Managed Care

There are two managed care programs in Pennsylvania that provide home health, hospice and homecare services to Medicaid recipients: HealthChoices, which was implemented in 1997, and Community HealthChoices, which will begin implementation in January 2018.

Click here for a guide from the Department of Human Services to help understand the similarities and differences between the programs. 

HealthChoices

This program provides physical health services such as home health and hospice care. HealthChoices is coordinated by physical health managed care organizations (PH-MCOs) in five geographic zones throughout the state.

HealthChoices Zone Map
Current RFP & Draft Agreement (guidelines PH-MCOs must meet to participate in the program)

Recent News

  • In March, DHS announced that the effective date for the new HealthChoices managed care organization (MCO) agreements has been delayed. Previously, the new agreements in all five regions across the state were to go into effect in June 2017. Now, the implementation will be phased in across the regions, beginning with the Southwest and Northwest Regions in January 2018. The Northeast Region will follow in March 2018, the Southeast Region in July 2018 and the Lehigh/Capital Region in January 2019. DHS said this delay will allow time for transition after several bid protests from MCOs that were not selected. Click here to view the full announcement from DHS.

  • In January, DHS announced the results of the HealthChoices procurement for the 2017 contract year, which was reissued in July 2016 following a lawsuit in Commonwealth Court. The current 2016 contracts are being extended until June 2017 at which point the new agreement will be put into place. DHS has selected the following MCOs in five geographic regions:

Southeast Region
Gateway Health
Health Partners Plans 
PA Health and Wellness
UPMC for You 
Vista - Keystone First Health Plan
Southwest Region
Gateway Health 
PA Health and Wellness
UPMC for You 
Vista - AmeriHealth Caritas Health Plan
Lehigh/Capital Region
Gateway Health
Geisinger Health Plan
Health Partners Plans
PA Health and Wellness
Northeast Region
Gateway Health
Geisinger Health Plan
UPMC for You
Northwest Region
Gateway Health 
UPMC for You 
Vista - AmeriHealth Caritas Health Plan
 

 

  • New Medicaid face-to-face requirements that took effect July 1, 2016 will not affect providers of pediatric shift nursing services. This is true even if the pediatric patient is under a HealthChoices plan. More information: MA Bulletin on Face-to-Face

Community HealthChoices (CHC)

This new long-term services and supports program will replace the state’s Medicaid waiver programs for individuals age 21 and older and seniors who need long-term care. Like HealthChoices, this care will be coordinated by CHC managed care organizations (CHC-MCOs) in five zones across the state. Implementation will begin in the Southwest Zone on January 1, 2018, move to the Southeast Zone on July 1, 2018 and complete statewide implementation on January 1, 2019.

CHC Zone Map
Current RFP & Draft Agreement (guidelines CHC-MCOs must meet to participate in the program)

FYI on CHC

PHA’s Overview of CHC

Recent News

  • In June 2017, DHS developed a one-pager to outline the CHC-Provider relationship going forward, including quality monitoring and oversight, claims payment and provider dispute resolution. Click here to view the resource. 
  • In May 2017, DHS released a timeline to help consumers and providers navigate the transition from waivers to Community HealthChoices (CHC). CHC will serve participants currently in the Aging, Attendant Care, Independence and COMMCARE waivers. OBRA participants who are nursing facility clinically eligible will also move to CHC. The OBRA Waiver will continue to serve participants 18 years of age and older who have a severe developmental disability requiring the level of care provided in an intermediate care facility. Click here to view the timeline. 
  • In August 2016, DHS announced the three MCOs that were selected to participate statewide: Amerihealth Caritas, Pennsylvania Health and Wellness (Centene) and UPMC for You. 
  • Following this announcement, several MCOs that did not receive awards filed bid protests: Aetna (this protest was later withdrawn), Gateway, Geisinger, Molina, United Healthcare and Wellcare. Contract negotiations were paused from August to December due to the bid protests. 
  • In December 2016, DHS announced that all protests were resolved but due to the delay in contract negotiations, the timeline for CHC implementation would be pushed back—Southwest in January 2018 rather than July 2017, Southeast in July 2018 rather than January 2018 and the remainder of the state will be on track for the originally planned January 2019 implementation.