Medicare vs Medicaid for Home Care in Pennsylvania
Medicare vs Medicaid for Home Care in Pennsylvania
Short answer: Medicare covers short-term, skilled home health care for homebound patients. It does not pay for ongoing personal care. PA Medicaid (the CHC waiver) pays for long-term personal assistance services at home for eligible adults who need daily help.
- Medicare requires a skilled need (nursing, physical therapy) and homebound status to cover home health services.
- Medicare does not pay for home health aides if personal care is the only care you need.
- Pennsylvania’s Medicaid CHC waiver covers long-term personal assistance services for daily living activities.
- Dual-eligible adults (having both Medicare and Medicaid) must apply separately for the Medicaid CHC waiver.
- New Century Home Care provides Medicaid-funded non-medical personal care in the Philadelphia area.
The short version
Families often assume Medicare will pay for an aide to help an aging relative bathe, dress, and stay safe at home. This is a common misunderstanding. Medicare is a health insurance program focused on medical recovery and rehabilitation. It pays for short-term, skilled home health care when ordered by a doctor.
Medicaid operates differently. In Pennsylvania, PA Medicaid home care is designed for long-term support. Through the Community HealthChoices (CHC) waiver, Medicaid pays for ongoing personal care to help people with daily living tasks so they can remain in the community rather than moving to a nursing facility.
Comparison table: Medicare vs. Medicaid Home Care
| Feature | Medicare Home Health | Medicaid Home Care (CHC Waiver) |
|---|---|---|
| Who it is for | People needing medical recovery or rehab at home. | Adults 21+ needing long-term daily assistance. |
| What it covers | Skilled nursing, physical/occupational/speech therapy, medical social services. | Personal Assistance Services (bathing, dressing, eating, supervision), respite, home adaptations and more. |
| Personal care/ADLs alone? | No. Aide care is only covered if you also receive skilled care. | Yes. This is the primary purpose of the CHC waiver. |
| Homebound required? | Yes. Leaving home must require major effort. | No homebound rule. |
| Cost to you | $0 for covered services; 20% for medical equipment after deductible. | Depends on the eligibility category; ask the County Assistance Office. |
| How long | Short-term, part-time, or intermittent. | Long-term, ongoing based on your care plan. |
| Who to call | Your doctor or hospital discharge planner. | The Independent Enrollment Broker (1-877-550-4227). |
Medicare home health in detail
Medicare Part A and/or Part B cover eligible home health services only if specific conditions are met. According to Medicare.gov, you must need part-time or intermittent skilled services, such as skilled nursing, physical therapy, occupational therapy, or speech-language pathology. You must also be certified by a doctor as homebound. Being homebound means that leaving your home requires a major effort, though short, infrequent absences for religious services or adult day care are allowed.
If you meet these rules, Medicare covers the skilled therapies, medical social services, and durable medical equipment (DME). Medicare will only cover home health aide care if you are also receiving skilled care at the same time. You are not eligible if you need more than part-time or intermittent skilled nursing.
Medicare strictly limits what it will not cover. It does not cover 24-hour care at home, meal delivery, or homemaker services if they are unrelated to your care plan. Most importantly, Medicare does not cover personal care (help with bathing, dressing, and toileting) if that is the only care you need. For covered home health services, your cost is $0. For durable medical equipment, you pay a 20% coinsurance of the Medicare-approved amount after meeting your Part B deductible.
Medicaid home care in PA (CHC waiver summary)
Pennsylvania uses the Community HealthChoices (CHC) program to provide Medicaid coverage for adults 21 and older who need long-term services and supports (LTSS). This program operates in the Southeast zone, including Philadelphia, Bucks, Chester, Delaware, and Montgomery counties.
To get help with daily living, you must apply for the Medicaid CHC waiver. Eligibility requires you to be 21 or older, meet financial limits (an income limit of $2,982 per month in 2026 for the applicant), and meet the functional requirement known as Nursing Facility Clinically Eligible (NFCE). A local Area Agency on Aging, such as PCA in Philadelphia, determines this functional eligibility by assessing your need for hands-on help with activities of daily living.
The CHC waiver covers non-medical services designed to keep you safe at home. This includes Personal Assistance Services, non-medical transportation, respite care, home adaptations, and personal emergency response systems. A person-centered service plan dictates which services you receive and how many hours are approved.
Need help finding a caregiver through the CHC waiver? New Century Home Care serves the Philadelphia area. Call 215-974-0000 or contact us by selecting “I am a client” and “I need services” on our form. Our office staff speak English, Russian, and Ukrainian.
If you have both (dual eligible)
People who qualify for both Medicare and Medicaid are known as dual eligible. In Pennsylvania, most dual-eligible adults receive their Medicaid physical health coverage through a CHC managed care plan, such as Keystone First CHC, UPMC Community HealthChoices, or Pennsylvania Health & Wellness.
Having a CHC plan for your medical coverage does not automatically give you home care hours. You must apply separately for waiver services. Once approved for the CHC waiver, Medicare still covers what Medicare covers, including skilled home health when you qualify. Your CHC plan then steps in to manage and pay for your long-term Personal Assistance Services.
Which one fits your situation
| Your Situation | The Right Program | Why |
|---|---|---|
| Discharged from the hospital needing wound care and physical therapy. | Medicare Home Health | Requires short-term, skilled medical care ordered by a physician. |
| Needs daily help with bathing, dressing, and using the bathroom long-term. | Medicaid CHC Waiver | Requires ongoing non-medical personal assistance, which Medicare excludes. |
| Recovering from a stroke (needs therapy) AND has dementia (needs daily supervision). | Both (Dual Eligible) | Medicare covers the therapy; the CHC waiver may cover the daily personal care. Confirm coordination with your CHC plan. |
Frequently asked questions
What is one key difference between Medicare and Medicaid?
Medicare is a federal health insurance program that covers medical recovery and short-term skilled care. Medicaid is a joint federal-state program that covers medical costs and long-term personal care for people with limited income and resources.
What is home health care through Medicare?
Medicare home health care includes part-time or intermittent skilled nursing, physical therapy, occupational therapy, and speech-language pathology for homebound individuals. It covers a home health aide only if you are also receiving skilled care at the same time.
Does Medicare pay for a caregiver at home?
Medicare does not pay for a caregiver if your only need is personal care, such as help with bathing, dressing, or toileting. It also does not cover 24-hour care or homemaker services unrelated to your specific medical care plan.
Does Medicare pay family caregivers?
No, Medicare does not pay family members to provide personal care. In Pennsylvania, family caregivers can get paid to provide non-medical personal assistance through the Medicaid CHC waiver, either through a licensed agency or Services My Way.
Can I have both Medicare and Medicaid?
Yes. People who qualify for both are called dual eligible. Your Medicare covers medical services and skilled home health, while your Medicaid Community HealthChoices (CHC) plan covers long-term personal assistance services if you apply and qualify for the waiver.
What is the downside of being on Medicaid?
One consideration is the estate recovery program. Pennsylvania can recover the costs of home and community-based waiver services from the estate of a recipient who is 55 or older, though hardship waivers exist. The state also reviews all financial transfers from the past five years when you apply.
Get paid through Medicaid CHC as a New Century caregiver. Weekly pay, $350 signing bonus, free health insurance plan available. Call 215-974-0000.
Apply now