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6. Introduction to Long-Term Care Overview

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Updated
ByErin Carlin

Overview of Long Term Care

The Department of Human Services (DHS) administers/manages services for improving quality of life for PA’s residents and their families. 

The Office of Long Term Living (OLTL) is an office under DHS that manages the Long Term Care System and provides independent living resources for the elderly and/or disabled that qualify. 

Some of the programs which OLTL manages include receiving care while living at home, rather than in a facility. These are called Medicaid Home and Community-Based Services (HCBS) waivers. 

There are numerous waivers that participants can choose, based on their eligibility and needs. The most common at this point is Community Health Choices (CHC).

There are two approaches to how OLTL manages its network of providers:

  • Fee-for-service – the method where participants manage their care plans and providers are paid for their work 
  • Managed Care – participants choose a Managed Care Organization (MCOs) which have a network of providers for physical, medical and long-term care needs. There are also separate MCOs for Behavioral Health.

Participants enroll in OLTL programs through Independent Enrollment Brokers (IEB) who assist/manage participants through the processes of:

  • Determining eligibility for enrollment
    • As well as referring ineligible individuals to other resources
  • Educating participants on the various programs to enroll in 
    • Selecting an MCO if they enroll with CHC 
  • Selecting their own Service Coordinator if they choose/are eligible for the Fee-for-service waiver.

Whichever waiver program the participant enrolls in, they will use Service Coordinators (SCs) for assistance in accessing and managing their needed waiver services.

Amcord Care, Inc. is a Service Coordination Entity (SCE) contracted with an MCO.

Our role as an SCE with an MCO is to assist participants with accessing their Long Term Services and Supports (LTSS) from the CHC waiver by:

  • Identifying the need for services through Comprehensive Needs Assessments
  • Management and assurance of service delivery as approved by the MCO
  • Coordination of LTSS with all other services
    • Including Physical and Behavioral Health Services

SCs also assist participants with:

  • Housing Services
  • Pest Eradication
  • Community Engagement with Employment and Volunteering services

Managed Care Organizations (MCOs) manage both physical and long-term care services for participants enrolled in CHC. They will also coordinate with Behavioral Health MCOs as needed. There are 3 CHC-MCOs in PA:

  • Amerihealth Caritas/Keystone First
  • PA Health & Wellness
    • Amcord Care is contracted with PA Health & Wellness 
  • UPMC
  • The providers under each MCO will bill the MCO directly for services provided to participants. 
    • Amcord Care, is a provider of Service Coordination Services. 
      • Through extensive Comprehensive Needs Assessments, SCs developed service plans with participants and assist them with choosing providers for the services identified. 
  • Other important terms/facts to know:
    • Long Term Care – The services and supports provided through OLTL programs. Also known as Long Term Services and Supports (LTSS)
      • Primarily it is about services and support for older adults and those with disabilities who want to continue living independently in their choice of living situation. Rather than having to be admitted to a facility
    • Activities of Daily Living (ADLs) – Daily tasks necessary to remain healthy. If these activities are not performed it would result in immediate risk to the participant’s health or safety. ADLs include:
      • Bathing, grooming, hygiene
      • Toileting and continence
      • Transferring
      • Eating
    • Instrumental Activities of Daily Living (IADLs) – Tasks that are necessary to live in the world. If these activities are not performed, it would result in a risk to a participant’s ability to live independently. IADLs include: 
      • Meal Preparation
      • Shopping
      • Transportation
      • Housework
      • Making and keeping appointments
      • Managing household finances
      • Social Interaction

DHS Structure

There are 5 offices under the PA Department of Human Services

The Office of Long Term Living is responsible for administering programs for adults with long term care needs

There are multiple Bureau’s under the Office of Long Term Living

  • The Bureau of Coordinate & Integrated Services is responsible for the administration and oversight of the Community HealthChoices managed care organizations (CHC-MCOs)

OLTL Program Specifics

  • Community Health Choices (CHC) – for individuals ages 21 and over who have been assessed to require service at the level of nursing facility level of care or who are dually eligible for Medicare and Medicaid services. 
    • Features the use of MCOs to coordinate physical health and long-term care needs. 
  • OBRA Waiver – for individuals ages 18 to 59 who have a severe developmental physical disability requiring an Intermediate Care Facility/Other Related Conditions (ICF/ORC) level of care
  • Act 150 – a state-funded program for individuals ages 18-59 who have been assessed to require services at the level of nursing facility level of care, but do not financially qualify for waiver. 
  • Living Independently for the Elderly (LIFE) – A managed care program for individuals 55 and older.
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