Three tests at a glance

Pennsylvania Medicaid provides personal assistance and other long-term services through the Community HealthChoices (CHC) waiver. Most people who have both Medicare and Medicaid receive their physical health coverage through a CHC plan. To get waiver services like in-home care, your loved one must apply separately and be approved for the CHC waiver.

The state evaluates every applicant based on three specific criteria. Eligibility requires meeting the standards in all three categories. There are no guarantees of eligibility, and the final decision rests with state agencies.

During the application process, the Independent Enrollment Broker handles the initial intake and home visits. The local Area Agency on Aging and the County Assistance Office handle the actual assessments and financial reviews.

Functional eligibility: Nursing Facility Clinically Eligible (NFCE)

To receive home care through the CHC waiver, your loved one must be Nursing Facility Clinically Eligible (NFCE). This means they require the level of care typically provided in a nursing home. The local Area Agency on Aging conducts a Functional Eligibility Determination (FED) to assess this need. In Philadelphia, the Philadelphia Corporation for Aging (PCA) sends an assessor to your home.

The FED looks at the applicant’s condition over the last three days. To be found functionally eligible, the applicant must meet the criteria in either Group 1 or Group 2.

Group 1 criteria (requires at least one):

• Hands-on help with three or more Activities of Daily Living (ADLs), which include bathing, personal hygiene, dressing, walking, toileting, and eating.
• Being bed bound.
• Being frequently or always incontinent of bowel.
• Being in a coma.

Group 2 criteria (requires at least three):

• Hands-on help with two ADLs.
• Mild to severe cognitive impairment.
• Memory problems.
• Confused or disorganized thinking.
• Behavioral symptoms, such as wandering, verbal or physical aggression, or socially disruptive behavior.
• Uses a wheelchair or scooter.
• Needs significant help managing medications.

The FED assessment has strict rules about what counts. Help with meal preparation, shopping, and housekeeping is NOT counted toward functional eligibility. Furthermore, the FED limits its focus and ignores skilled or rehab needs. It also ignores the need for supervision or cueing. Because of this limitation, people with cognitive impairment may be wrongly denied.

If the state denies functional eligibility, they will send a notice with appeal rights. You can appeal a denial to a Department of Human Services (DHS) Fair Hearing. For free legal help with OLTL waiver appeals, you can contact the Pennsylvania Health Law Project (PHLP) Helpline at 1-800-274-3258.

Income limit 2026

The financial rules for the CHC waiver are the same as all Pennsylvania waivers. The income limit is set at 300% of the Supplemental Security Income (SSI) Federal Benefit Rate. For 2026, the gross income limit is $2,982 per month.

The County Assistance Office (CAO) reviews the financial application. They usually count gross income, because the waiver allows very few deductions. The CAO only counts the applicant’s income. If the applicant is married, the non-applying spouse’s income does not count toward this $2,982 limit.

If your loved one’s monthly income is over the limit, they may still qualify. They can often gain eligibility by setting up an income trust for the excess income. Alternatively, applicants under age 65 who are working might qualify through Medical Assistance for Workers with Disabilities (MAWD) or Workers with Job Success. You can read more about what to do if your income is too high.

Need help starting services in Philadelphia? Call New Century Home Care at 215-974-0000 or fill out our contact form. Select “I am a client” and “I need services” to get started. Our office staff speaks English, Russian, and Ukrainian.

Asset limits

In addition to income, the CAO checks the applicant’s resources. Resources include bank accounts, investments, and other property that can be turned into cash. The limits depend on the applicant’s marital and living situation.

When a married person applies for the waiver, the state uses a spousal impoverishment formula. This protects the spouse who is not applying for Medicaid (the community spouse). The CAO looks at the couple’s combined countable resources. The community spouse is allowed to keep a minimum of $32,532 in 2026, and often more depending on the total combined assets. The applicant is still allowed their $8,000 limit on top of the spouse’s protected share.

What doesn’t count

Not everything you own counts toward the $8,000 asset limit. The DHS Long-Term Care Handbook outlines specific excluded resources. When the CAO calculates your total assets, they will not include the following items:

• The home the applicant lives in.
• One motor vehicle.
• Irrevocable burial accounts.
• Life insurance policies that do not have a cash value.
• The non-applying spouse’s pension or retirement account.

While the home does not count toward the asset limit during the application process, the state may try to recover costs after the recipient passes away. Pennsylvania can recover the costs of HCBS waiver services from the estate of a recipient age 55 or older. You can learn more about estate recovery rules and when hardship waivers apply.

The 5-year look-back

When you submit a financial application, the CAO conducts a 5-year look-back review. They will examine tax returns and bank records for both the applicant and the spouse. The state looks for any asset transfers made for less than fair market value during the five years before the application date.

If you gave away money, transferred property to a relative, or sold a house for less than it was worth, it can cause a penalty period of ineligibility. The length of this penalty period depends on the exact amount transferred. If a penalty is applied, the applicant can appeal the decision or request an undue hardship waiver. Read more about the 5-year look-back to understand how transfers are evaluated.

Quick self-check list

Reviewing the rules can help you decide if it is time to start the application process. Based on the rules above, it is likely worth applying if your loved one meets these conditions:

• They are 21 years of age or older.
• They need hands-on help with three or more daily activities (like bathing, toileting and eating), or meet the Group 2 combination above.
• Their individual gross monthly income is under $2,982, or they are prepared to form an income trust.
• Their countable assets are under $8,000 (excluding their home, one car, and irrevocable burial funds).

If your loved one meets these criteria, you can review the steps on how to apply to begin the process with the Independent Enrollment Broker.

New Century serves Philadelphia, Bucks, Montgomery, Delaware and Chester counties. Call 215-974-0000, or use the online form and choose “I am a client” and “I need services”.