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Community HealthChoices' Impact on Medicare Services

February 22, 2019
Documentation, Billing, & Coding By Jennifer Matoushek, Senior Consultant

Community HealthChoices (CHC), as a mandatory managed care program,  is working to improve services for hundreds of thousands of Pennsylvanians. According to a recent press release from CHC, 94 percent of their participants are dually eligible for Medicare and Medicaid. Under CHC, Medicaid will continue to be the the payer for the remainder of the claims.

CHC has released information on what will stay the same and what will change after they are implemented.

What Doesn't Change:

  • Dually eligible participants will continue to have all of their Medicare options. These include Original Medicare and Medicare Advantage managed care plans. They only way the participants Medicare will change is if they decide to change it. 
  • Medicare will continue to be the primary payor for any service covered by Medicare. Providers should bill Medicare for all eligible services before billing Medicaid. 
  • There will be no change in the services that are covered by Medicare. 
  • Providers cannot balance-bill dually eligible participants when either Medicare or Medicaid does not cover the entire amount billed for a service delivered. 
  • Participants must have access to Medicare services of their choice. CHC must pay any co-insurance and/or deductible whether the provider is in the CHC-MCO or has had prior authorization. 

What Does Change:

  • Dual eligible participants can keep their existing primary care physicians, but this provider must enroll in Medicaid under federal guidance. If the provider refuses, then CHC-MCO will work with participant to find a new Medicaid enrolled provider. 
  • Each CHC-MCO is required to offer a Dual-Eligible Speial Needs Plans (D-SNPs) which is a companion Medicare managed care plan. It is voluntary to enroll, but participants who do enroll will have the opportunity to receive additional benefits and will improve health care coordination for participants. 
  • All Medicaid bills for participants will be sent directly to the participant's CHC-MCO instead of being sent to the Department of Human Services. This includes bills that are submitted after Medicare has denied or paid part of a claim. 
  • The CHC-MCO may not require prior authorization for services covered by Medicare. Service coordinators will work with participants to coordinate prior authorization of services when needed.

CHC: Your Guide to Medicare and Medicaid Dual Eligibility


The experts at LW Consulting, Inc. can help answer any of your questions as you prepare
for these changes. 

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