The CHC managed care program is being developed to enhance access and improve coordination of care and services. It is a person-centered model in which people have choice, control, and access to a full array of quality services providing independence, health, and quality of life. CHC will help manage the services provided to people (21 and older) who are covered by both Medicare and Medicaid (dual eligible), funded by specific waiver programs (living independently) or those Medicaid-reimbursed services received in a long-term care environment. The goal of CHC is to improve services for hundreds of thousands of Pennsylvanians.
Participants will receive health care and related services through plans with managed care organizations (MCOs) coordinated and arranged by private insurance companies. MCOs will receive what is called a capitation payment, or one payment per participant per month.
Each of the three MCOs will receive this capitation payment to cover any and all expenses related to items and services per month.
Independent Enrollment Brokers are available to assist eligible Pennsylvanians in the process. The toll-free CHC Helpline at 1-844-824-3655 (TTY:1-833-254-0690), Monday through Friday from 8:00 AM to 6:00 PM. (Website: www.enrollchc.com)
What is an MCO?
MCO refers to one of the three Managed Care Organizations under which an individual’s health care services and programs will be provided.
In the Commonwealth of Pennsylvania, participants in CHC will have three MCOs from which to choose and enroll.
Who is Eligible?
Those required to make the switch to CHC include:
Individuals at least 21 years old who receive full Medicare and full Medicaid coverage;
Individuals who need or already receive Medicaid long-term services and supports through the Attendant Care, Independence, COMMCARE, or Aging Waivers;
Individuals who need or already receive long-term services and supports through the OBRA Waiver AND are Nursing Facility Clinically Eligible (NFCE)
Individuals who receive care in a nursing home paid for by Medicaid
Those excluded from CHC include:
Participants in Act 150 but do not have full Medicare and full Medicaid
Those with intellectual or developmental disabilities (ID/DD) and who are enrolled in services (other than or in addition to supports coordination) through the DHS’s Office of Developmental Programs (ODP)
Those who reside in a nursing facility that is state-operated (include state veterans’ homes)
Participants in the OBRA waiver but who are not determined to be NFCE
Participants in the Living Independence for the Elderly (LIFE) program or those who are eligible for and select this program in place of CHC
What Services Are Included?
CHC covers all physical health services and Long-Term Services and Supports (LTSS)
Physical health services include inpatient and outpatient hospital and clinic services, dental services, nursing facility services, and more
LTSS include items such as employment services, pest eradication, assistive technology, and more
Each MCO provides a list of the services they will cover under each of their plans. (plans are listed alphabetically).
KeystoneFirst CHC
PA Health & Wellness
UPMC
Continuity of Care
Continuity of Care (COC) refers to the form of protection participants will receive to more easily manage the transitions occurring under CHC. It gives both participants and Medicaid providers extended time to adapt and adjust to CHC.
MCOs are required to contract with all willing and existing qualified Medicaid providers during the first 180 days after CHC implementation
During this period, participants will be able to keep their existing healthcare providers; this applies to:
individuals participating in any Home and Community-Based Services (HCBS) Waiver Program
Inglis House Residents
Individuals within the community that have eligibility for CHC (see above)
A few exceptions and special cases to CoC that are important to note:
Nursing Facility (NF) residents: those residing in or receiving care from a nursing facility paid for by Medicaid at the same time CHC is being introduced in the Southeast can remain in or keep their existing nursing facility. This is regardless of whether or not the nursing facility is part of any given CHC-MCO’s networks. Thus, the participant can enroll in any CHC-MCO.
If the participant is admitted into an NF after enrolling into CHC, they will receive a 60-day CoC period as described for other existing services besides NFs and HCBS
HCBS Waiver Program and other CHC-eligible participants: if a participant switches to a different CHC-MCO DURING the 180-day CoC period:
they will receive their healthcare and relevant services for whichever of the following dates comes later:
the greater of 60 days or the remainder of the 180 days
Date that a comprehensive needs assessment (CNA) has been completed and a PCSP has been developed and implemented
if a participant switches to a different CHC-MCO AFTER the 180-day CoC period:
they will receive CoC for whichever of the following dates comes later:
60 days CoC
CNA has been completed and a PCSP has been developed and implemented
