PHLP provides free legal services and advocacy to Pennsylvanians having trouble accessing publicly funded health care coverage or services. For assistance, call our helpline at 1-800-274-3258 or 1-866-236-6310 TTY or e-mail us at staff@phlp.org.

Many people receive insurance coverage through managed care plans. A Managed Care plan is a health insurance company that provides coverage in a managed or coordinated way. Managed care plans include a variety of different health insurance options, including health maintenance organizations (HMOs), Preferred Provider Organizations (PPOs), or Point of Service Organizations (PSOs). These plans vary in provider choice, access to specialists and services, and more. Often, consumers in managed care must select one primary care provider (PCP) from within the plan network of providers. It is this PCP who will approve much of the consumer's health care.

Managed care organizations are governed by both federal and Pennsylvania law. If you have a complaint or grievance about your managed care organization, see our complaints and grievances page. You may also wish to contact the Pennsylvania Department of Health through their website or at 1-888-466-2787.

Medical Assistance and Managed Care

In Pennsylvania, Medical Assistance recipients in some counties may be required to be in managed care. This Mandatory Medical Assistance Managed Care program is known as HealthChoices. The three regions of the state that are currently in HealthChoices are:

Southeast PA
Bucks
Chester
Delaware
Montgomery
Philadelphia

Southwest PA
Allegheny
Armstrong
Beaver
Butler
Fayette
Greene
Indiana
Lawrence
Washington
Westmoreland

Leigh-Capital
Adams
Berks
Cumberland
Dauphin
Lancaster
Lebanon
Leigh
Northampton
Perry
York

Under HealthChoices, consumers get a choice of HMO for their physical health care needs but can only get their behavioral health care services through one MCO. If you are in a HealthChoices area, the HealthChoices Program Hotline will assist you in choosing the HMO that is best for you. You can also change your HMO at any time by calling the HealthChoices Program Hotline. For more information on selecting or changing your HMO, please contact HealthChoices. In the Southeast region, call 1-800-440-3989. In the Southwest region, call 1-800-485-5998. In the Leigh-Capital zone, call 1-877-214-3901.

Some of the counties that do not have mandatory managed care allow consumers to enroll in an HMO if they choose. Ask your County Assistance Office caseworker if there is a Voluntary Medical Assistance HMO in your county.

The Medical Assistance HMOs have signed contracts with the Department of Public Welfare outlining your rights as a Medical Assistance consumer. You can see the contract on the Department of Public Welfare Office of Medical Assistance website.

For more information on using a managed care plan in Medical Assistance, see publications on managed care listed on our publications page.

If your HMO denies you services or prescription drugs that your doctor thinks you need, you have the right to appeal the decision. See our section on Complaints and Grievances or our brochure on appealing denials, reductions or terminations of benefits.

To help you choose your plan, the Department of Public Welfare has created report cards on how the plans do in each area. Click here to compare the plans in your area.

Medicare and Managed Care

In many areas, Medicare recipients can sign up with a managed care organization to receive their Medicare benefits. These plans are called Medicare + Choice plans. You pay an additional monthly premium to the plan and often receive additional benefits such as vision or prescription coverage. To see what plans are available in your area, as well as the benefits each plan offers, you should look at the Medicare Personal Plan Finder at www.medicare.gov or call APPRISE at 1-800-783-7067.