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UPMC 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 now available in all Pennsylvania counties.
Individuals are eligible for UPMC Community HealthChoices if they are 21 years old or older, a resident of Pennsylvania, and either:
- Dually eligible for Medicare and Medical Assistance (with or without long-term services and supports [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 UPMC Community HealthChoices if they are any one of the following:
- 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.
Read more about eligibility
UPMC 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.
No, Medical Assistance claims for UPMC 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).
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.
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, individual, and others who are involved in the individual’s person-centered planning team to ensure the individual receives timely and quality services.
No. A total of three MCOs were contracted to provide UPMC 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 UPMC Community HealthChoices plan to take effect.
For more information, please call UPMC UPMC Community HealthChoices Provider Services at 1-844-860-9303 or email firstname.lastname@example.org. For general questions about UPMC Community HealthChoices, call the Department of Human Services Provider Hotline at 1-833-735-4417.