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Pa. set to start mandatory managed care for people who are eligible for both Medicare and Medicaid

There's a lot of confusion about the new need to choose both a Medicare and a Medicaid provider. The first deadline is Sunday.


A big change is in the works for people who are eligible for both Medicare and Medicaid.

Starting in January, 127,000 Medicaid recipients in Southeastern Pennsylvania who also get Medicare will have to get their Medicaid coverage from one of three managed-care plans. New rules apply as well to about 14,000 people who have Medicaid alone and receive long-term care services. The deadline for choosing a plan for the new Community HealthChoices (CHC) program is Saturday, Nov. 17.

The program, which began last year with 80,000 subscribers in Southwestern Pennsylvania, is designed to improve care coordination and efficiency in a population that often has complex needs, said Kevin Hancock, deputy secretary of the Office of Long-term Living in the state Department of Human Services.  It creates incentives for providers to care for older or disabled people in their communities, rather than in nursing homes, and to foster innovation in helping subscribers with housing, employment, and technology. Saving money is not the primary goal of the program, Hancock said.

He said the state learned from the western Pennsylvania rollout to start educating consumers and medical providers earlier. It is too early to tell, he said, how well CHC is performing in the Pittsburgh area.

Currently, the state administers the Medicaid program, which provides health benefits for poor people, in this "dual-eligible" population, as people who qualify for both forms of insurance are known. (Younger, healthier people on Medicaid already choose managed-care plans.) Medicare is the insurer for the disabled and people ages 65 and up. Medicare is the first to pay, and Medicaid then picks up bills for cost-sharing, doctor visits, home care, and nursing-home care.  CHC does not include dual-eligibles who need services for intellectual disabilities.

If you find all that confusing, you're not the only one. Advocates for Medicare subscribers said many are having trouble understanding that this year they may need to choose not only a Medicare Advantage plan, but also a Medicaid managed-care plan — possibly, but not necessarily, from the same company.

"People are really confused out there," said Diane Menio, executive director of Center for Advocacy for the Rights and Interests of the Elderly (CARIE).

Menio said both consumers and providers are having trouble understanding the changes. She worries that some doctors could find billing under the new program too much of a hassle and decide not to care for dual-eligible patients.

As of last week, 90,000 people affected by the new program had yet to choose one of the three insurers: Keystone First, PA Health & Wellness, or UPMC Community HealthChoices. If they don't make their choices by Saturday, the state will assign them to one of the three insurers. They'll then have until Dec. 21 to make their own choices. Patients will always have the option of changing insurance plans, but in the future it could take longer for the change to take effect.

The insurance companies, which are required to have an adequate provider network, are still assembling their panels of doctors, hospitals, and other care providers.  During the first six months of the program, patients will be able to keep their current service providers regardless of whether they have contracts with their new insurers.

Hancock agreed that the need to pick both Medicare Advantage — it's open-enrollment time — and Medicaid companies at the same time of year is confusing.

The important thing is that you don't have to change your Medicare coverage. That said, you can if you want to, and it may be easier for you and your doctor if you get both Medicaid and Medicare from the same company. "This program will work better if there's an alignment between the Medicare and Medicaid products," Hancock said.

Holly Lange, president and CEO of Philadelphia Corporation for Aging, said close to 30 other states have similar programs, and she's hopeful about this one's potential. "We hope it will be better because it will enhance access and improve the coordination of medical care … and the care that [subscribers] get at home when they need home care," she said.

For help with the new program, you can talk with an independent enrollment broker at 844-824-3655.  The number for the hearing impaired is 833-254-0690.  Or go to