Frequently Asked Questions

If you have questions about Community HealthChoices, please browse our FAQs below.

What is CHC?

Community HealthChoices is the Department of Human Services’ (DHS) new mandatory 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 the state to provide this program beginning January 1, 2018, in the following counties: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington, and Westmoreland.

The UPMC Community HealthChoices program will be rolled out in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties on January 1, 2019. All other Pennsylvania counties will be rolled into the program on January 1, 2020.

Who is eligible for CHC?

Individuals are eligible for CHC if they are 21 years old and older

  • Dually eligible for Medicare and Medicaid (with or without LTSS); OR
  • Qualify for Medicaid long-term services and supports (LTSS) because they need the level of care provided by a nursing facility.

Individuals are not eligible for CHC if they are:

  • An Act 150 program participant;
  • An individual with intellectual or developmental disabilities (ID/DD) who is eligible for services through DHS’ Office of Developmental Programs; OR
  • A resident in a state-operated nursing facility, including the state veterans’ homes.

If an individual is dual eligible for Medicare and Medicaid, how does CHC affect their Medicare?

Community HealthChoices is a Medicaid product and does not affect an individual’s Medicare. Medicare will continue to be the primary payer and Medicaid is secondary.

Do I still submit Medicaid claims to the Department of Human Services?

No, Medicaid claims for UPMC Community HealthChoices should be submitted to UPMC Health Plan. If the individual is dual eligible for Medicare and Medicaid, and has chosen UPMC for Life Dual and UPMC Community HealthChoices, you may submit one claim to be reimbursed for both Medicare and Medicaid.

If an individual has UPMC Community HealthChoices and is dual eligible for Medicare and Medicaid, to whom should I submit Medicare claims?

Medicare claims should be submitted to the individual’s Medicare plan. This may or may not be UPMC Health Plan. It is the provider's responsibility to determine who provides the individual’s Medicare and Medicaid benefits and submit claims to the appropriate entity.

If an individual has LTSS, what do I have to do?

All individuals with LTSS have a service coordinator to assist in the coordination of medical and long-term services. Providers are expected to work with service coordinators, individuals, and others involved in the individual’s person-centered planning team to ensure the individual receives timely and quality services.

Is UPMC Community HealthChoices the only MCO that provides CHC?

No. A total of three MCOs were contracted to provide CHC. Participants may choose their MCO and may switch MCOs at any time by contacting the state’s Independent Enrollment Broker (IEB). It can take up to 6 weeks for a change to a member’s Community HealthChoices plan to take effect.

How can I get more information about UPMC Community HealthChoices?

For more information, please call UPMC Community HealthChoices Provider Services at 1-844-860-9303 or email chcproviders@upmc.edu. For general questions about Community HealthChoices, call the Department of Human Services Provider Hotline at 1-833-735-4417. For additional FAQs about Home and Community Based Services, click here.

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