If you have questions about Community HealthChoices, please browse our FAQ below.
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. UPMC Community HealthChoices is 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:
Individuals are not eligible for UPMC Community HealthChoices if they are any one of the following:
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. Secondary Medical Assistance claims can be submitted to the individual’s CHC-MCO for review even if you are not in the CHC-MCO’s network.
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).
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 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.
For more information, please call Community HealthChoices Provider Services at 1-844-860-9303 or email email@example.com. For general questions about Community HealthChoices, call the Department of Human Services Provider Hotline at 1-833-735-4417.