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NURSING FACILITY TRANSITION SERVICES PROVIDER IN PENNSYLVANIA

  • Writer: Fatumata Kaba
    Fatumata Kaba
  • Oct 8
  • 3 min read

HELPING INDIVIDUALS SAFELY RETURN TO COMMUNITY LIVING WITH DIGNITY, SUPPORT, AND PERSON-CENTERED PLANNING

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Nursing Facility Transition (NFT) Services in Pennsylvania are Medicaid-funded supports that assist individuals in moving from nursing facilities back into their homes or community-based settings. These services are designed to reduce unnecessary institutionalization and are coordinated through Pennsylvania’s Community HealthChoices (CHC) program, the Office of Long-Term Living (OLTL), and local Managed Care Organizations (MCOs). They include service planning, housing search, home setup, and linkage to Home and Community-Based Services (HCBS).

 

1. GOVERNING AGENCIES

Agency: Pennsylvania Department of Human Services (DHS) – Office of Long-Term Living (OLTL)

Role: Oversees Nursing Facility Transition services under Medicaid HCBS waivers.

Agency: Community HealthChoices (CHC) Managed Care Organizations (MCOs)

Role: Coordinate transitions, authorize funding, and contract with NFT providers.

Agency: Centers for Medicare & Medicaid Services (CMS)

Role: Ensures compliance with federal Medicaid requirements and Money Follows the Person (MFP) initiatives.

Agency: Pennsylvania Department of State

Role: Registers legal business entities operating as NFT service providers.

 

2. NURSING FACILITY TRANSITION SERVICES OVERVIEW

NFT Services support individuals in developing a transition plan, securing housing, obtaining furnishings, and arranging for HCBS supports after discharge.

Approved providers may deliver:

  • Transition Planning: Person-centered discharge planning and coordination with facility staff.

  • Housing Search & Coordination: Locating affordable housing, submitting applications, and arranging utilities.

  • One-Time Transition Expenses: Purchasing furniture, appliances, linens, and household items needed to set up a safe home.

  • Caregiver Training & Support: Educating informal caregivers about care needs and resources.

  • Community Support Connection: Linking individuals to personal assistance, meal programs, and health services.

  • Follow-Up Monitoring: Post-discharge check-ins to ensure service access and stability.

  • Documentation: Transition plans, purchase logs, follow-up notes, and Medicaid billing records.

 

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

  • Register your business with the Pennsylvania Department of State.

  • Obtain an EIN from the IRS and a Type 2 NPI.

  • Enroll in PROMISe™ as a Medicaid provider.

  • Contract with CHC Managed Care Organizations (MCOs) as a transition service provider.

  • Maintain liability and workers’ compensation insurance.

  • Develop a Nursing Facility Transition Policy & Procedure Manual that meets OLTL and CHC program requirements.

 

4. PENNSYLVANIA PROVIDER ENROLLMENT PROCESS

Step 1: Register business and secure EIN, NPI, and insurances.

Step 2: Apply for PROMISe™ enrollment as a transition support or waiver service provider.

Step 3: Submit applications to contract with CHC MCOs (UPMC, PA Health & Wellness, Keystone First).

Step 4: Upload policy documents, training plans, and staff background checks.

Step 5: Once approved, begin receiving transition referrals from MCO Service Coordinators.

 

5. REQUIRED DOCUMENTATION

  • Articles of Incorporation and business registration

  • EIN and NPI confirmations

  • Insurance certificates

  • CHC MCO contract confirmation

  • NFT Services Policy & Procedure Manual including:

    • Housing search and coordination protocols

    • Authorization and funding request workflows

    • Safety checklists for move-in setup

    • Emergency planning and backup supports

    • Participant consent and rights materials

    • Service tracking logs and expense reports

    • Medicaid billing and transition completion forms

 

6. STAFFING REQUIREMENTS

Role: Transition Coordinator

Requirements: Experience in care coordination, Medicaid waivers, and housing support; background check required.

Role: Program Supervisor

Requirements: Oversees quality control, service tracking, and compliance with CHC contracts.

Role: Housing Liaison (optional)

Requirements: Connects clients to landlords and housing authorities; familiar with local housing programs.

All staff must complete:

  • HIPAA and participant rights training

  • Person-centered planning and motivational interviewing

  • Housing readiness and safety assessment training

  • Medicaid documentation and compliance courses

  • Annual performance reviews and policy refreshers

 

7. MEDICAID WAIVER PROGRAMS

NFT Services are covered through:

  • Community HealthChoices (CHC): Coordinated by MCOs for Medicaid-eligible individuals transitioning from nursing homes.

  • Aging Waiver & Independence Waiver (OLTL): For individuals requiring HCBS post-discharge.

  • Money Follows the Person (MFP): May provide additional funding for transition expenses.

  • OBRA Waiver: For adults with physical disabilities under 60 requiring home-based supports.

 

8. TIMELINE TO LAUNCH

Phase: Business Registration & Policy Manual Development

Timeline: 1–2 months

Phase: Medicaid Enrollment & MCO Contracting

Timeline: 2–3 months

Phase: Staff Hiring & Credentialing

Timeline: 30–60 days

Phase: Referral Activation & Transition Coordination

Timeline: Begins once authorization agreements and MCO onboarding are complete

 

9. CONTACT INFORMATION

PA Department of Human Services – OLTL

PROMISe™ Medicaid Provider Portal

CHC MCO Contacts:

Centers for Medicare & Medicaid Services (CMS)

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PENNSYLVANIA Nursing Facility Transition

WAIVER CONSULTING GROUP’S START-UP ASSISTANCE SERVICE — PENNSYLVANIA NFT PROVIDER

WCG helps providers build person-centered, fully compliant NFT programs that ease the transition from institutional to community living.

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Scope of Work:

  • Business formation, Medicaid enrollment, and MCO contract support

  • Custom NFT Policy & Procedure Manual and housing tools

  • Transition tracking logs, safety checklists, and expense documentation templates

  • Staff onboarding plans, training logs, and credentialing checklists

  • Medicaid billing and audit preparation tools

  • Referral and partnership-building strategies with MCOs and discharge planners



Our Client Portal offers a wealth of resources that you can explore related to various programs and state requirements. 

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