Pennsylvania Community HealthChoices: The Lies and the Truths

Pennsylvania Community HealthChoices: The Lies and the Truths

This article is an attempt to educate “Dual Eligibles, who have been enrolled into the PA Community HealthChoices program, about two serious issues:  provider selection and balance-billing.  Through mailings and through community meetings, the PA CHC program (and it’s affiliates and supportive organizations) disseminated false information about the program.  This article pertains mostly to “Dual Eligibles” living independently and might not necessarily pertain those who are in long-term care facilities or receiving  long-term services at home.


This article is NOT legal advice.  It is based on the experiences and opinions of one individual.  Read further to find out how to receive free legal counsel if you are being negatively affected by the PA Community HealthChoices program.


First, let’s get some definitions out of the way – it will make the article much easier to understand.

MediCARE:  The health insurance program administered by the US federal govt for older citizens as well as some disabled citizens.

MediCAID:  A state-funded health insurance program administered by a US state for lower-income citizens.  Some state governments have begun to privatize the administration of their MediCAID programs and in Pennsylvania this privatization is called “PA Community HealthChoices”.

PA Community HealthChoices (CHC):  The name given to the program designed to essentially privatize the administration of the Pennslvania MediCAID system for certain individuals – mainly those identified as “Dual Eligibles” and/or receive Long-Term Care services.  This article only looks at the “Dual Eligibles” but parts may apply to all PA Community HealthChoices members.

Managed Care Organization (MCO):  An insurance company contracted by a state MediCAID program as a result of the privatization of the state MediCAID program.  MCOs are NOT MediCARE Advantage Plans or Supplement Plans & they are secondary payers for all MediCARE-covered services.  In Southwestern PA, you have three MCOs to choose from:  PA Health & Wellness, AmeriHealth Caritas and UPMC.

Dual Eligibles:  people who are on both MediCARE and MediCAID.  These are usually low-income elderly citizens but can include those who are not elderly but have major disabilities.

Balance-Billing:  The act of billing a patient for the portion of a medical bill that is not covered by an insurance plan, MediCARE , MediCAID or any other program or organization that pays medical bills on behalf of the patient.  The act of balance-billing in and of itself isn’t illegal, but it is in some cases (which will be covered in this article).

Services – any medical visit, procedure or service, even prescriptions.

Part B Medications – medications that are administered by medical providers at their place of business.  However, some Part B medications are administered by the patient in their own home.  Part B medications are usually not covered by a Part D prescription plan, they are covered by MediCARE.  If these medications are administered by the patient in their own home, they are usually ordered through a mail-order Specialty Pharmacy, not a local retail pharmacy.

Part D Medications – medications that are administered in your own home and ordered through a local or mail-order pharmacy.  These medications are rarely covered by MediCARE and patients must purchase a Part D prescription plan unless they want to pay for their medications themselves, or get Part D coverage through Social Security’s “Extral Help” program or their state’s MediCAID if they qualify financially.

OK, now let’s get to the meat and potatoes…

PA Commuinty HealthChoice was giving out false information in both their mailings and at their community meetings as well as through poorly-trained, clueless call-center workers.  They were telling Dual Eligibles that all your doctors and other providers you choose must be in-network with the MCO you choose.  This is false information!  For Dual Eligibles, MediCARE pays as the primary payer and your MCO (privatized MediCAID) pays as the secondary payer, just as the original PA MediCAID program worked.  NOTHING REALLY CHANGED.  Just as before PA Community HealthChoices was implemented, as long as you receive MediCARE-covered/approved services and medications it will be covered and you don’t owe a dime.

For MediCARE-covered services, your MCO cannot dictate what provider you use because they are not the primary payer.  Only the primary payer can dictate which providers you can use.  Unfortunately, many doctors offices and other providers see the MCO card, and if they normally don’t take that brand of insurance,  they will deny acceptance of that “plan” as payment.  If they don’t see the Yellow or Greenish-blue PA Assistance card, they think that the MCO card is a MediCARE Advantage Plan that they do not accept.  When in fact they can bill that MCO no matter what health insurance company plans they usually accept.  Since MCO is the secondary payer, they must accept billing from your provider and pay out what original PA MediCAID pays out (if anything), as long as the service is MediCARE-approved.

The only time you do have to pick a provider that is in-network with your MCO is if you are getting services that are not approved by mediCARE.  For instance, any Dental, Vision and Behavioral Heal services are usually not covered by MediCARE.  So for these services, your MCO (MediCAID) is the primary payer for these services and can therefore force you to use only providers in their network in order to cover those services.

Now back to MediCARE-approved services.  It is illegal for any provider who provides services to you to balance-bill Dual Eligibles for any portion that is not covered by MediCARE or MediCAID, as mandated by US Federal statute 42 U.S.C. §1396a and §1902(n)(3)(B) of the Social Security Act.  By providing services to you, a provider agrees to not to bill you for ant unpaid balances and to accept whatever MediCARE and MediCAID pays them as payment in full.  In fact, it is also illegal for them to tell you that the only way they will provide service if you agree to balance-billing.  It’s also illegal for Dual Eligibles to tell a provider themselves that they will agree to pay balances on any uncovered portions of medical bills.

Unfortunately, what they can do (assuming they are not a MediCAID-enrolled provider) is to refuse service to you altogether.  This is unfortunate but they are not legally bound to provide services to mediCAID patients unless they are a MediCAID-enrolled provider.  But, if they do provide service because they made a mistake in not understanding that you are a Dual Eligible and that the MCO card is merely a replacement for the original MediCAID cards, and realized later that they are not going to get paid 100% by MediCARE and MediCAID, that’s not your problem.  They cannot balance-bill you for the remainder of the bill that’s not covered – PERIOD.

Unfortunately, most medical facilities poorly train their billing departments so they do not know that it is illegal to balance-bill Dual Eligibles.  Heck, even their managers and their managers’ managers might not even be trained in this fact.  Regardless, as a Dual Eligible, you are protected by the Federal Social Security Act from balance-billing so you don’t owe them a red cent and the provider can be sanctioned for even balance-billing you in the first place.  These sanctions can mean that the provider may lose their ability to bill MediCARE in the future.  This would be problematic for most PA providers.

If you are having problems like being balance-billed or any other problem with this new PA Community HealthChoices system, you can get free legal help from the Pennsylvania Health Law Project.  Visit them at http://www.phlp.org

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