Medicaid recipients in Pennsylvania can get a waiver for that funding, which traditionally covers nursing home care, to pay for services that allow them to stay at home instead.

With that waiver comes eligibility for a "care manager" who helps coordinate home nurses, gets grab bars and wheelchair slides for stairs installed, and arranges for home meal delivery or rides to doctor's offices.

"Anything that will allow them to remain safely in the community for as long as possible," said care manager Celeste Paylor-Sulaiman.

Those services are provided in each county by the Area Agencies on Aging, which get a lump sum of about $260 a month per person for the service.

"Right now we have an annual budget, and we can work within that budget," said Rodney Williams, president of Philadelphia's Area Agency on Aging, the Philadelphia Corporation for Aging. "That means as many hours, as many visits, whatever we have to do, we can do for the consumer as long as we stay within the budget."

Changes to the program set to go into effect July 1 would allow other organizations, besides the Area Agencies on Aging, to provide those services. And instead of a block grant, each service coordinator would bill the state for time spent, capped at an average of three hours per month -- unless the state approves extra time.

Case manager Paylor-Sulaiman said she now spends an average of five or so hours a month with clients.

Williams argues that, with the more limited staffing, seniors with complex needs will lose out.

"When it comes to difficult, complex cases ... people who used to stay home in the community will be forced to go into nursing homes," Williams said. "That's a fact, the state will not save any money, it will cost the state more money."

Department of Public Welfare spokeswoman Carey Miller said the changes are projected to save the state a bit – about $500,000. But more importantly, the idea is to provide the same level of services as before while giving consumers a choice.

"The monopoly that PCA has is the actual issue," Miller said. "Under the monopoly, the senior population has no choice of their coordinator of services, so should they be dissatisfied, they're kind of stuck in that position.

"So we're trying to offer consumers a choice," she said.

Williams said the PCA said it is not worried about new competition, just reimbursement rates too low to provide the services seniors need.