Medical Assistance (MA) services which are provided in Pennsylvania will be undergoing a change beginning in January of 2020. Services in the community which were provided under the waiver program and services provided in nursing homes are all moving to a new program called Community HealthChoices (CHC), which will transition services from a fee for service model to a managed care model. Instead of directly reimbursing service providers, the Department of Human Services will pay a flat monthly rate for each member to one of three managed care programs.
Medicare services will not be affected, and Medicare will continue as the primary payer for individuals who are eligible for both Medicare and Medical Assistance. A primary goal of CHC is to improve coordination between Medicare and MA. There will be no additional cost to MA recipients for this new managed care program.
Individuals who are age 21 and older who are eligible for Medicare and Medical Assistance, as well as individuals who reside in a nursing home (other than a state owned home) and are eligible for MA, will be required to choose a CHC plan. Enrollment packets which contain information about each of the available plans are being mailed to eligible individuals, or you may visit https://www.enrollchc.com/.
Individuals who have an intellectual or developmental disabilities and receive services through the Department of Human Services’ Office of Developmental Programs will not participate in CHC. Individuals who receive Medical Assistance services through LIFE (Living Independence for the Elderly) also will not utilize CHC.
The deadline to choose a CHC plan is 11/13/19. Individuals who do not choose a plan by this date will be automatically enrolled in one of the three available plans. When choosing a plan, verify that your primary care physician and other preferred health care providers (hospital, specialists) participate in the plan you are considering. If your provider has not joined the plan you wish to choose, a six month adjustment period will allow you to continue to see your current provider while you search for a new one.
All plans will offer the same basic physical and behavioral health services, however each one will also have additional benefits such as wellness plans, care transition assistance, and caregiver supports. The potential value of these extra benefits will depend upon one’s individual circumstances.
Unlike Medicare, which has specific periods for enrolling in or changing your Medicare plan, individuals will be permitted to change their CHC plan at any time https://keystoneelderlaw.com/medicare/4216/.
Every CHC member will be assigned a service coordinator who will be the primary contact between the member and the managed care program. If the personalities of a member and service coordinator don’t connect well with each other, the member may request a different service coordinator.
Service coordinators are required to conduct an initial screening of a new member within 90 days of enrollment, or a comprehensive assessment of members who have been determined to be nursing facility clinically eligible by a physician and the local Office of Aging. Annual assessments will also be conducted, as well as when specific services are requested or a determination is made that the member has unmet needs, service gaps, or would benefit from assistance with care coordination.
This change in MA services has been phased in gradually and started in the southwestern corner of the Commonwealth in 2018. It was followed by the southeastern corner in 2019. The remainder of the Commonwealth (including our area) will transition in January. Many of the potential kinks in this transition were ironed out during the first two phases of implementation.
This change to the delivery of MA services has been undertaken to provide opportunities for more individuals to remain in their homes and to promote improved care and safety for those individuals who do; to encourage the development of new approaches to health care; to foster improved care management for those who require ongoing care services/assistance; and to provide greater accountability for the outcomes of care services.
For additional questions or assistance with this transition visit the enrollment website noted above or http://www.healthchoices.pa.gov/. Telephone inquiries can be directed to the Office of Long Term Living Help Line at 1-800-757-5042 or the Independent Enrollment Broker at 1-844-824-3655 or (TTY 1-833-254-0690).
Karen Kaslow, RN, BSN