Frequently Asked Questions

Questions about UPMC Community HealthChoices? 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, seven days a week. TTY users should call 711.

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 Community HealthChoices?

Community HealthChoices is the Department of Human Services’ (DHS) Medical Assistance (Medicaid) program that allows 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 one of three CHC-MCOs selected by the state to provide this program in Pennsylvania.

Community HealthChoices program availability and participant service areas

January 1, 2018
Southwestern Pennsylvania counties:

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

January 1, 2019
Southeastern Pennsylvania counties:

Bucks, Chester, Delaware, Montgomery, Philadelphia

January 1, 2020
All other Pennsylvania counties

Anyone who is dually eligible for Medicare and Medical Assistance (with or without LTSS) or is eligible for Medical Assistance with LTSS must have a CHC-MCO or be enrolled in the Living Independence for the Elderly (LIFE) program on the date Community HealthChoices 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 and community. 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 of this page to learn more information.

Section 2 – Enrollment and Eligibility for Community HealthChoices

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

Anyone who is dually eligible for Medicare and Medical Assistance or is eligible for Medical Assistance with long-term services and supports (LTSS) is eligible for UPMC Community HealthChoices and must have a Community HealthChoices MCO, or participate in the Living Independence for the Elderly (LIFE) program.

If you live in southwestern Pennsylvania, 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 change your CHC-MCO 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 six weeks for a change to your Community HealthChoices plan to take effect.

If you live in Bucks, Chester, Delaware, Montgomery, or Philadelphia counties, Community HealthChoices enrollment began in September 2018. You can enroll by contacting the IEB at 1-844-824-3655 (TTY: 1-833-254-0690) or online at www.enrollchc.com.

If you participate in a Living Independence for the Elderly (LIFE) program, you can remain in the LIFE program and not be moved into Community HealthChoices unless you specifically ask to change. If you are enrolled in Community HealthChoices but would rather participate in the LIFE program, you may do so if you qualify for LIFE.

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, seven days a week. TTY users should call 711.

Section 3 – Services

What services will Community HealthChoices cover?

If you are dually eligible for Medicare and Medical Assistance, your current Medicare benefits will not change or be affected by Community HealthChoices. Your CHC-MCO will become the secondary Medicaid payer instead of the PA Department of Human Services.

Community HealthChoices covers the same physical health benefits that are available through the Medical Assistance fee-for-service program (ACCESS) and Medical Assistance Adult Benefit Package.

If you are eligible for LTSS, all services available in the Office of Long-Term Living home and community based waiver programs will be included in Community HealthChoices. Long-term nursing facility care is also covered. See Section 5 of this page to learn more.

What will my copays be?

If you are a member of UPMC for Life Dual or any other Medicare plan, your Medicare copays will not change under UPMC Community HealthChoices. Refer to your Medicare plan for more information on Medicare copays. Copays for Medicaid (Medical Assistance) benefits can be found in the Summary of Benefits.

Copays do not apply to pregnant participants.

Does UPMC Community HealthChoices provide any services that are not provided by traditional Medicaid?

Yes. As a participant in UPMC Community HealthChoices, you may be eligible to receive additional value-added benefits. These include:

$500 dental allowance. This allowance can be used toward 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. Refer to Summary of Benefits for more dental benefit information

$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. Refer to Summary of Benefits for additional vision benefit information.

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

Smartphone. Eligible participants may receive a smartphone with 350 minutes of talk and unlimited text. Household and lifetime limits may apply.

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. This service is best for minor issues such as colds, the flu, sore throats, rashes, and other nonemergency problems.

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.

Medical Assistance redetermination assistance. This service provides assistance to help you maintain your Medical Assistance eligibility so you do not lose access to your Medical Assistance benefits.

UPMC Community HealthChoices participants who are Nursing Facility Clinically Eligible (NFCE) may be eligible for additional services, 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 receive a daily stipend based on the participant’s level of need.

Enhanced community transition services. This service offers a yearly allowance of up to $6,000 to assist participants who are transitioning from a nursing facility to the community. The allowance can be used on a variety of items including 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 $4,000 lifetime maximum benefit provided by the Office of Long-Term Living's waiver 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 the 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 participants who have applied for a permanent subsidy program and 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 participants can seek treatment through UPMC AnywhereCare. UPMC Community HealthChoices partcipants 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 participants are traveling outside Pennsylvania.

Does Community HealthChoices provide behavioral health services?

Behavioral health services are offered through the existing network of behavioral health managed care organizations (BH-MCOs). To find the BH-MCO in your county, call the UPMC Community HealthChoices Health Care Concierge team.

Section 4 – Provider Network

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

If you are dually eligible for Medicare and Medical Assistance, your medical providers do not need to be in UPMC Community HealthChoices' network. Since Medicare is your primary insurer, you should make sure your providers are in your Medicare plan's network. You can choose UPMC Community HealthChoices and continue seeing your Medicare providers.

If you are only eligible for Medical Assistance with LTSS, your medical and home and community based services providers must be in UPMC Community HealthChoices' network.

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 Home & Community Based Services.

If I have Medicare and my PCP is not in UPMC Community HealthChoices' network, do I have to change my 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 a person 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. Those who would like to apply for LTSS should contact the Independent Enrollment Broker (IEB) at 1-877-550-4227 and request an assessment. (Please note that the IEB phone number for LTSS enrollment is different from Community HealthChoices enrollment.)

What LTSS are covered by UPMC Community HealthChoices?

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

Here are some examples of HCBS covered by UPMC Community HealthChoices:

  • 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 HealthChoices service coordinators will work with participants, their caregivers, and other supports to ensure the participant’s person-centered service plan meets their needs. Participants must receive all covered services they need. DHS monitors this 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).
  • Participant surveys.
Does UPMC Community HealthChoices cover assisted living facilities?

Community HealthChoices benefits do not include payment for room and board in assisted living facilities. However, participants are eligible to receive certain HCBS covered by Community HealthChoices in assisted living facilities.

Section 6 – Other Waiver Programs

As Community HealthChoices is rolled out, will the Living Independence for the Elderly (LIFE) program still be available?

Yes. In locations where the LIFE program is available, it will continue to be offered. Individuals who are eligible or currently enrolled can choose or stay in the LIFE program. For more information on the LIFE program, visit DHS' 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 Community HealthChoices unless you ask to be moved to Community HealthChoices.

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

If you are dually 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 Medical Assistance health care services through Community HealthChoices and your LTSS through Options. If you become clinically eligible for nursing facility level of care, you may apply to get your LTSS through Community HealthChoices.

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

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

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. Individuals who participate in the Act 150 program or have intellectual or developmental disabilities (ID/DD) and are eligible for services through the Office of Developmental Programs will not participate in Community HealthChoices.

Section 7 – Additional Resources

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