How Community HealthChoices Covers Adult Day Services in Pennsylvania
1 monthYes — Medicaid pays for adult day care in Pennsylvania. Adult day services are a covered benefit under Community HealthChoices (CHC), the state’s mandatory Medicaid managed long-term services and supports program. To qualify, a person must be found nursing facility clinically eligible and meet Medical Assistance financial requirements.
CHC waiver participants pay no cost-sharing for covered services. Enrollment runs through the Independent Enrollment Broker at 1-844-824-3655 or paieb.com, and the process realistically takes three months or more.
Here’s how the program actually works, in the order a family encounters it.
What Community HealthChoices is
CHC is Pennsylvania’s managed long-term services and supports (MLTSS) program, administered by the Department of Human Services through the Office of Long-Term Living. It combines physical health coverage with long-term services and supports under a single managed care plan.
It’s mandatory, not optional, for the people it covers — CHC is the sole program option for fully dual-eligible beneficiaries and for most people determined nursing facility clinically eligible in the covered zones.
Who it covers:
- Adults dually eligible for both Medicare and Medicaid
- Adults 21 and older with physical disabilities who need long-term services and supports
That age threshold matters and gets missed constantly. CHC is not a seniors-only program. Adults in their thirties, forties, and fifties with physical disabilities routinely qualify.
→ Broader context: our complete guide to adult day care in the Philadelphia area.
The Southeast zone and your three plan choices
CHC operates in five regional zones. The Southeast zone covers Bucks, Chester, Delaware, Montgomery, and Philadelphia counties — the entire SarahCare service area.
Three managed care organizations serve it:
- Keystone First Community HealthChoices (AmeriHealth Caritas operates under
this name in the Southeast zone) - PA Health & Wellness
- UPMC Community HealthChoices
You choose your MCO, and you can change it at any time. The practical question isn’t which plan is best in the abstract — it’s whether the adult day center you want and the doctors you already see are in that plan’s network. Ask the center directly which plans they contract with before you choose.
The two eligibility tests
Everyone gets tested twice, on different things.
Clinical eligibility
A determination that the person is nursing facility clinically eligible (NFCE) — that without community-based services, they’d need nursing home level care.
This trips families up emotionally. “Nursing facility clinically eligible” sounds like a verdict about where someone should live. It isn’t. It’s the threshold that unlocks community services precisely so the person doesn’t have to go into a facility. Meeting it is what gets you adult day care at home.
The determination comes out of a clinical assessment of function, cognition, and care needs.
Financial eligibility
Medical Assistance income and asset limits. This is administered separately, through the county assistance office and the state’s eligibility system.
If someone is over the limits, this is where most families stop — and where they shouldn’t. There’s a separate program with no income cutoff.
What adult day looks like as a CHC benefit
Adult day services sit in the CHC home and community-based services array — the same array that includes personal assistance, home-delivered meals, home modifications, personal emergency response systems, transportation, and service coordination.
Pennsylvania defines adult day services broadly as programs providing care and companionship for adults who need supervision or assistance during the day, generally four or more hours a day, on a regular schedule of one or more days a week — with the explicit purpose of offering relief to family members and caregivers so they can work, handle personal business, or rest.
Your specific authorization — how many days, how many hours — is set in your person centered service plan (PCSP), which comes out of a comprehensive needs assessment. The PCSP covers both your care management plan and your LTSS services plan.
And this is the practical thing to know: the plan reflects the needs you describe at the assessment. Go in prepared. If you need five days because you work full time, say so, and say why, and be specific about what happens on an uncovered day.
Assessments are not the moment to minimize.
Cost-sharing: there isn’t any
Community HealthChoices waiver participants do not pay cost-sharing for covered services, and there’s no cap on services.
For adult day, that means an eligible participant attends at no out-of-pocket cost.
How to enroll, and how long it really takes
Enrollment goes through the Independent Enrollment Broker (IEB), currently Maximus. The IEB is the state’s front door for LTSS enrollment — it starts your application, explains what documentation is needed, schedules the assessment, and tracks status.
Contact: 1-844-824-3655 (TTY 711) or paieb.com. You can also start through your county assistance office.
The sequence:
1. Contact the IEB and open an application
2. Financial eligibility determination through Medical Assistance
3. Clinical assessment for the NFCE determination
4. Select a CHC managed care organization
5. Comprehensive needs assessment
6. Person-centered service plan developed with your service coordinator
7. Services authorized and begin
Timeline: the Medicaid application process can take up to three months or longer from the start of the application through the determination letter. Generally it takes several weeks just to complete the application and gather supporting documentation, and an incomplete application delays everything.
Reassessment happens at least every 12 months, or sooner if circumstances change.
What we see in practice
The service coordinator is the person who matters most. Once someone is enrolled\ in a CHC plan, a service coordinator manages their plan. That person’s understanding of what adult day actually provides drives whether it gets authorized and for how many days. Some are deeply familiar with adult day; some have never toured a center.
What helps: be specific and concrete with your coordinator. “He can’t be alone” is weaker than “he left the stove on twice in March, and I work Monday through Friday in Center City with a fifty-minute commute.”
Applications stall on documents, not on eligibility. The determination itself is rarely the bottleneck.
Families under-ask at the assessment. The most common regret we hear is authorization for fewer days than the family actually needs, because they were modest in the assessment and then found two days a week didn’t solve the problem.
Frequently asked questions
Does Medicaid pay for adult day care in Pennsylvania? Yes. Adult day services are a covered benefit under Community HealthChoices.
Do CHC participants pay anything for adult day care? No. Community HealthChoices waiver participants pay no cost-sharing for covered services.
What does “nursing facility clinically eligible” mean? That without community based supports, the person would need nursing home level care. It’s the clinical threshold for waiver services — meeting it is what gets you community services instead
of a facility.
Which CHC plans serve Montgomery County? Keystone First Community HealthChoices, PA Health & Wellness, and UPMC Community HealthChoices all serve the Southeast zone, which covers Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.
Can I switch CHC plans? Yes, at any time. Confirm first that your center and doctors are in the new plan’s network.
Does CHC cover both adult day and in-home care? Yes — both are covered services and can appear in the same person-centered service plan.
Is CHC only for seniors? No. It covers dual-eligible adults and adults 21 and older with physical disabilities.
How long does approval take? Plan on three months or more from application to determination. Start early.
What if we don’t qualify financially? Look at the county OPTIONS program, which has no income requirement to participate, though a sliding co-pay applies.
Not sure where you are in this process? Call 215-999-1200. We work with CHC service coordinators across the Southeast zone every week and can usually tell you what your next concrete step is.
Sophia Aloia is Content & SEO Manager for SarahCare of Jenkintown and CareChoice,
