How to Fill Out the PA 1768: Pennsylvania HCBS Eligibility Form

To fill out the PA 1768, enter the participant’s identifying and assessment information at the top of the form, complete only the page and section that matches the event you are reporting, and file it with the County Assistance Office that serves the participant’s address. Page one is for initial eligibility or a reassessment that changes eligibility. Page two is for reporting a change after enrollment: an admission, a discharge, a move, a death, a termination, a program transfer, or a financial change. The County Assistance Office will not accept any other document to record an HCBS eligibility or status change, so the fields on this two-page form have to be right.¹

Who Files the Form

For initial enrollment, the Independent Enrollment Broker completes and files the form once the applicant is found functionally eligible through a clinical assessment. After enrollment, the managed care organization or assessing agency files it whenever the participant’s situation changes. Participants and family members generally do not fill out this form themselves; it moves between the assessing entity, the managed care organization, and the County Assistance Office.²

Information Required on Every Submission

No matter which page you are using, every PA 1768 must carry the following five items. A form missing any of them will not be processed.¹

The participant’s full name and Medical Assistance (MA) record number at the top of the form. The MA record number is how the County Assistance Office matches the form to the Medicaid case, so verify it before you sign.
The name of the assessment agency that conducted the clinical evaluation.
The signature and direct telephone number of the assessor who completed the evaluation.
The assessment date, meaning the date the functional eligibility determination was performed.
The designated HCBS program the participant is entering, leaving, or changing within. If the participant is transferring between programs, list both.

If your agency’s records also reference a Master Client Index (MCI) number, confirm it aligns with the MA record number before submitting.

Page One: Initial Eligibility

Use page one when a participant first applies for HCBS or when a clinical reassessment changes their eligibility status. For Community HealthChoices, the Independent Enrollment Broker completes page one after a Functional Eligibility Determination confirms the applicant meets the nursing facility level of care standard. That standard requires a diagnosed illness, injury, or disability and a demonstrated need for skilled nursing, rehabilitation, or regular health-related care that would otherwise only be available in an institutional setting.²

Page one only documents clinical eligibility. The County Assistance Office handles financial eligibility separately, confirming the applicant meets Medicaid income and resource limits. Enrollment proceeds once both sides are established.

Page Two: Pick the One Section That Fits

Page two is organized into labeled sections. Complete only the section that matches the event you are reporting, and leave the rest blank.²

Admission to a Long-Term Care Facility

Enter the facility name, address, and admission date. Check the “Short Term Admission” box if services are expected to resume at discharge. Respite-care admissions do not trigger a PA 1768, so do not file for those.

Discharge from a Long-Term Care Facility

Use this section when the participant leaves the facility and resumes waiver services. The form reopens the waiver as of the discharge date you enter.

Change of Address

Enter the new address, the date of the move, and a telephone number. This applies to moves within the same county, to another county in the same Community HealthChoices zone, and out of state.

Death of the Participant

Include the date of death along with a contact person and phone number.

Termination of HCBS Program

Use this section for incarceration, admission to a veterans’ home or state facility, admission to a personal care home that does not provide residential habilitation, voluntary withdrawal, inability to contact, or refusal of services. Enter the termination date and the reason.

Two of those reasons have process requirements before you file. If the managed care organization cannot reach the participant, it must send a certified letter giving at least 10 days to respond, and 30 days of no contact must pass before termination. Refusal of services also requires 30 days before you can file. For voluntary withdrawal, the participant signs a Voluntary Withdrawal Form first, and the managed care organization then files the PA 1768.

Transferring Between HCBS Programs

List the program the participant is leaving, the services end date, the program being entered, and the services begin date. Both programs must appear on the form.

Change in Financial Status

Check the box for this section and attach the supporting documentation with your submission.

Dates Drive Payment

The effective date you write on the form dictates when Medicaid reimbursements start or stop. An incorrect admission, discharge, move, or termination date can create payment errors that are difficult to unwind after the fact. Check every date against your case records before signing.

Where to Get the Form and How to Submit It

The PA 1768 is available as a PDF through Pennsylvania’s Department of Human Services policy manuals site. Providers and service coordinators working within Community HealthChoices generally access it through their managed care organization’s internal systems, and the County Assistance Office can supply copies as well.³

The completed form goes to the County Assistance Office responsible for the geographic area where the participant lives. You can find the correct office through the Department of Human Services website. Submission options include drop-off at the local office and COMPASS, Pennsylvania’s online benefits system at compass.dhs.pa.gov.

Most managed care organizations move their PA 1768 filings through established electronic channels with the County Assistance Office. If you are submitting outside those channels, confirm with the receiving office that they accept fax or electronic uploads, and get delivery confirmation. From the County Assistance Office’s perspective, a form that never arrived looks the same as a form that arrived late: the Medicaid record no longer matches reality.

What Happens After You Submit

The County Assistance Office reviews the form to confirm the requested action complies with Medicaid eligibility standards. For initial enrollment, it verifies financial eligibility alongside the clinical eligibility already documented on the form. For status changes, it updates the participant’s case record.

Once the review is complete, the office issues a PA 162, the Notice of Determination, to the participant or their representative. The PA 162 states whether the individual is eligible or ineligible, or confirms the change in status, and explains appeal rights. Watch the case for follow-up requests. An incomplete PA 1768 or missing documentation will delay the determination, and delays can ripple into billing.

If the participant disagrees with what the PA 162 says, Pennsylvania requires the appeal request within 30 days of the notice. Filing before the effective date of a termination or reduction generally keeps services in place during the appeal.

1
Commonwealth of Pennsylvania Department of Public Welfare. Operations Memorandum – Home and Community-Based Service (HCBS) Eligibility/Ineligibility/Change Form (PA 1768)
2
Commonwealth of Pennsylvania Department of Human Services. Community HealthChoices Operations Memorandum 2019-05
3
Commonwealth of Pennsylvania Department of Human Services. County Assistance Offices (CAO)