More than 1,700 people across Pennsylvania in the Community HealthChoices (CHC) Waiver have received notices telling them they no longer meet the medical (clinical) criteria to stay enrolled in the Waiver program. Thousands more are at risk of being terminated in the near future. We recently reported on these terminations and encourage readers to review that article, which includes more details about these terminations and specific tips for challenging these terminations.
These terminations occur after the person is assessed by their CHC Service Coordinator and found to no longer meet the Nursing Facility Clinically Eligible standard for CHC Waiver eligibility. When people are terminated for medical or clinical reasons, the notice they get should come from the Office of Long-Term Living (OLTL). People should also get a notice from their local County Assistance Office (CAO) about a reduction in or termination of their Medicaid. Some people report only getting one of these notices.
People who get notices telling them they are no longer eligible for the CHC Waiver should appeal as soon as possible regardless of whether the notice is from OLTL or their CAO! Appeals must be in writing. The notice people get should include an appeal form to fill out and return.
The Pennsylvania Department of Human Services (DHS) recently updated their policy guidance to clarify the right to continued benefits while an appeal is pending. If someone appeals either the OLTL notice or the notice from their CAO within 15 days of the mail date printed on these notices, their Medicaid and Waiver benefits must continue during the appeal process. The updated guidance requires the CAO to reinstate benefits within three (3) business days when a timely (i.e. within 15 days) appeal is filed.
People who are being terminated from the CHC Waiver or who experience gaps in care or coverage following a timely appeal can contact PHLP’s Helpline at 1-800-274-3258 or seek help from their local legal aid office.