On September 1, 2022, over 400,000 Pennsylvania Medicaid participants will be moved to new Medicaid physical health (HealthChoices) plans after their existing health plans exit the Medicaid program. Consumers who did not select a health plan by August 16th will be automatically assigned to a new plan. That new plan starts September 1st. This article addresses frequently asked questions consumers may have as they receive communications from their new health plan over the coming weeks.
How will I know if I have been auto-assigned to a new Medicaid HealthChoices plan?
Auto assigned consumers will get their new plan information and Member ID card directly from the plan they have been auto-assigned. Be on the lookout in the mail for this welcome packet. You may also get a phone call from your new plan. Your previous plan will continue covering your medical needs until August 31st, 2022.
I liked my Medicaid HealthChoices plan. Why was I moved to a new one?
As previously reported, the Medicaid physical health plans available in Pennsylvania are changing September 1st. Importantly, several health plans will no longer be operating in certain zones:
- Aetna will no longer operate a Medicaid plan anywhere in Pennsylvania after September 1st.
- United will no longer operate in the Southwest and Lehigh/Capital zones.
- Highmark (formerly Gateway) will no longer operate in the Northwest zone.
If you were in a health plan that is going away, you were asked to select a new plan by August 16th. If you did not select a new plan by that date, you were automatically assigned to one.
I’m not sure I like the plan I was assigned. Can I change plans?
Yes! You can review plans and request a plan change any time by contacting the PA Enrollment Services. If you submit your request by September 8th, your new plan will start October 1. Otherwise, your new plan will not start until November 1st, unless there are extraordinary circumstances.
To see the plans offered in your part of the state, see PHLP’s zone-by-zone breakdown. You can change your plan online, using the PA Enrollment Services mobile app, or by phone:
- EnrollNow.Net: Enroll in a new plan through the enrollment service website, www.enrollnow.net. Here, individuals can compare the health plans being offered in their respective regions and make the best decision. They can also find answers to frequently asked questions.
- Mobile app: Download the PA Enrollment Services mobile app (available free of charge through the Apple store or Google play).
- Phone: Call 1-800-440-3989 (TTY: 1-800-618-4225) and select Option 6 to speak with a representative. (Open Monday through Friday, 8 a.m. to 6 p.m.).
What should I consider if before changing plans?
There are a few things you should consider before deciding to change health plans:
- Provider Network: Each health plan has different networks of providers. Before changing plans, you should check to see which health plans have your current doctor(s), preferred hospital, and other providers in-network. PA Enrollment Services can help you find this information. You might also want to confirm with your key healthcare providers whether they accept the plan you are thinking of switching into.
- Timing: While you can request a plan change at any time, your new plan will not start right away. If you request your plan change before the second Thursday of the month, your new plan will start on the first of the next month. Otherwise, the new plan will not start until the month after.
- “Extra Benefits”: While all health plans must offer the same basic health benefit package, each plan is allowed to offer extra benefits. These might include additional dental or adult vision benefits that go beyond what is included in your regular Medicaid package. PA Enrollment Services has a Comparison Tool where you can see the benefits offered by the different health plans.
For more information on selecting a plan, see PHLP’s factsheet, which provides a step-by-step guide on what to consider when changing health plans.
I selected a health plan before the August 16th deadline, but I was moved into a different plan. What do I do?
If you made a plan selection before August 16th and were moved into the wrong plan, you should call PA Enrollment Services ASAP and ask to be moved into your chosen plan on an expedited basis. Call 1-800-440-3989 (TTY: 1-800-618-4225) and select Option 6 to speak with a representative. PA Enrollment Services is open Monday through Friday, 8 a.m. to 6 p.m. Be sure to explain that you selected a different plan and were moved into the wrong one.
You can also call PHLP’s Helpline at 1-800-274-3258 for assistance getting moved into the correct plan.
I am supposed to change plans September 1st, but I haven’t heard from my new plan yet. What do I do?
You should receive a welcome packet and a member ID card from your new health plan by mail in late August or early September. If you have not received information from your new plan by mid-September, try the following:
- Call PA Enrollment Services at 1-800-440-3989 (TTY: 1-800-618-4225) to see which plan you were moved to, and to ask for contact information for the new plan.
- Contact member services for your new health plan and ask them to send you your member ID card. While on the phone, you should ask if they can give you your member ID number so you can write it down in case you need it while you are waiting for your ID card. You can find phone numbers for each health plan here.
- Call PHLP’s Helpline at 1-800-274-3258 if you need more help.
Does this change what Medicaid benefits are available to me?
No, with few exceptions. All Medicaid physical health plans are required to cover the same basic benefits package including ambulance, dental care, well child visits, eye care, inpatient and outpatient hospital care, primary care, specialist visits, medical equipment, non-emergency medical transportation, pregnancy and newborn care, prescriptions, and diagnostic tests. However, some health plans offer extra benefits on top of what is already included in the basic Medicaid health package. These “extra benefits” can vary from plan to plan, so you might see changes in any extra benefits.
Does this change my healthcare costs?
No, most likely not. The co-pays allowed under Pennsylvania’s Medicaid program are largely set by the state, not the health plans. Some health plans have waived copays for certain services, like medical equipment. Unless you have moved from a plan that has waived the allowed copays to one that charges them, the co-pays you pay at the doctor’s office or pharmacy (if there is a co-pay at all) should not change.
I'm in a Community HealthChoices (CHC) Plan and I haven't heard anything about my plan changing. Does this apply to me?
No. HealthChoices and Community HealthChoices (CHC) are separate programs that serve separate Medicaid populations. The September 1st plan changes only involve HealthChoices plans, not CHC. If you are in a CHC plan, none of this applies to you.
My child is in a plan through the Children's Health Insurance Program (CHIP) and I haven't heard anything about that plan changing. Does this apply to my child?
No. The Children's Health Insurance Program (CHIP) is not impated by these changes.
Does this affect my behavioral health plan?
No, this change does not affect your behavioral health plan (e.g. Magellan, Performcare, Community Behavioral Health, CCBH, etc.) You will continue to receive behavioral and mental health services through the behavioral health plan that serves your county. Find our which behavioral health plan serves your county here.
Can I still see the same doctors under my new health plan?
It depends. For the first 60 days (until November 1st) you will be allowed to continue seeing your existing doctors whether they are in your new plan or not. After that 60-day transition period, your doctors will have to be “in-network” with your new health plan to continue getting paid.
When you get the member ID card, we suggest calling your existing doctors to 1) give them your updated insurance information, and 2) make sure they accept your new plan. If your health plan does not have all your providers in-network, you might have to find new providers who accept your new health plan. Your other option is to change to a different health plan that has most or all of your providers in-network.
What if I’m pregnant or in the middle of an ongoing course of treatment? Can I continue treatment with the same providers?
Yes. If you are undergoing a course of treatment with a provider that is not in your new health plan, the new plan must allow you to continue treatment with the out-of-network provider for up to 60 days. This can be extended beyond 60 days if it is determined to be clinically appropriate. A “course of treatment” includes a planned series of medical, surgical, dental interventions or procedures (such as chemotherapy), as well as a prescription for a particular medication or piece of durable medical equipment.
If you are an adult 21 years or older, your new health plan must also honor prior authorizations for any services you were receiving as of September 1st and allow you to continue receiving these services at the same level and from the same provider for up to 60 days, or until the new plan completes its own “concurrent clinical review.”
Finally, if you are pregnant and your OB-GYN is not in your new plan’s network, your new health plan must allow you to continue seeing your OB-GYN for the rest of your pregnancy, as well as for any postpartum care.
My child is receiving skilled nursing or home health aide services through their Medicaid health plan. How will these services be affected?
If your child under age 21 is receiving skilled nursing or home health aide services requiring prior authorization, your child’s new health plan is required to honor that prior authorization for the rest of the time remaining on the authorization. During this period, your child’s services will continue at the same level and with the same providers that were authorized under the previous plan. The new plan may not change, reduce, or terminate the services.
When the existing authorization ends, your child’s doctors and home health agency will need to submit a new prior authorization request to your new plan. At that time, your child’s new plan may change, reduce, or terminate services, the same way your old plan could when it was time to renew a prior authorization. If you disagree with the new plan’s decision about your child’s services, you will have the right to appeal it. PHLP’s factsheet, “How to Appeal a Denial in HealthChoices", contains valuable information about the appeal process. Call PHLP’s Helpline at 1-800-274-3258 if you need more help.
Where can I get more information?
- DHS has created a toolkit that discusses the plan changes and next steps for consumers.
- DHS has a website about the Medicaid plan changes which is available here.
- Call PA Enrollment Services at 1-800-440-3989 (TTY: 1-800-618-4225) or visit them online at www.enrollnow.net.
- Call PHLP’s Helpline at 1-800-274-3258 or e-mail email@example.com if you still need help.