In Pennsylvania, the integration of care for individuals eligible for both Medicare and Medicaid—known as dual-eligible beneficiaries—has evolved significantly over the years. Historically, these individuals navigated two separate systems, often leading to fragmented care and administrative complexities. To address these challenges, Pennsylvania implemented the Community HealthChoices (CHC) program, a managed care initiative aimed at coordinating health services for dual-eligible individuals and those with physical disabilities. Launched in phases starting in 2018, CHC seeks to enhance service delivery by integrating Medicare and Medicaid benefits, emphasizing person-centered care, and expanding access to home- and community-based services (HCBS).
The current landscape in Pennsylvania offers several resources to support dual-eligible consumers:
- Community HealthChoices (CHC): This program provides managed care plans that coordinate physical health and long-term services for dual-eligible individuals. Participants can choose from various managed care organizations (MCOs) to receive integrated services, including medical care, behavioral health, and HCBS. Enrollment information and plan options are available through the Pennsylvania Department of Human Services.
pa.gov - Dual Eligible Special Needs Plans (D-SNPs): These Medicare Advantage plans are specifically designed for dual-eligible individuals, offering additional benefits beyond Original Medicare, such as transportation to medical appointments and routine vision exams. For instance, UnitedHealthcare provides D-SNPs in Pennsylvania, aiming to enhance care coordination and access to services.
uhcprovider.com - Pennsylvania Health Law Project (PHLP): PHLP offers free legal services and advocacy to Pennsylvanians seeking to access publicly funded healthcare coverage, including Medicare and Medicaid. They provide guidance on navigating dual eligibility, understanding benefits, and resolving coverage disputes. Their resources are invaluable for consumers needing assistance with healthcare-related legal issues.
- 4. Highmark Wholecare Dual Eligible Special Needs Plan (D-SNPs): Highmark Wholecare offers a D-SNP that combines Medicare and Medicaid benefits, providing comprehensive coverage including hospital and doctor visits, prescription drugs, and additional services like transportation, food, and utility assistance. This plan is designed to address the holistic needs of dual-eligible members, ensuring access to essential health services and support.
highmark.com - 5. UPMC for Life Complete Care (HMO SNP): UPMC offers specialized plans for dual-eligible individuals, coordinating Medicare and Medicaid benefits to provide comprehensive coverage. Members have access to a broad network of providers and additional benefits such as dental, vision, and hearing coverage, as well as health and wellness programs. UPMC’s plan integrates medical and long-term care services to improve health outcomes for beneficiaries.
upmchealthplan.com - 6. Pennsylvania Department of Aging – APPRISE (Medicare Counseling): APPRISE is a free health insurance counseling program for Medicare beneficiaries, including those eligible for both Medicare and Medicaid. Trained counselors provide unbiased guidance on selecting health plans, understanding benefits, and navigating cost-saving programs like the Medicare Savings Program and Extra Help for prescription drugs. This resource helps dual-eligible individuals make informed decisions about their healthcare options.
aging.pa.gov - 7. Pennsylvania Medicaid Long-Term Services & Supports (LTSS): This program helps dual-eligible individuals access long-term services, including nursing home care and home- and community-based services (HCBS). It provides financial and medical assistance to help seniors and people with disabilities receive the care they need in the most appropriate setting. Medicaid LTSS is critical for ensuring continuity of care and quality of life for Pennsylvania’s dual-eligible population.
medicaid.gov - 8. Legal Aid of Southeastern PA – Healthcare Advocacy: Legal Aid of Southeastern PA provides legal assistance to low-income individuals, including help with Medicare and Medicaid eligibility, appeals, and access to healthcare services. Their healthcare advocacy services ensure that dual-eligible consumers receive the benefits they are entitled to and can challenge coverage denials. They also assist with Social Security and disability-related healthcare issues.
lasp.org - 9. SeniorLAW Center – Medicare & Medicaid Assistance: The SeniorLAW Center provides free legal services and advocacy for older adults in Pennsylvania, including guidance on Medicare and Medicaid benefits, long-term care rights, and healthcare fraud prevention. Their services help dual-eligible seniors navigate complex eligibility rules and access necessary care. They also support elder abuse prevention and financial protection for vulnerable populations.
seniorlawcenter.org - 10. Pennsylvania Health Access Network (PHAN): PHAN is a consumer advocacy organization that helps Pennsylvanians access affordable healthcare, including those who are dual-eligible. They provide direct assistance with Medicaid and Medicare enrollment, troubleshooting coverage issues, and understanding policy changes affecting beneficiaries. PHAN also works on statewide advocacy efforts to improve healthcare access and equity.
pahealthaccess.org
