The Office of Long-Term Living (OLTL) administers the Community HealthChoices (CHC) and Omnibus Reconciliation Act (OBRA) Waivers as well as the Living Independence for the Elderly (LIFE) program.
OLTL
uses an agency called the Independent
Enrollment Broker (IEB) to determine an
individual’s medical eligibility and to provide enrollment services for
its HCBS Waiver programs. The IEB works with consumers,
service providers, and CAOs to ensure that consumers are enrolled in the HCBS
program that best serves their needs.
The IEB will
inform the CAO of a consumer’s medical eligibility by sending a
Home
and Community Based Services (HCBS)
Eligibility/Ineligibility/Change
Form (PA 1768)
with all necessary information
completed. Upon
receipt of the PA 1768 and
a PA 600 form,
along with required documentation, the CAO will determine financial eligibility.
IEB Contact Information:
Toll free helpline: 877-550-4227 Toll free TTY line: 877-824-9346 Fax number: 717-540-6201
PA Independent
Enrollment Broker
P.O. Box 61560
Harrisburg, PA 17106
The CHC Waiver consolidates the OLTL waivers into a single waiver, except for the Living Independence for the Elderly (LIFE) and the Omnibus Budget Reconciliation Act (OBRA) Waivers. It provides services to individuals age 21 and over who need an NFCE level of care. CHC waiver recipients are enrolled into a managed care plan which helps coordinate the recipient's services.
The CHC Population includes:
· Nursing Facility Ineligible Dual (NFI Dual) population.
Adults age 21 or older who receive Medicaid and either Medicare A, B, C or D.
· Nursing Facility Clinically Eligible Dual (NFCE Dual) population.
Adults age 21 or older who receive Medicaid and either Medicare A, B, C or D.
These individuals receive Long Term Services and Supports (LTSS) in either a private or a county nursing facility or in a community setting.
· Nursing Facility Clinically Eligible Non-Dual (NFCE Non-Dual) population.
Adults age 21 or older, who receive Medicaid and who are not eligible for either Medicare A, B, C or D.
These individuals receive LTSS in either a private or a county nursing facility or in a community setting.
The CHC population does not include:
· Individuals under age 21.
· Individuals receiving their services through the State-funded Options Program (Act 150 Program).
Exception: NFI Duals enrolled in Act 150 will be enrolled in CHC for their physical health services and will receive their waiver services through Act 150.
· Individuals with intellectual/developmental disabilities (ID/DD), who receive services through the DHS Office of Developmental Programs (ODP).
· Residents of state-operated nursing facilities, including the State Veterans’ Homes and South Mountain Restoration Center.
Individuals enrolled in a CHC managed care plan may change their MCO by contacting the IEB.
489.33 Living Independence for the Elderly (LIFE) Program
The LIFE Program, once known as the Long-Term Care Capitated Assistance Program (LTCCAP) in PA, is known nationally as the Program for All-inclusive Care for the Elderly (PACE). LIFE is a managed-care program for individuals eligible for HCBS who, when provided with proper support services, can safely be maintained in their own homes. The LIFE Program is administered by the OLTL. It is designated with waiver code 96 in eCIS.
To be eligible for LIFE, an individual must meet the following conditions:
Eligible for MA or choose to pay privately for services and;
Age 55 or older and;
Assessed as Nursing Facility Clinically Eligible (NFCE) and;
Able to safely live in the community with services made available through the provider at the time of enrollment, and;
Reside in locations where LIFE services are available.
The LIFE Program is like other waiver programs in the following ways:
LIFE recipients eligible for MA and residing in the community are authorized in waiver category PAW/PJW/PMW.
NOTE: SSI recipients will remain in the SSI category with waiver code 96.
LIFE applicants must meet the HCBS resource and income limits and policy found in LTC Handbook Chapters 440 and 450 to be eligible for MA HCBS.
LIFE recipients residing in a LTC facility for more than 30 days are authorized in a LTC facility category with entry of a LTC facility code.
Fair consideration and spousal impoverishment provisions, including determination of the protected share of resources for the community spouse apply.
The LIFE Program is different than other waiver programs in the following ways:
If and when a LIFE recipient can no longer receive services in the home, they can transition into a LTC facility and remain in the LIFE Program.
NOTE: The LIFE waiver code 96 must remain on the case as long as the individual is enrolled in the LIFE Program.
LIFE recipients who enter a LTC facility for 30 days or less remain in the HCBS category and are not charged a cost of care. If the LIFE recipient is in an LTC facility 30 days or fewer no system changes are needed.
NOTE: The LIFE provider is responsible for payment to the facility from their capitated rate from the date of admission to the 30th day.
LIFE recipients who enter a facility for 31 days or more must be transferred to a LTC facility category and a cost of care must be determined. Although the HCBS category must be closed the waiver code must remain on the case.
NOTE: The begin date of the LTC facility category and 902Z cost of care TPL is always the first day of the calendar month the 31st day fell in.
Example: Andrew has been open and receiving MA and HCBS in the LIFE Program since 5/10/19. On 1/21/21, he enters an LTC facility. On 2/20/21, Andrew has resided in the LTC facility for 31 days. Andrew should be authorized in an LTC facility category (PAN, PJN, PMN) and a cost of care should be determined effective 2/1/21, the first day of the calendar month in which Andrew has resided in the LTC facility for 31 days.
The transition from the HCBS budget to the LTC budget must be processed in two separate workflows. The system will end the 96 waiver code on the last day of the month in which processing occurs. As a result, the CAO must re-enter the 96 waiver code with a begin date on the first day of the following month in addition to:
Adding the 35/36 facility code, which begins on the first day of the calendar month in which the 31st day of admission fell,
Authorizing the PAN/PJN/PMN budget, and
Calculating the cost of care contribution which begins on the first day of the month in which the 31st day of institutionalization occurred.
Enter the Medicare B monthly premium amount as code 96 “LIFE Medicare B premium” as a paid medical expense on the Medical Expenses screen.
NOTE: Do not designate the Medicare B monthly premium as code 12 “Medicare B” on the Medical Expenses screen for LIFE consumers residing in an LTC facility. The use of the 96 medical expense code will ensure that the premium is correctly deducted from the LIFE consumer’s monthly income.
NOTE: Should the LIFE consumer later be found eligible for the Buy-In program, the medical expense code 96, reflecting the monthly Medicare B premium, should be end dated prior to the month Buy-In begins based on information received via Data Exchange 3.
The CAO will no longer send a notice of eligibility or ineligibility to OLTL. Send a notice of eligibility/ineligibility for LIFE waiver to the client as well as the POA and all other involved parties.
LIFE applicants with income exceeding 300% of the Federal Benefit Rate may be reviewed for eligibility in an ongoing NMP spend-down category. See Section 468.231 for more information on LIFE spend-down.
489.34 Omnibus Budget Reconciliation Act (OBRA) Waiver
OBRA serves individuals who are ages 18 to 21 assessed NFI with an Intermediate Care for Persons with Other Related Conditions (ICF/ORC) level of care who have been diagnosed with severe developmental disabilities. Once an individual turns 21 the system creates an alert (011) to notify the caseworker to rerun eligibility for enrollment into a CHC Managed Care plan.
Note: Individuals who were enrolled in OBRA prior to 07/01/2006 will remain in an OBRA waiver until the age of 60 when they will be transitioned systematically into a CHC waiver.
Updated January 19, 2024, Replacing August 30, 2021