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managed care in pennsylvania

The Department of Human Services, Bureau of Procurement and Contracts Management has released the Request for Application (RFA) for Managed Care Organizations to provide physical health services in the Commonwealth of Pennsylvania in the five HealthChoices zones. These zones include the Southeast, Southwest, Lehigh/Capital, Northeast, and Northwest.

The RFA can be found here. Appendix A of the agreement can be viewed here. Contact Sarah Eyster, RCPA Mental Health Division Director, with questions.

Beginning January 2020, Community HealthChoices (CHC) will be the mandatory managed care program for Pennsylvanians residing in the Lehigh/Capital, Northeast, and Northwest CHC zones* who are dually eligible for both Medicare and Medicaid (Medical Assistance), enrolled in Medicaid waivers for physical disabilities, and Medicaid-eligible consumers who reside in a nursing facility. As a managed care program, CHC gives individuals the choice of health plans to best match all their health care and long-term care needs.

Members located in this zone are invited to attend a community meeting to learn about the CHC program and have an opportunity to ask questions. If you wish to attend one of these community meetings, a list of dates and locations are available on the event registration page. Most locations have two sessions — a morning session and an afternoon session. Each session will run for approximately two hours. Space is limited; if you are not planning to attend alone, please be sure that each additional person registers as well. You can view the invitation that was sent to CHC participants here.

Need more information about CHC? Please Visit www.Healthchoices.Pa.Gov or call 833-735-4416.

*The Lehigh/Capital Zone includes Adams, Berks, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Lancaster, Lebanon, Lehigh, Northampton, Perry, and York counties. The Northeast Zone includes Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill, Sullivan, Susquehanna, Tioga, Union, Wayne, and Wyoming counties. The Northwest Zone includes Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Potter, Venango, and Warren counties.

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Pennsylvania Continues Shift to Outcome and Value-based Payment Structure

On April 27, Department of Human Services (DHS) Secretary Ted Dallas announced that the state has agreed to move forward and negotiate contracts with eight managed care organizations (MCOs) to deliver physical health services to Pennsylvanians through HealthChoices, Pennsylvania’s mandatory Medicaid managed care program since 1997.

“These agreements mark the most significant change in Pennsylvania’s Medicaid program since we moved to managed care 18 years ago,” said Dallas. “Over the next three years, MCOs will be investing billions of dollars in innovative approaches that reward high-quality care that improves patient health rather than just providing services for a fee. The result will be higher levels of quality care for the 2.1 million Pennsylvanians served by Medicaid.”

HealthChoices delivers quality medical care and timely access to all appropriate services to children, individuals with disabilities, pregnant women, and low-income Pennsylvanians. For more information, visit the HealthChoices website or DHS website.

DHS has selected the following MCOs to proceed with negotiations to deliver services in Pennsylvania beginning in 2017. The agreements are awarded in five geographic regions:

Southeast Region

 

Centene (Pennsylvania Health and Wellness)
Health Partners Plans
United Healthcare of Pennsylvania, Inc.
UPMC for You, Inc.
Vista–Keystone First Health Plan
Lehigh/Capital Region Centene (Pennsylvania Health and Wellness)
Gateway Health
United Healthcare of Pennsylvania, Inc.
UPMC for You
Vista—AmeriHealth Caritas Health Plan
Southwest Region

 

Centene (Pennsylvania Health and Wellness)
Gateway Health
United Healthcare of Pennsylvania, Inc.
UPMC for You
Vista—AmeriHealth Caritas Health Plan
Northwest Region Aetna Better Health of Pennsylvania
United Healthcare of Pennsylvania, Inc.
UPMC for You
Vista—AmeriHealth Caritas Health Plan
Northeast Region Geisinger Health Plan
United Healthcare of Pennsylvania, Inc.
UPMC for You
Vista—AmeriHealth Caritas Health Plan