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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?

Individuals age 21 and older are eligible for CHC if they are dually eligible for Medicare and Medicaid (with or without LTSS) or if they qualify for Medicaid long-term services and supports (LTSS) because they need the level of care provided by a nursing facility.

Read more about eligibility

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.

After enrolling in Community HealthChoices, 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 711. 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 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 are covered by 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. There are no UPMC Community HealthChoices copays for medical services and generic medications. There is a $3 copay for brand-name medications.

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:

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 and. 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
Day services in a community-based center to help with personal care, social, nutritional, and therapeutic needs, 4 or more hours a day on a regular schedule for one or more days every week.
Assistive technology
An item, piece of equipment, or product system to increase or maintain ability to communicate or do things for yourself as much as possible.
Benefits counseling
Counseling about whether having a job will increase your ability to support yourself and/or have a net financial benefit.
Career assessment
Review of your interests and strengths to identify potential career options.
Community integration
Short-term services to improve self-help, communication, socialization, and other skills needed to live in the community, provided during life-changing events such as a moving from a nursing home, moving to a new community or from a parent's home, or other change that requires new skills.
Community transition services
One-time expenses, such as security deposits, moving expenses, and household products, for participants who move from an institution to their own home, apartment or other living arrangement.
Employment skills development
Learning and work experiences, including volunteer work, where the participant can develop strengths and skills to be able to get a job that pays good wages.
Home adaptations
Physical changes to a participant’s home, such as ramps, handrails, and grab bars, to make the home safe and enable the participant to be more independent in the home.
Home-delivered meals
Prepared meals delivered to participants who cannot prepare or get nutritious meals for themselves.
Home health services
Nursing
Services of a registered nurse or licensed practical nurse that are ordered by a doctor, which include diagnosing and treating health problems through health teaching, health counseling, and skilled care prescribed by the doctor or a dentist.
Occupational therapy
Services of an occupational therapist ordered by a doctor, which include evaluating a participant’s skills and helping to change daily activities so that the participant can perform activities of daily living.
Physical therapy
Services of a physical therapist and ordered by a doctor, which include evaluation and treatment of a participant to limit or prevent disability after an injury or illness.
Home health aide
Services ordered by a doctor that include personal care such as help with bathing, monitoring a participant’s medical condition, and help with walking, medical equipment, and exercises.
Speech therapy
Services of a licensed American Speech-Language-Hearing associate or certified speech-language pathologist and ordered by a doctor, which include evaluation, counseling, and rehabilitation of a participant with speech disabilities.
Job coaching
Support to help learn a new job and keep a job that pays. Could include helping the participant to develop natural supports in the workplace and working with employers or employees, coworkers, and customers to make it possible for the participant to have a paid job.
Job finding
Help in finding potential jobs and helping the participant get a job that fits what he or she wants to and can do and the employer’s needs.
Nonmedical transportation
Tickets, tokens, and mileage reimbursement to help a participant get to community and other activities.
Participant-directed community supports
Services and support for participants who want to direct their services, hire their own workers, and keep a budget for their services under Services My Way, which include helping the participant with basic living skills such as eating, drinking, toileting; and household chores such as shopping, laundry, and cleaning; and help with participating in community activities.
Participant-directed goods and services
Services, equipment, or supplies for participants who want to direct their services and keep a budget for their services under Services My Way, so that they can be safe and independent in their homes and be part of their community.
Personal assistance services
Hands-on help for activities of daily living such as eating, bathing, dressing, and toileting.
Personal emergency response system
An electronic device which is connected to a participant’s phone and programmed to signal a response center with trained staff when the participant presses a portable “help” button to get help in an emergency.
Pest eradication
Services to remove insects and other pests from a participant’s home that, if not treated, would prevent the participant from staying in the community due to a risk of health and safety.
Residential habilitation
Services delivered in a provider-owned or provider- operated setting where the participant lives, which include community integration, nighttime assistance, personal assistance services to help with activities of daily living such as bathing, dressing, eating, mobility, and toileting, and instrumental activities of daily living such as cooking, housework, and shopping, so that the participant get the skills needed to be as independent as possible and fully participate in community life.
Respite
Short-term service to support a participant when the unpaid caregiver is away or needs relief.
Specialized medical equipment and supplies
Items that allow a participant to increase or maintain the ability to perform activities of daily living.
Structured day habilitation
Day services in a small group setting directed to preparing a participant to live in the community, which include supervision, training, and support in social skills training.
Telecare
Health status measuring and monitoring telecare services
Uses wireless technology or a phone line to collect health-related data such as pulse and blood pressure to help a provider in know what the participant’s condition is and providing education and consultation.
Activity and sensor monitoring telecare service
Uses sensor-based technology 24 hours a day, 7 days a week by remotely monitoring and passively tracking participants’ daily routines.
Medication dispensing and monitoring telecare service
Helps a participant by dispensing medicine and monitoring whether the participant is taking the medicine as prescribed.
Therapeutic and counseling services
Cognitive rehabilitation therapy
Services for participants with brain injury that include consultation with a therapist, ongoing counseling, and coaching or cueing that focus on helping the participant to function in real-world situations.
Nutritional consultation
Services to help the participant and a paid and unpaid caregiver in planning meals that meet the participant’s nutritional needs and avoid any problem foods.
Counseling services
Counseling for a participant to help resolve conflicts and family issues, such as helping the participant to develop and keep positive support networks, improve personal relationships, or improve communication with family members or others.
Behavior therapy
Services to assess a participant, develop a home treatment/support plan, train family members/staff and provide technical assistance to carry out the plan, and monitor the participant in the implementation of the plan.
Vehicle modifications
Physical changes to a car or van that is used by a participant with special needs, even if the car or van is owned by a family member with whom the participant lives or another person who provides the main support to the participant, so that the participant can use the car or van.
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

CHC Fact Sheet

CHC Glossary

DHS Community HealthChoices Page

Copyright 2018.

UPMC Health Plan, Inc.

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