OBRA Waiver Eligibility for Applicants 18 through 20 Years of Age
In the past year, young adults with disabilities (ages 18-20) have had difficulty enrolling in the OBRA waiver, a program operated by Pennsylvania’s Office of Long-Term Living (OLTL). Many of these applicants were told they were not clinically eligible for waiver services based on how OLTL administers the Functional Eligibility Determination, a functional assessment administered to all OBRA waiver applicants to see if they meet the level of care needed to qualify. After advocacy by PHLP, OLTL has agreed that these young adults can now enroll in the OBRA waiver, which means they will have access to services such as service coordination, respite for caregivers, structured day habilitation, and other waiver-funded supports that help people with disabilities live in the community and are not available through even traditional Medicaid. We have summarized the OBRA waiver application process below. This flyer also summarizes the application steps.
OBRA Waiver: How to Apply
To apply for the OBRA waiver, start by calling the Independent Enrollment Broker at 1-877-550-4227. Tell them you want to apply for waiver services. They will schedule your first home visit, where someone will come to your house to begin the application process with you. They will explain more about the waiver program and the services it offers, and they will help the applicant complete the application forms. They will also schedule a second, follow-up home visit.
During the second home visit, applicants undergo a "Functional Eligibility Determination", which is an assessment administered to determine if the applicant meets the level of care required for waiver enrollment. The assessor will determine the level and extent of care the applicant needs with various daily activities like eating, bathing, dressing, toileting, and more.
Next, the applicant's doctor must complete and submit a Physician Certification form. It must state that the applicant meets the level of care appropriate for the OBRA waiver. The form must also identify the major life activities with which the applicant needs help.
The level of care needed for the OBRA waiver is called Intermediate Care Facility for Other Related Conditions (ICF-ORC). To meet this level of care, the applicant must demonstrate that they have a severe, chronic disability (other than a mental illness or an intellectual disability) that manifested before age 22, is likely to continue indefinitely, results in an impairment of either general intellectual functioning or adaptive behavior, and results in substantial functional limitations in at least three major life areas. The list of major life areas, and the full definition of each level of care, can be found on the second page of the Physician Certification form.
Advocacy at the Start of the Pandemic
In 2020, many young OBRA waiver applicants were denied enrollment in the program, despite meeting all other criteria, because they were determined to be Nursing Facility Clinically Eligible (NFCE), a higher level of care than the ICF-ORC level needed for the OBRA waiver. PHLP engaged in advocacy to push OLTL to accept these young adults into the OBRA waiver despite the assessment determining that they need NFCE level of care. Our efforts worked and OLTL agreed that these individuals could receive OBRA waiver services.
What if I Need More Help?
If you encounter young adults ages 18-20 with severe developmental physical disabilities who have been denied the OBRA waiver because they were found to be NFCE, encourage them to reapply by contacting the Independent Enrollment Broker at 1-877-550-4227. They will also need to submit a Physician Certification Form identifying their level of care as ICF-ORC.
Any young adult denied the OBRA Waiver because they are found NFCE should also contact the Helpline of the Pennsylvania Health Law Project (PHLP) at 1-800-274-3258 or staff@phlp.org for further advice and/or assistance.
