Overview
CHC has improved healthcare services for hundreds of thousands of Pennsylvanians who need long-term services and supports.
CHC aims to enhance the quality, accountability, efficiency, and effectiveness of Long-Term Services and Supports (LTSS) for Medicaid participants in Pennsylvania. By improving the coordination of these supports, Pennsylvanians can have choice, control, and access to a full array of quality services that provide independence, health, and quality of life within their communities.
Available Services
For All Participants
The following physical and behavioral health benefits are available to all CHC participants:
- Certified registered nurse practitioner services
- Chiropractic services
- Clinic services
- Crisis services
- Contact lenses (limited to individuals with aphakia)
- Dental care services
- Durable medical equipment
- Emergency room/ ambulance services
- Eyeglass frames and lenses (limited to individuals with aphakia)
- Family planning services and supplies
- Federally qualified health center services/rural health clinic services
- Home health services
- Hospice services
- ICF/IID and ICF/ORC (requires an institutional level of care)
- Inpatient hospital services
- Laboratory services
- Maternity (physician, certified nurse, midwives, birth centers)
- Medical supplies
- Mobile mental health treatment
- Non-emergency Transportation (only to and from Medicaid covered services)
- Nursing facility services
- Nutritional supplements
- Optometrist services
- Outpatient hospital services
- Peer support services
- Physician services
- Podiatrist services
- Prescription drugs
- Primary care provider services
- Prosthetics and orthotics (Orthopedic shoes and hearing aids are not covered)
- Radiology services (i.e., x-rays, MRIs, CTs)
- Renal dialysis services
- Targeted case management services (behavioral health only, limited to individuals with SMI only; other than behavioral health; limited to individuals identified in the target group)
- Therapy (physical, occupational, speech); habilitative and rehabilitative; only when provided by a hospital, outpatient clinic or home health provider)
- Tobacco cessation
NOTE: Behavioral Health benefits will be provided by the Behavioral Health managed care organizations (MCO). The CHC MCO must coordinate care with their members’ HealthChoices Behavioral Health MCOs.
For Long-Term Services and Supports (LTSS) Participants
- Adult daily living services
- Assistive technology
- Behavior therapy
- Benefits counseling
- Career assessment
- Cognitive rehabilitation therapy
- Community integration
- Community transition services
- Counseling
- Employment skills development
- Financial management services
- Home adaptations
- Home delivered meals
- Home health aide
- Home health – nursing
- Job coaching
- Job finding
- Nutritional counseling
- Participant-directed community supports
- Participant-directed goods and services
- Personal assistance services
- Personal emergency response system (PERS)
- Pest eradication
- Residential habilitation
- Respite
- Service coordination (including information and assistance in support of participant direction. Service coordination is furnished as a distinct activity to waiver participants as an administrative activity)
- Structured day habilitation
- TeleCare
- Vehicle modifications
Extended State Plan Services
- Home health – physical, occupational, and speech and language therapies
- Specialized medical equipment and supplies
Eligibility
If you are age age 21 or older and enrolled in Medicaid, you may be enrolled in CHC if you fall into one of the following two groups.
- Dual eligible participants — People enrolled in both Medicare and Medical Assistance.
- Participants needing LTSS services — People who qualify for LTSS through Medicaid because of a need for the level of care provided by a nursing facility. If you are receiving LTSS at home through a waiver program or reside in a nursing facility. You may also be enrolled in both Medicare and Medicaid.
Ineligible Individuals
You are NOT eligible for CHC if:
- You are a person with an intellectual or developmental disability receiving services beyond supports coordination through the Department of Human Services’ Office of Developmental Programs (ODP); OR
- You are a resident in a state-operated nursing facility, including state veterans homes.
Enroll in CHC
You can enroll in CHC if you are a Medicaid participant and meet eligibility requirements.
If You Need LTSS
Contact the Independent Enrollment Broker (IEB). They will be available to help you apply for long-term services and supports through CHC.
The IEB will schedule an in-person assessment for you, which is done in your home, in a hospital, or in a nursing facility — wherever you are. This will determine if you need LTSS. The IEB will also help you complete a Medicaid application, which is sent to the county assistance office (CAO).
When you meet with the IEB, they will talk to you about the CHC plan options in your area. If you do not make a selection, a CHC plan will be assigned to you. If you want to change your CHC plan, you may do so at any time.
Your coverage with the CHC plan begins on the date you are determined eligible.
If You Do Not Need LTSS
To qualify, you must be on Medicare and financially eligible. Your CAO will determine if you are financially eligible and might contact you for additional information. Once those things are completed, the Commonwealth will let you know if you quality. Then you will need to work with our IEB to choose which CHC plan you will get coverage from.
Once approved, your Medicaid coverage will begin on the date of your application.
The MCOs are AmeriHealth Caritas, PA Health & Wellness, and UPMC Community HealthChoices. You can choose a new MCO at any time.
The MCO must:
• Complete a screening within 90 days of your start date if you are a new enrollee who is eligible for both Medicaid and Medicare.
• Complete a comprehensive needs assessment if you are determined nursing facility clinically eligible (NFCE)
• Complete a comprehensive needs assessment when one is requested, you identify yourself as needing LTSS, or if either the MCO or the Independent Enrollment Broker (IEB) determines that you have unmet needs, service gaps or a need for service coordination.
Complete a reassessment at least every 12 months (unless an event happens to cause an assessment to happen sooner).
All LTSS participants will have a person-centered service plan (PCSP). The PSCP includes both your care management plan and the LTSS services plan. PCSPs are developed through the person-centered planning team process, which includes the participant, service coordinator, participant’s supports, and participant’s providers.
A care management plan is developed through the person-centered planning team process, which includes the participant, service coordinator, participant’s supports, and participant’s providers. It is used to identify and address how your physical, cognitive, and behavioral health care needs will be managed.
Every participant receiving LTSS must pick a service coordinator. The service coordinator will coordinate Medicare, LTSS, physical health services, and behavioral health services. They will also help in accessing, locating, and coordinating needed covered services and noncovered services such as social, housing, educational and other services and supports.
You will have a person-centered planning team that includes your doctors, service providers, and natural supports.