How Pennsylvania Medicaid Pays for Adult Daily Living: Three CHC Plans, a Rate Sheet Unchanged Since 2016, and a Re-Procurement Back to Square One

Pennsylvania's Community HealthChoices program covered 397,086 people in April 2026, 153,534 of them receiving long-term services at home or in the community, and for the adult day centers that serve them there is one route to payment: the participant's CHC plan. Three plans hold those contracts. The state's own rate study says the day rate they track is a fifth below market. And the procurement that was supposed to replace them fell apart this spring. If you run an Older Adult Daily Living Center in Pennsylvania, here is where things stand.

ElderSuite serves adult day care centers nationwide. This piece is Pennsylvania-specific — the Adult Daily Living service under Community HealthChoices for seniors and adults with physical disabilities, not the Office of Developmental Programs' day programs.

One waiver service, two levels

In Pennsylvania the Medicaid benefit is called Adult Daily Living, and it lives in the CHC 1915(c) waiver, not the State Plan. The waiver defines it as services "designed to assist participants in meeting, at a minimum, personal care, social, nutritional and therapeutic needs," furnished four or more hours a day on a regular schedule in a licensed, non-institutional center. The current waiver term runs January 1, 2025 through December 31, 2029; the latest amendment took effect July 1, 2026.

The service comes in two levels, and the difference matters to your staffing plan. Basic Adult Daily Living is the core package a licensed center already provides: personal assistance, nursing as the licensing rule requires, social and therapeutic activity, nutrition, and emergency care. Enhanced Adult Daily Living adds four commitments: a registered nurse on site one hour a week for every enrolled waiver participant, with each participant observed by the RN at least every other week; a staff-to-participant ratio of 1:5; doors open at least eleven hours a day, Monday through Friday; and access to physical, occupational, speech, and medical services. Once a center is certified as Enhanced, every participant attending it is billed at the Enhanced level.

Either level is billed by the day. A full day is four hours or more; anything under four hours must be billed as a half day.

Three plans, five zones, and a re-procurement that went nowhere

CHC rolled out in three phases — the Southwest on January 1, 2018, the Southeast a year later, and the rest of the state on January 1, 2020 — and the same three organizations have held the contracts since: AmeriHealth Caritas (operating as Keystone First Community HealthChoices in the Southeast), Pennsylvania Health & Wellness, and UPMC Community HealthChoices. The Department of Human Services lists all three in each of the five zones. Nearly all adult daily living money flows through them: in the state's most recent rate-study data, CHC plans paid $52.2 million for adult day while fee-for-service paid $41,000.

That was supposed to change. In August 2024 DHS announced it had selected five plans — three of them new to the program — to negotiate the next round of CHC agreements. Two losing bidders protested, and on April 2, 2026 the Commonwealth Court reversed the denials and cancelled the award, finding that DHS had not evaluated the applications zone by zone as its own solicitation required. On June 1, 2026, DHS cancelled the solicitation altogether and issued a request for information instead; comments closed July 15. At the August 5 meeting of the Long-Term Services and Supports Subcommittee, the Office of Long-Term Living told providers the program "will continue to operate under the current CHC-MCOs and agreements until further notice," with a summary of the comments promised for September or October.

The 2026 CHC Agreement expires December 31, 2026, with two optional six-month extensions. For a center, the practical reading is that the three plans you contract with today are the three plans you will be billing into 2027, and the plan transition many providers had been preparing for has no date.

The rate sheet that has not moved

Pennsylvania publishes a fee schedule for CHC waiver services. On the OLTL rate sheet effective January 1, 2025, Adult Daily Living is S5102 at $58.39 to $60.86 per day depending on region, with a half day (modifier U5) at $29.20 to $30.43; Enhanced (U4) is $68.42 to $75.01 per day, with the Enhanced half day (U3) at $34.21 to $37.51. Those are exactly the figures on the January 2022 sheet and on the January 2016 sheet. The state has not changed the adult day rate in at least a decade.

Two things make that number bite. First, the plans track it: OLTL's 2025 Rate and Wage Study says that while the plans negotiate their own rates, "unit costs in the most recent CHC encounter data suggest a close relationship between MCO payment rates and the FFS fee schedule." Second, the same study found the Basic day rate 19 percent below the low end of its market-based range — $59.49 against a lower bound of $70.91 — and put the cost of closing that gap at about $13 million a year. The 2026 budget cycle moved rates for participant-directed personal assistance, retroactive to January 1, 2026, and left adult daily living where it was.

One more asymmetry worth knowing: the CHC Agreement requires the plans to pay personal assistance services at no less than the fee schedule. It sets no such floor for adult daily living.

Who qualifies, and how the service gets authorized

CHC serves adults 21 and older who are dually eligible for Medicare and Medicaid, or who are financially eligible for Medicaid and clinically eligible for nursing facility care. Functional eligibility is determined by an independent assessment entity under contract to OLTL, referred through the Independent Enrollment Broker, with the County Assistance Office making the final call. Once enrolled, the participant's service coordinator builds the Person-Centered Service Plan, and under the agreement a service listed in that plan "is authorized by virtue of inclusion" in it. There is no separate weekly cap on adult daily living; frequency and duration are whatever the plan documents.

The waiver does draw lines around overlapping services. Adult daily living cannot be billed at the same time as a home health aide, participant-directed community supports, or — when your center provides the ride — non-medical transportation.

Licensing under Chapter 11

The Department of Aging licenses Older Adult Daily Living Centers under 6 Pa. Code Chapter 11, a chapter adopted in 1993 and still the operating rulebook. A license is required once a center serves four or more unrelated clients at the same time, it must be renewed every year after an on-site inspection, and the annual fee is modest: $10 for centers serving four to ten clients, rising to $40 at thirty-six or more. The Department's Division of Licensing takes new applications by email and generally schedules the interim inspection three to six weeks after accepting one.

The standards most likely to shape your operation: a program staff-to-client ratio of at least 1:7 at all times; at least 50 square feet of indoor program space per client; a registered nurse or a licensed practical nurse under RN or physician direction, who may be staff, part-time, or a consultant; a director with a bachelor's degree and two years' experience or a high school diploma and three; a physical exam within three months before admission and annually after; an individual care plan within 30 days of admission, reviewed at least every six months; progress notes at least monthly; and at least one person certified in CPR and first aid on site at all times. A change of ownership or location voids the license, so plan any such move with the Department 60 days ahead.

Note the gap between the licensing floor and the waiver's Enhanced level. Chapter 11 requires a nurse "through some other arrangement which meets the needs of clients"; Enhanced requires an RN on site weekly for every waiver participant. Chapter 11 sets 1:7; Enhanced sets 1:5.

Billing: the claim goes to the plan

A CHC participant's claim goes to the participant's plan, never to the state's claims system — DHS says so directly in its provider guidance. You still need to be enrolled as a Medical Assistance provider with an active provider ID for each location, and the plans are not required to contract with every willing provider, though they must respond to any center's letter of interest and must keep at least two Basic and two Enhanced adult day providers within 30 minutes' travel in urban counties and 60 in rural ones.

The agreement sets the plans' clock: 90 percent of clean home- and community-based claims adjudicated within 30 days of receipt, 100 percent within 45, and checks in the mail within three business days of the check date. All three plans' provider manuals set the same clock for you — 180 calendar days from the date of service to file, 365 days for corrected claims.

Electronic claims go out as 837P files, and the AmeriHealth Caritas plans — AmeriHealth Caritas Pennsylvania Community HealthChoices (payer ID 77062) and Keystone First Community HealthChoices (42344) — are available payers for batch claims on the Availity clearinghouse, the same clearinghouse ElderSuite submits claims through; UPMC Health Plan is listed there under its parent name (23281). That means a Pennsylvania center can run the whole pipeline in one system: daily attendance becomes service documentation, documentation becomes claims, and claims go out electronically. Availity requires a one-time payer enrollment before the first claim goes out. For the full workflow from attendance record to electronic claim, see ElderSuite's Medicaid billing guide.

One thing you do not need: electronic visit verification. The waiver lists the services subject to EVV — personal assistance, participant-directed community supports, unlicensed-facility respite, home health aide, nursing, and the three therapies — and adult daily living is not among them.

The records behind every billed day

Two rulebooks apply. Chapter 11 requires client records with entries that are "legible, dated and signed," retained at least four years after the client leaves, a medication log showing drug, dose, time, date, and who administered it, monthly progress notes, and incident reports filed with the Department and the funding agency within one working day of an unusual incident. On top of that, 55 Pa. Code Chapter 52, which every waiver provider must follow, requires a provider to "complete and maintain documentation on service delivery," accepts electronic records when they are the original and carry an audit trail, bars billing for any date the participant had no approved service plan, and bars billing "when the participant is unavailable to receive the service." Because the unit is a day and the line between a day and a half day is four hours, your attendance record — with arrival and departure times — is the document that proves which one you billed.

Where to check

• The CHC 1915(c) waiver (service definition, provider qualifications, EVV list) and the 2026 CHC Agreement
• OLTL's HCBS rate sheet and the 2025 Rate and Wage Study
• 6 Pa. Code Chapter 11 and the Department of Aging's adult day center licensing page
• DHS's CHC contact page for the plans, and the OLTL Data Dashboard for enrollment
• The plans' HCBS billing guides: Keystone First CHC, Pennsylvania Health & Wellness, and UPMC