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 and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, like nursing home care and personal care services. (2nd payer)
Will there be any 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 time with the families and have a better quality of life.
1. INTRODUCTION:
Hi, my name is RA, calling form Medical Supply incorporated, we are provider of (insert patient’s name) incontinence/medical supplies (if not patient)
2. REASON FOR CALL– Why we are 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 call COMMUNITY HEALTHCHOICES, purpose of this CHC is to have a better of care for 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 by their health programs, this is just a way to coordinate all their health benefits.
6. RECOMMENDATION FOR CHC-MCO
CHC will be managed by 3 MCOs. It’s AmeriHealth, PAHealthand Wellness and UPMC4U. Ass of this time, we are just in contract with 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 be going to AmeriHEALTH , we only have until June2018 to be your 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 clarifications, I would like you to to contact your care managers or the PENNSYLVANIA HEALTH LAW PROJECT. (don’t give out any info about numbers because the may not be CHC ready)
- CHC – COMMUNITY HEALTH CHOICES
- COMMUNITY HEALTH CHOICES is the replacement for all the waiver programs in PA. CHC will managed by MCO selected by the state of PA.
- The following MCOs was selected:
- UPMC FOR YOU
- AMERIHEALTH
- PA HEALTH AND WELLNESS
- Currently we are in network with the PA HEALTH AND WELLNESS AND UPMC FOR YOU (in selected areas). There are over 1500 consumers that received waiver items form MSI. To make sure that we can continue to service these patients along the 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 UPMC consumer, even consumer from counties we service.
- CHC transition will start in January 2018. We need list of all waiver consumers. I sort consumer area and care managers. We need to start 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
- The state has ordain 6 months of continuation of care. Importantly, we may need to send prior Auths. to MCO starting January 2018
- MSI Denied. If we are denied, then 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 contact the Amerihealth and UPMC for you to let us in- network. Again, we have to learn how the billing will work. We have to keep up on the approval for payment. The state oprdained the 6 month continuation of care and CHC-MCO will get in trouble or fined for non-payment.
There is another way to get in-network.
- If a consumer has another MCO and received waiver items, they may be pushed to get all the item form CHC-MCO. Example: If a consumer has GESINGER and also gets Waiver items, this con may have to switch everything into AmeriHEALTH. To battle this we would have to send letters or make calls to inform consumer about upcoming change. We need to learn when the consumer will receive the letter from 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 me know if the when consumer comes in with this coverage.