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 (TTY: 711) 24 hours a day, seven days a week.
Section 1 – General FAQ
What is UPMC Community HealthChoices?
UPMC Community HealthChoices is a managed care plan that provides coverage for medical care and long-term services and supports (LTSS) for eligible individuals who qualify for Medical Assistance and also qualify for Medicare or require a nursing facility level of care.
Where is UPMC Community HealthChoices available?
UPMC Community HealthChoices is available in all Pennsylvania counties.
What is LTSS?
Long-term services and supports (LTSS) help individuals live as independently as possible. LTSS is provided in a nursing facility or in an individual’s home and community. It may include assistance with activities such as bathing, dressing, preparing meals, and taking medications. Services include but are not limited to personal assistance services, in-home nursing care, therapy, nonmedical transportation, and employment services. Eligibility for LTSS and type of services received are based on each individual’s needs. See Section 5 of this page for more information.
How can UPMC Community HealthChoices Participants provide feedback?
Join the UPMC CHC Participant Advisory Committee (PAC)! The PAC is a committee of Participants, caregivers, community groups, and providers who meet four times a year to provide feedback and suggestions based on their experiences with UPMC CHC.
If you are interested in joining the PAC, act now. Space is limited. For more information about the PAC or how to apply, please call our Health Care Concierge team at 1-844-833-0523 (TTY: 711). A member of the UPMC CHC Community Engagement Team will promptly return your call. You can also apply by completing our Participant Advisory Committee application.
Section 2 – Enrollment and Eligibility
Who is eligible for UPMC Community HealthChoices?
Individuals are eligible for UPMC Community HealthChoices if they are 21 years old or older, live in Pennsylvania, and are::
- 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 UPMC Community HealthChoices if they are 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.
How do I enroll in UPMC Community HealthChoices?
You can enroll in UPMC Community HealthChoices by calling the Independent Enrollment Broker (IEB) at 1-844-824-3655 (TTY: 711) or online at paieb.com.
After enrolling in a Community HealthChoices plan, you may change your Community HealthChoices plan at any time by contacting the IEB. It can take up to six weeks for a change to your Community HealthChoices plan to take effect.
Section 3 – Services
What medical services does UPMC Community HealthChoices cover?
UPMC Community HealthChoices covers the same medical services that are available through the Medical Assistance Adult Benefit Package and more. See the Medical Services Benefits page for more information.
If you are dually eligible for Medicare and Medical Assistance, your Medicare benefits are not changed or affected by UPMC Community HealthChoices. Your Medicare plan is your primary payer. UPMC Community HealthChoices is your secondary Medical Assistance payer. That means that you must use your Medicare benefits before you use your UPMC Community HealthChoices benefits.
What will my copays be?
If you are dually eligiblefor Medicare and Medical Assistance, your Medicare copays are not changed or affected by UPMC Community HealthChoices. Refer to your Medicare plan for more information on Medicare copays. There are no UPMC Community HealthChoices copays for medical services, LTSS, and generic medications. There is a $3 copay for brand-name medications.
Copays do not apply to pregnant participants.
Does UPMC Community HealthChoices cover any services that are not covered by Medical Assistance?
Yes. As a participant in UPMC Community HealthChoices, you may be eligible to receive additional value-added benefits. See the Additional Benefits page for more information.
Does UPMC Community HealthChoices cover behavioral health services?
UPMC Community HealthChoices does not cover behavioral health services. However, participants are eligible to receive behavioral health services from behavioral health managed care organizations (BH-MCOs). To find the BH-MCO in your county, visit dhs.pa.gov or call the UPMC Community HealthChoices Health Care Concierge team.
Section 4 – Provider Network
How do I know if my providers are in the UPMC Community HealthChoices Network?
If you are dually eligible for Medicare and Medical Assistance, for most services, your medical providers do not need to be in the UPMC Community HealthChoices network. Since Medicare is your primary insurer, you should make sure your providers are in your Medicare plan's network.
If you are only eligible for Medical Assistance, your medical providers must be in the UPMC Community HealthChoices network.
All LTSS providers must be in the UPMC Community HealthChoices network.
To find providers in our network, you can search our provider directory or call the UPMC Community HealthChoices Health Care Concierge team.
If I have Medicare and my PCP is not in the UPMC Community HealthChoices network, do I have to change my PCP if I enroll in UPMC Community HealthChoices?
No, you do not. Your Medicare providers, including PCPs, do not have to be in the UPMC Community HealthChoices network. You can enroll in UPMC Community HealthChoices and continue seeing your Medicare PCP.
Section 5 – Long-term Services and Supports
Who decides if someone is clinically eligible for LTSS?
UPMC Community HealthChoices does not decide if an individual 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?
If you are eligible for LTSS, all Home and Community-Based Services (HCBS) available in the Office of Long-Term Living’s physical disability waiver programs are covered by UPMC Community HealthChoices. See the LTSS Benefits page for more information.
For more information about Community HealthChoices, visit the Department of Human Services website.