDS, and people with traumatic brain injuries.
Pennsylvania also has a program for individuals who are 55 or older called Living Independence for the Elderly (LIFE). LIFE is not a Medicaid Waiver program; it operates under a Medicaid provision called Programs of All-Inclusive Care for the Elderly (PACE). PACE programs provide a system of comprehensive wrap-around services to allow seniors who are at risk of institutionalization to remain in their homes. Pennsylvania’s LIFE programs are managed care programs that are operated by private entities. LIFE is not available in all areas of the state. To see whether there is a LIFE provider near you, check this Department of Public Welfare list or call the OLTL Helpline at 866-286-3636.
If you do not qualify for Medicaid and do not meet the nursing home level of care, you may still qualify for some home health services if you are at least 60 years old. Pennsylvania’s Area Agencies on Aging operate a program called OPTIONS that provides a variety of services like personal care services, home-delivered meals, transportation, medical equipment, accessibility modifications, and home health services. You may be required to pay a co-payment, depending on your income. To apply, contact your local Area Agency on Aging or call the OLTL Helpline at 866-286-3636.