Frequently Asked Questions

Questions about Community HealthChoices (CHC)? Browse our FAQ below. If you don’t see your question here, we can help. Call the UPMC Community HealthChoices Health Care Concierge team at 1-844-833-0523 24 hours a day, 7 days a week. TTY users should call toll-free 1-866-407-8762.

Please click on the bolded sections below to see questions in that category. You can also click on the questions listed under each section to look at a specific topic.

Section 1 – General FAQ

What is CHC?

CHC is the Department of Human Services’ (DHS) new program that will allow managed care organizations (MCOs) to coordinate medical care and long-term services and supports (LTSS) for individuals who qualify for Medical Assistance and also qualify for Medicare or require a nursing facility level of care.

UPMC Community HealthChoices is an MCO selected by DHS to provide this program in Pennsylvania.

When will CHC become available where I live?

Beginning January 1, 2018, CHC will be available in the following counties:

Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Green, Indiana, Lawrence, Somerset, Washington, Westmoreland

The program will be rolled out in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties on January 1, 2019. CHC will expand to all other Pennsylvania counties on January 1, 2020.

Anyone who is dual eligible for Medicare and Medicaid (with or without LTSS) or is eligible for Medicaid with LTSS must have a CHC MCO on the date CHC begins in your county.

What is LTSS?

Long-term services and supports (LTSS) helps individuals live as independently as possible. LTSS is either provided in a nursing facility or in a person’s home. It may include assistance with activities such as bathing, dressing, preparing meals, and taking medications. Services may also include in-home nursing care, therapy, nonmedical transportation, and career services, as well as home and vehicle modifications. The type of service and setting is based on each person’s needs and preferences. See Section 5 – Service Coordination, Functional Eligibility Determination, and LTSS Services for more information.

Section 2 – Enrollment and Eligibility for Community HealthChoices

Who is eligible for CHC?
How do I choose a Community HealthChoices MCO?

Anyone who is dual eligible for Medicare and Medicaid or is eligible for Medicaid benefits with long-term services and supports (LTSS) are eligible for Community HealthChoices (CHC) and must have a Community HealthChoices MCO.

Community HealthChoices will begin on January 1, 2018, for individuals who live in the following southwestern Pennsylvania counties:

Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington, Westmoreland.

You may change your CHC MCO at any time by contacting the state’s Independent Enrollment Broker (IEB) at 1-844-824-3655. TTY users should call toll-free 1-833-254-0690. Or you can enroll online at www.enrollchc.com. They will tell you when the change to your new Community HealthChoices plan will start. It can take up to 6 weeks for a change to your Community HealthChoices plan to take effect.

Those who already participate in a Living Independence for the Elderly (LIFE) program can remain in their LIFE program and will not be moved into CHC unless they specifically ask to change. Anyone who is enrolled in CHC but would rather be in a LIFE program will be free to participate in LIFE if they qualify.

If you have questions about eligibility or enrollment, please contact the UPMC Community HealthChoices Health Care Concierge team at 1-844-833-0523 24 hours a day, 7 days a week. TTY users should call toll-free 1-866-407-8762.

Section 3 – Services

What services will CHC cover?

If you are dual eligible for Medicare and Medicaid, your current Medicare benefits will not change or be affected by CHC. Your CHC MCO will become the secondary Medicaid payer instead of the current fee-for-service arrangement through the PA Department of Human Services.

CHC will cover the same physical health benefits currently available through the Medicaid Adult Benefit Package. You will continue to be eligible for any medical services you currently receive as long as they are medically necessary.

If you are eligible for LTSS, all services currently available in the Office of Long-Term Living home and community based waivers will be included in CHC. See Section 5 – Service Coordination, Functional Eligibility Determination, and LTSS Services for more information.

What will my copays be?

If you are a member of UPMC for Life Dual or any other Medicare coverage, your Medicare copays will not change under UPMC Community HealthChoices. Copays for Medicaid benefits can be found in the Summary of Benefits.

Copays do not apply to pregnant members.

Will I get any additional services that are not provided by traditional Medicaid?

Yes. As a member of UPMC Community HealthChoices, you are eligible to receive additional value-added benefits. These include:

$500 dental allowance. This allowance can be used towards certain dental procedures after a benefit limit has been reached. If the procedure cost exceeds $500, you will be responsible for any cost over the $500. A prescription from a participating provider is required.

$100 vision allowance and glasses fitting each year. This allowance can be used toward purchasing new glasses (one frame and two lenses) or contact lenses (one pair) and one fitting per year. If the cost of the glasses or contact lenses exceeds $100, you will be responsible for any cost over the $100. A prescription from a participating provider is required.

Extended coverage of home and community based services. This service will provide personal assistance services to eligible members who are unable to perform activities of daily living and are at risk of entering a nursing facility. Eligibility is based on a nursing facility clinical eligibility assessment and pending application with the county assistance office.

Safelink Android smartphone. This free smartphone for eligible participants comes with 350 minutes of talk and unlimited text.

Health coaches. This service provides one-on-one coaching to help you eat healthier, lose weight, reduce stress, and quit smoking. Health coaches can also help you manage symptoms and provide treatment options for heart disease, asthma, COPD, low back pain, diabetes, or depression.

AnywhereCare.** This service lets you access a UPMC provider via live video from your computer, tablet, or smartphone — anytime, day or night. Use AnywhereCare for minor issues such as colds, flu, sore throats, skin rashes, and other nonemergency conditions.

Maternity program. This service can help pregnant women get the support and care they need to have a healthy baby.

Stress management program. This service provides online access to a program to help you feel more confident, overcome setbacks, and take control of your life and mood.

Medicaid redetermination assistance. This service gives you help with maintaining your Medicaid coverage to make sure you do not lose access to your Medicaid benefits.

Additional services are available to UPMC Community HealthChoices members who are Nursing Facility Clinical Eligible (NFCE), including:

Caregiver support program. This service offers individualized coaching support for caregivers through in person home visits and through a user-friendly technology platform. Eligible caregivers may also receive a daily stipend based on the participant’s level of need.

Enhanced community transition services. This service offers up to $6,000 yearly allowance to help participants who are transitioning from a nursing facility to the community. The allowance can be used on a variety of items such as household supplies, essential furniture, general moving expenses,security deposits and other items associated with personal and environmental health and safety assurances.. (This service exceeds the $4000 lifetime maximum benefit provided by the state’s fee-for-service Medicaid program.) UPMC Community HealthChoices will administer this benefit in conjunction with a nursing home transition team, led by the participant, which will develop a budget for distributing these funds to support the facility to community transition.

Temporary rental assistance. This service provides rental assistance to those whose only barrier to transition from a nursing facility to the community is access to affordable housing. The benefit may provide rental assistance for up to 24 months for those participants who have applied for a permanent subsidy program and where the subsidy is likely to become available within the 24-month period. The benefit will cover rent in the amount that would be covered under the subsidy program and will be administered in conjunction with the nursing home transition team.

**UPMC Community HealthChoices members can seek treatment through UPMC AnywhereCare. UPMC Community HealthChoices members located in Pennsylvania at the time of the service will have a virtual visit with a UPMC-employed provider. UPMC AnywhereCare virtual visits are not covered services when UPMC Community HealthChoices members are traveling outside of Pennsylvania.

How will I get behavioral health services through CHC?

Behavioral health services will be offered through the existing network of behavioral health managed care organizations (BH-MCOs). UPMC Community HealthChoices will work with BH-MCOs to ensure you get the coordinated services you need.

Section 4 – Provider Network

How do I know if my providers are in UPMC Community HealthChoices Network?

If you are a UPMC for Life Dual member or a UPMC for You member, your providers — including your primary care provider (PCP) — are in our network. However, if you have a D-SNP or Medicare Advantage plan with a different MCO, your doctor is not required to be in our network. You can choose UPMC Community HealthChoices and continue seeing your provider.

To check our network, you can search our directory at www.upmchealthplan.com/find. To find a medical doctor, choose UPMC Community HealthChoices in the Coverage Type dropdown and search by specialty or location. To find a home and community based provider, choose the Hospital/Urgent Care/Services tab at top of the page and then choose HCBS.

Do I have to change my D-SNP PCP if I choose UPMC Community HealthChoices as my MCO?

No, you do not. Your Medicare providers, including PCPs, do not have to be in UPMC Community HealthChoices’ network. You can choose UPMC Community HealthChoices and continue seeing your PCP.

Section 5 – Service Coordination, Functional Eligibility Determination, and LTSS Services

Who decides if someone is clinically eligible for LTSS?

UPMC Community HealthChoices does not decide if an individual is eligible for LTSS. A representative from the Area Agency on Aging or Aging Well assesses the individual’s needs. The representative bases the decision on this assessment. If you would like to apply for LTSS, contact the Independent Enrollment Broker at 1-877-550-4227 and request an assessment.

What LTSS are covered by CHC?

You can receive LTSS in a nursing facility or in your home. The services you receive at home are called home and community based services (HCBS) and are based on your needs as noted in your Person-Centered Service Plan by your service coordinator.

Here are some examples of HCBS covered by CHC:

  • Adult daily living
  • Assistive technology
  • Benefits counseling
  • Career assessment
  • Community integration
  • Community transition services
  • Employment skills development
  • Home adaptations
  • Home-delivered meals
  • Home health services
    • Nursing
    • Occupational Therapy
    • Physical Therapy
    • Home Health Aide
    • Speech Therapy
  • Job coaching
  • Job finding
  • Nonmedical transportation
  • Participant-directed community supports
  • Participant-directed goods and services
  • Personal assistance services
  • Personal emergency response system
  • Pest eradication
  • Residential habilitation
  • Respite
  • Specialized medical equipment and supplies
  • Structured day habilitation
  • Telecare
    • Health Status Measuring and Monitoring TeleCare Services
    • Activity and Sensor Monitoring TeleCare Service
    • Medication Dispensing and Monitoring TeleCare Service
  • Therapeutic and counseling services
    • Cognitive Rehabilitation Therapy
    • Nutritional Consultation
    • Counseling Services
    • Behavior Therapy
  • Vehicle modifications
How will the PA Department of Human Services make sure that service coordinators include all needed services in the service plan?

UPMC Community Health Choices service coordinators will work with members, their caregivers, and other supports to ensure the member’s person-centered service plan meets their needs. Members must receive all covered services they need. The PA Department of Human Services will monitor this requirement once CHC is in place through:

  • Monitoring service plan authorization reductions.
  • Service plan change reporting from the CHC-MCOs.
  • Grievance and appeal reviews.
  • Fair Hearing decision reviews.
  • Encounter data and plan comparison reviews.
  • CHC-MCO member changes (switching plans).
  • Member surveys.
Does CHC cover assisted living facilities?

CHC benefits do not include payment for room and board in assisted living facilities. However, members will be allowed to receive certain HCBS covered by CHC in assisted living facilities.

Section 6 – Other Waiver Programs

As CHC is rolled out, will the LIFE program still be available?

Yes. In locations where the LIFE program is available, it will continue to be. Individuals who are eligible or currently enrolled can choose or stay in the LIFE program. For more information on the LIFE program, visit the Pennsylvania Department of Human Services website at www.dhs.pa.gov/citizens/alternativestonursinghomes/lifelivingindependencefortheelderly. If you are eligible for, and choose, the LIFE program, you will not be enrolled in CHC unless you ask to be moved to CHC.

I receive services through the Department of Aging’s Options Program. Will I still be able to get services through them?

If you are dual eligible but do not qualify for Medicaid LTSS, you can continue to get your long-term services through the Options program. You will get your Medicaid health care services through CHC and your LTSS through Options. If you become clinically eligible for nursing facility level of care, you may apply to get your LTSS through CHC.

Will the current OLTL waiver programs continue to function as separate waivers?

One CHC waiver will cover all participants who meet eligibility for a nursing facility level of care. As CHC rolls out in three phases across Pennsylvania, participants will move from their waiver programs into CHC.

The OBRA waiver will continue to serve 18- to 20-year-olds, as well as Individuals 21 years old and older who meet the intermediate care facility/other related conditions level of care.

Section 7 – Additional Resources

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