Pennsylvania - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In Pennsylvania, Assisted Living Residences (ALRs) are licensed by the Department of Human Services (DHS) to provide shelter, meals, and assisted living services, including personal care and medication administration. Medicaid does not pay for the room and board portion of assisted living, but it does cover the home and community-based services (HCBS) provided within the facility through the Community HealthChoices (CHC) waiver program.

The single biggest structural barrier to entry for a new Medicaid ALR provider in Pennsylvania is the mandatory managed care delivery system. Simply obtaining a state license and enrolling in the state's Medicaid portal (PROMISe) does not guarantee patients or payment; providers must successfully negotiate and secure a network contract with one of the regional CHC Managed Care Organizations (MCOs), which may have closed networks or strict credentialing prerequisites.

1. Service Definition and Scope

Pennsylvania defines an Assisted Living Residence (ALR) as a facility that provides housing, meals, and assisted living services to older adults and adults with disabilities. Governed by 55 Pa. Code Chapter 2800, ALRs differ from Personal Care Homes (PCHs) by offering a higher level of medical acuity care, requiring private units with lockable doors, and providing kitchenettes.

Under the Medicaid Community HealthChoices (CHC) waiver, the state covers the cost of the personal care, supervision, and supplemental health services delivered in the ALR. Medicaid funds cannot be used to cover room and board, which the resident must pay using private funds or Supplemental Security Income (SSI).

• Regulatory Definition: 55 Pa. Code § 2800.4 defines Assisted Living Residences and their required service scope.
• Medicaid Vehicle: Services are funded through the Community HealthChoices (CHC) 1915(c) waiver.
• Room and Board: Explicitly excluded from Medicaid reimbursement; residents are responsible for these costs.
• Physical Plant Mandates: Facilities must provide private units (unless sharing is requested), lockable doors, and accessible or adaptable doors for wheelchair use.
• Service Scope: Includes assistance with activities of daily living (ADLs), medication administration, and supplemental health care services.

2. Regulatory and Oversight Agencies

The Pennsylvania Department of Human Services (DHS) is the primary umbrella agency regulating assisted living. Within DHS, the Bureau of Human Services Licensing (BHSL) is responsible for physical facility inspections, issuing licenses, and enforcing Chapter 2800 regulations.

The DHS Office of Long-Term Living (OLTL) manages the Medicaid HCBS waiver programs, including Community HealthChoices. However, day-to-day Medicaid oversight, care coordination, and provider network management are delegated to the contracted CHC Managed Care Organizations (MCOs).

• Licensing Authority: DHS Bureau of Human Services Licensing (BHSL) issues the ALR license and conducts surveys.
• Medicaid Authority: DHS Office of Long-Term Living (OLTL) oversees the CHC waiver program.
• Managed Care Oversight: CHC MCOs (AmeriHealth Caritas, PA Health & Wellness, UPMC Community HealthChoices) manage provider networks and claims.
• Life Safety: PA Department of Labor & Industry (L&I) issues the required Certificate of Occupancy.
• Background Checks: Pennsylvania State Police (PSP) administers the PATCH system for criminal history clearances.

3. Gatekeeping Prerequisites: Who Can Even Apply

Pennsylvania does not require a Certificate of Need (CON) for Assisted Living Residences. However, the absolute gatekeeper for Medicaid reimbursement is the Community HealthChoices (CHC) MCO network contracting process. A facility cannot bill Medicaid simply by obtaining a license and a state Medicaid ID.

Before an MCO will even consider a contract, the facility must be fully licensed under Chapter 2800 and enrolled in the PROMISe system. Because MCOs manage their own networks, they may impose moratoria on new contracts if they determine their network is adequate, meaning Medicaid participation is never guaranteed for a new facility.

• Certificate of Need: Not required in Pennsylvania for Assisted Living Residences.
• MCO Contracting: Mandatory affiliation with at least one CHC MCO (UPMC, PA Health & Wellness, or AmeriHealth Caritas) is required to bill Medicaid.
• Licensure Prerequisite: Must hold an active Chapter 2800 ALR license from BHSL before PROMISe Medicaid enrollment is permitted.
• Local Zoning: Must obtain local municipal zoning approval and an L&I Certificate of Occupancy prior to submitting the state licensure application.
• Network Adequacy: MCOs may restrict new provider enrollment based on regional network adequacy and member need.

4. Licensure and Certification Requirements

Initial licensure requires submitting the HS 633 Application for Certificate of Compliance to BHSL, along with required fees and architectural plans. The facility must pass a rigorous initial on-site inspection to verify compliance with 55 Pa. Code Chapter 2800 before admitting residents.

Once licensed and operational, the Department mandates a reinspection within three months of the initial licensure date. Facilities seeking to operate a secured dementia care unit must apply for a Special Care Designation, which requires additional staffing and environmental safeguards.

• Application Form: HS 633 (Application for Certificate of Compliance) submitted to BHSL.
• Base Fee: $300 initial license application or renewal fee.
• Per-Bed Fee: $75 per bed fee, adjusted annually not to exceed the Consumer Price Index.
• Inspection Timeline: Initial inspection prior to opening, plus a mandatory reinspection within 3 months of licensure.
• Special Care Designation: Additional approval required under § 2800.11 for Alzheimer's/Dementia memory care units.
• Waiver of Regulations: Providers may submit formal requests to BHSL to waive specific Chapter 2800 regulations, subject to a 30-day public comment period.

5. Medicaid Provider Enrollment

Once licensed, the ALR must enroll in Pennsylvania's Medicaid Management Information System, known as PROMISe (Provider Reimbursement and Operations Management Information System). Enrollment is completed electronically via the DHS provider portal.

Providers must select the correct Provider Type and Specialty code for HCBS Assisted Living and upload their BHSL license, W-9, and ownership disclosures. Federal rules require state Medicaid agencies to revalidate the enrollment of all providers at least every five years.

• System Name: PROMISe (Provider Reimbursement and Operations Management Information System).
• Application Portal: DHS Electronic Provider Enrollment application.
• Required Identifiers: National Provider Identifier (NPI), FEIN, and matching Taxonomy Code.
• Application Fee: Subject to the federal ACA institutional provider application fee, unless already paid to Medicare or another state.
• Required Attachments: BHSL license, W-9, ownership and control disclosures, and EFT banking information.
• Revalidation: Required every 5 years via the PROMISe 'My Home' portal.

6. Staffing, Training and Background Checks

Chapter 2800 mandates strict qualifications for ALR Administrators and direct care staff. Before hiring an administrator, the individual must complete a rigorous state-approved training curriculum and pass a competency test.

All staff must undergo criminal background checks through the PA State Police. If a staff member has not been a Pennsylvania resident for the past two consecutive years, an FBI fingerprint background check is also required.

• Administrator Training: Must complete a 100-hour standardized DHS-approved administrator training course.
• Administrator Orientation: Must complete an orientation program approved and administered by DHS.
• Administrator Testing: Requires a passing score on a DHS-approved competency-based training test.
• Direct Care Staff: Must be at least 18 years of age and possess a high school diploma or GED.
• Background Checks: PA State Police PATCH system check required; FBI fingerprinting required for out-of-state residents.
• Certifications: Staff must maintain current CPR and First Aid certifications.

7. Documentation, Policies and Records

ALRs must maintain comprehensive resident records and facility policies as dictated by § 2800.220 and related sections. This includes detailed pre-admission screenings, medical evaluations, and Individualized Support Plans (ISPs) that dictate the scope of assisted living services.

Facilities are strictly monitored on their incident reporting and financial transparency. Administrators must ensure that all resident agreements clearly delineate the costs of room and board versus care services.

• Medical Evaluation: Required within 60 days prior to admission or 15 days after admission.
• Support Plan: Individualized Support Plan (ISP) must be developed and updated annually or upon a significant change in condition.
• Resident Agreement: Written contract detailing fees, services, and room/board costs, signed prior to admission.
• Reportable Incidents: Must report deaths of residents under 60, abuse, or serious injuries to DHS within 24 hours per § 2800.28(e).
• Emergency Preparedness: Written disaster plan and fire safety procedures approved by local fire authorities.
• Financial Records: Administrator is responsible for maintaining transparent financial records and fee disclosures.

8. Billing, Rates and Claims

Medicaid HCBS billing in Pennsylvania is routed through the CHC MCOs, not directly to DHS. Providers must submit claims via the specific MCO's clearinghouse or provider portal (e.g., ProviderNet or Availity) according to their contracted rates.

Rates for the assisted living service tier are negotiated with the MCOs, though DHS establishes rate floors or fee schedules for HCBS. Room and board cannot be billed to PROMISe or the MCO and must be collected directly from the resident.

• Billing Pathway: Claims are submitted directly to the contracted CHC MCO (UPMC, PA Health & Wellness, AmeriHealth Caritas).
• Room and Board: Billed directly to the resident; often funded by SSI and the State Supplementary Payment (SSP).
• System Usage: PROMISe is used for enrollment and encounter data, but MCO portals are used for actual claims submission and payment.
• Modifiers/Codes: Billed using standard HCBS HCPCS codes as defined by the MCO contract and OLTL billing guidelines.
• Medicaid Pending: Facilities may negotiate to accept 'Medicaid pending' status, but families may be responsible for private-pay rates during the application window.

9. Approval Sequence and Timeline

The end-to-end process to become a Medicaid-reimbursed ALR in Pennsylvania takes 6 to 12 months. It begins with securing local zoning and building approvals, followed by the BHSL licensure application and physical inspection.

After the Chapter 2800 license is issued, PROMISe enrollment takes 30-60 days. Finally, MCO credentialing and contracting can add another 90-120 days before the facility can accept and bill for Medicaid waiver participants.

• Step 1: Local zoning approval and L&I Certificate of Occupancy (variable timeline).
• Step 2: Submit HS 633 to BHSL and pass initial physical inspection (3-6 months).
• Step 3: PROMISe Medicaid Enrollment via DHS portal (30-60 days).
• Step 4: CHC MCO Credentialing and Contracting (90-120 days).
• Step 5: Mandatory BHSL Reinspection (within 3 months of initial licensure).

10. Common Denials and Survey Findings

BHSL frequently cites facilities for physical plant deficiencies, medication administration errors, and incomplete staff training records. Failure to properly secure memory care units or maintain lockable doors is a major compliance issue that can delay licensure.

On the enrollment side, PROMISe applications are often rejected for mismatched NPI data, missing ownership disclosures, or applying under the wrong Provider Type. MCOs may also deny contracts if their network is deemed adequate.

• Physical Plant: Failure to provide lockable doors or accessible/adaptable wheelchair doors per Chapter 2800.
• Medication Errors: Improper documentation on the Medication Administration Record (MAR).
• Enrollment Denial: Inconsistent DBA names, wrong provider type selection, or missing W-9 forms in the PROMISe portal.
• Training Deficiencies: Missing CPR/First Aid cards or incomplete 100-hour administrator training documentation.
• MCO Rejection: MCO network adequacy met (closed network), resulting in a denial of the provider contract despite state licensure.

11. Key Contacts and Resources

Providers should utilize the DHS website for Chapter 2800 regulations, licensing forms, and PROMISe enrollment guides. The local Area Agency on Aging (AAA) is also a key partner for initial resident eligibility assessments.

For billing and contracting, providers must maintain direct contact with the Provider Relations departments of the three CHC MCOs operating in their specific region.

• Licensing Agency: DHS Bureau of Human Services Licensing (BHSL).
• Medicaid Agency: DHS Office of Long-Term Living (OLTL).
• Enrollment Portal: PROMISe Provider Enrollment portal.
• Regulations: 55 Pa. Code Chapter 2800 (Assisted Living Residences).
• Eligibility Assessments: Local Area Agency on Aging (AAA) or the Independent Enrollment Broker (IEB).
• MCO Contacts: Provider relations departments for UPMC Community HealthChoices, PA Health & Wellness, and AmeriHealth Caritas.

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