Federal laws establish the federal Medicaid program known as Medical Assistance in Pennsylvania. Medical Assistance is a cost-sharing arrangement between Pennsylvania and the federal government under which the federal government reimburses more than 50 percent of the costs to provide Medical Assistance to individuals who are eligible and unable to cover the costs of their medical care. Pennsylvania has chosen to participate in the Medical Assistance program so it has to follow federal laws and regulations.
Federal law requires that Pennsylvania offer certain services such as inpatient hospital services and doctor’s services. Some types of medical services are optional, such as dental care and medications but a state can decide to include them in the State Plan. Most community intellectual disability services (such as habilitation services; vocational training; respite care; environmental modifications; and socialization/day programs) cannot be covered as either mandatory or optional services under Medical Assistance.
Pennsylvania has permission from the federal government to offer home and community-based intellectual disability services. This permission is a waiver of the federal rules so it is called a waiver. The purpose of the waiver is to encourage states to provide services to assist individuals with disabilities to avoid institutionalization. Pennsylvania has two waivers for people with intellectual disabilities. One is called the Consolidated Waiver, and one is called the Person/Family Directed Support Waiver.
The Consolidated Waiver is the primary funding source for community-based intellectual disability services in Pennsylvania. Here are the eligibility criteria for Consolidated Waiver services:
- Be age three and older
- Have a diagnosis of an intellectual disability
- Require active treatment
- Be recommended for an intermediate care facility level of care based on a medical evaluation
- Determined eligible for Medical Assistance (MA)
- $2,000 resource limit (does not apply to dependent children under age 21)
- Income limit 300% of the Federal Benefit Rate
The Consolidated Waiver offers a broad range of community-based intellectual disability services, depending on the participant’s needs, including, but not limited to:
- Assistive technology
- Behavior support
- Companion
- Education support
- Home accessibility adaptations
- Home and community habilitation (unlicensed)
- Homemaker/chore
- Licensed day habilitation
- Nursing
- Prevocational
- (Licensed) residential habilitation
- (Unlicensed) residential habilitation
- Respite
- Specialized supplies
- Supported employment
- Supports broker
- Supports coordination
- Therapy (physical, occupational, visual/mobility, behavioral and speech and language)
- Transitional work
- Transportation
- Vehicle accessibility adaptations
The Waiver participant and his/her support team, including involved family, legal representative, supports coordinator, and provider staff, develop an Individual Service Plan (ISP) that delineates what types of services the individual requires and will receive. The ISP must be re-evaluated at least once a year and changed to meet the changing needs and desires of the participant.
You can apply for waiver services by contacting your Supports Coordinator or the Mental Health/Intellectual Disability office in your County. If you cannot find the contact information for your County, you can contact the Pennsylvania Department of Human Services, Office of Developmental Programs Customer Service Line at 1-888-565-9435 (Voice). It is important to apply for the Consolidated Waiver as soon as possible because there is a long waiting list. Currently, there are more than 4,000 Pennsylvanians with intellectual disabilities on the “emergency” waiting list and over 13,000 total waiting for Waiver services.
If you are in the Consolidated Waiver and are not receiving the services in your ISP, you may wish to contact the Disability Rights Pennsylvania at 1-800-692-7443 (Voice) or email at intake@disabilityrightspa.org