OBRA Waiver Eligibility for Applicants 18 through 20 Years of Age

In the past year young adults (ages 18 through 20) with chronic disabilities have had difficulty enrolling in the OBRA waiver operated by Pennsylvania’s Office of Long-Term Living of the Department of Human Services (OLTL).  Many of these applicants (and their families) were told that they were not clinically eligible.  However, after consultation with OLTL, PHLP is pleased to report that these young adults can enroll in the OBRA waiver to receive services such as respite for their caregivers, service coordination, structured day habilitation services, and other waiver-funded supports to prevent institutionalization that are not available to them through regular Medicaid.  We have summarized our understanding of the application process below.

The enrollment of young adults with chronic disabilities in the OBRA waiver requires a clinical assessment by a state contractor of the level of care needed by the applicant and a certification by the applicant’s physician that they meet the level of care required for the OBRA waiver.  The level of care needed for the OBRA waiver is Intermediate Care Facility for Other Related Conditions (ICF-ORC).  However, young adults aged 18 through 20 who are assessed by the state contractor as meeting a Nursing Facility Clinically Eligible (NFCE) level of care will also be found eligible, provided they meet other requirements.  One of those other requirements is that the physician certification about level of care must state that the OBRA applicant meets the requirements for being ICF-ORC and identify the major life activities in which the applicant is substantially limited.   A physician certification of NFCE alone is currently not adequate.  ICF-ORC is a lower level of care need than NFCE.  The definition of each level of care need—ICF-ORC and NFCE—is dense and can be found on the second page of the physician certification.       

In 2020, many young adult applicants for the OBRA waiver were denied enrollment because they were determined NFCE (the higher level of care need) by their clinical assessment.  If you encounter young adults aged 18 through 20 with chronic disabilities who have been denied the OBRA waiver because they were found to be NFCE, encourage them to reapply by contacting the Pennsylvania Independent Enrollment Broker at 877-550-4227 and remind them that their physician’s certification must identify them as ICF-ORC.  Any young adult denied the OBRA Waiver because they are found NFCE going forward should contact PHLP’s Helpline at 800-274-3258 or staff@phlp.org for advice or assistance.