What is Community Health Choices?

  • Community Health Choices is a new initiative that will use managed care organizations to coordinate physical health care and long-term services and supports (LTSS) for older persons, persons with physical disabilities, and Pennsylvanians who are dual eligible for Medicare and Medicaid (dual eligible).

Medicare

Any Pennsylvanians who is a Medicare is our country’s health insurance program for people age 65 or older. People younger than age 65 with certain disabilities, or permanent kidney failure, or amyotrophic lateral sclerosis (1st payer always)

Medicaid

Is a joint federal state program, that helps with medical costs for some people with limited income and resources. Medicaid also benefits not normally covered by Medicare, like nursing home care and personal services. (2nd payer)

Will there be changes when it comes to benefits? Medicare benefits will still be the same, but will just have more and better coordination. CHC will add more services, job openings for PWD, quality tile with the families and have a better quality of life.

1.INTRODUCTION:
Hi, My name is RA, calling from Medical Supply Incorporated, we are provider of (insert patient’s name) incontinence/medical supplies (if not patient)

2.REASON FOR THE CALL – Why are we calling?
This call is about the changes that will happen later this year in Pennsylvania that will affect you insurance.

3. ACQUIRE THE LETTER IN THE MAIL
Did you receive any letter or flyer in the mail? Did you understand the letter?

4. EXPLAIN COMMUNITY HEALTHCHOICES
This coming January 2018, PA will have a new program called COMMUNITY HEALTHCHOICES, purpose of CHC is to have a better coordination of care dor dual eligible (Medicare and Medicaid) and waiver holders.

5. REASON FOR CHC – Why PA wants to implement CHC
A lot of people were not getting all their benefits covered bty their health programs, this is just the way to coordinate all their health benefits.

6. RECOMMENDATION FOR CHC-MCO
CHC will be managed by 3 MCOs. it’s AmeriHealth, PA Health and wellness and UPMC4U. As of this time, we are just in contract with the PA health and Wellness and UPMC4U and we are trying to be in contract with AmeriHealth. We highly recommend that you choose either PA Health and Wellness or UPMC4U so we can still be your provider of incontinence supplies. Also, please make sure that your doctors will be in contract with them. In the event that you will belong to AmeriHealth, we only have until June2018 to be you incontinence provider. After that, you need to find another provider. You don’t need to decide now, you can still decide before the year ends since the changes will be on January 2018. Once decided, you can call your care managers for us.

7. OUR RESOURCES – websites, hotline, aging coordinator
If you have questions or clarification, I Would like you to contract your care managers or the PENNSYLVANIA HEALTH LAW PROJECT. (don’t give out any info about numbers because thy may not be CHC ready).

  • CHC – COMMUNITY HEALTH CHOICES
  • COMMUNITY HEALTH CHOICES is the replacement for all the waiver programs in PA CHC will be managed by MCO selected by the state of PA.
  • The following MCOs was selected:
    • UMPMC FOR YOU
    • AMERIHEALTH
    • PA HEALTH AND WELLNESS
  • Currently we are in network with PA HEALTH WELLNESS AND UPMC FOR YOU (in selected areas). There are over 1500 consumers that receive the waiver items from MSI. To make sure that we can continue to service these patients along with new patient we need a game plan.

What We Can Do:

  • Contact UPMC FOR YOU to expanse our contract to cover all counties. CSR need to inform Sheneka about all the UPMC consumer, even consumer from counties we can service.
  • CHC transition will start in January 2018. We need a list of all waiver consumers. I sort consumers area and care managers. We need to start to now while the State and CHC-MCOs are negotiating.
  • CHC-MCOs will either contract with care managing organizations (PCA) or use their own care managers within the company. (Many care managers will lose their jobs). We need to learn how they bill the waivers.
  • The state has ordain 6 months of Continuation of care. Very Important: We may need to send prior Auths. To MCO starting in January.
    • MSI DENIED – If we are denied them we need to make sure the consumer does not have a break with service. If there is a break in service we can bring notice to the State. The State will have an outside company monitoring the effectiveness of CHC-MCO.
    • MSI APPROVED – If we are approved, we can continue the care and contract the AmeriHealth and UPMC For You to let us be an in-network. Again, we have to learn how the billing will work. We have to keep up on the approval for the payment. The State ordained the 6 month continuation of care and the CHC-MCO will get in trouble or fined for non-payment.

There is also another way to get in-network

  • If a consumer had another MCO and received waiver items, they maybe pushed to get all items from CHC-MCO. Example, If a consumer has GESINGER and also gets Waiver items, this con ,ay have to switch everything into AMERIHEALTH to battle this, we would have to send letters or make call to inform consumer about the up-coming change. We need to learn when the consumer will receive the letter form CHC about the upcoming change.
  • Apply to get in contract with the LIFE program. The LIFE program, which is the PA version of PACE. This program will not be included in the CHC. Please let us know if when consumer comes in with this coverage.
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