Frequently Asked Questions

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

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.

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

Who is eligible for Community HealthChoices?

Individuals are eligible for Community HealthChoices if they are 21 years old or older and:

  • Dually eligible for Medicare and Medical Assistance (with or without LTSS); OR
  • Eligible for Medical Assistance and qualify for LTSS because they need the level of care provided by a nursing facility.

Individuals are not eligible for Community HealthChoices if they are one of the following:

  • 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.
  • A resident in a state-operated nursing facility, including the state veterans’ homes.

If an individual is dually eligible for Medicare and Medical Assistance, how does Community HealthChoices affect their Medicare?

Community HealthChoices is a Medical Assistance product and does not affect an individual’s Medicare. Medicare continues to be the primary payer and Medical Assistance is secondary. Providers in the individual’s Medicare network should continue seeing them and bill Medicare as primary for reimbursement. If you are registered with DHS as a Medical Assistance provider and have a PROMISe™ ID, you are able to submit secondary Medical Assistance claims to the individual’s CHC-MCO, even if you are not in the CHC-MCO’s network. If you are not a registered Medical Assistance provider, you cannot submit claims for secondary Medical Assistance payment.

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

No, Medical Assistance claims for Community HealthChoices should be submitted to the individual's CHC-MCO. If the individual is dually eligible for Medicare and Medical Assistance, you should submit claims to the Medicare plan first. Any remaining balance can be submitted to the CHC-MCO for possible secondary Medical Assistance payment. You should verify coverage at each visit using DHS' Eligibility Verification System (EVS).

If an individual has UPMC Community HealthChoices and is dual eligible for Medicare and Medical Assistance, 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 Medical Assistance 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 the service coordinator, individuals, and others who are 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 Community HealthChoices?

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