PA HealthChoices Agreement 2018: What You Need to Know

In Pennsylvania, the PA HealthChoices program is designed to provide comprehensive healthcare coverage for eligible residents. The program is managed by the Department of Human Services (DHS) and offers a range of benefits, including medical, dental, and behavioral health services.

Every year, the DHS enters into an agreement with managed care organizations (MCOs) to provide these services to HealthChoices enrollees. The most recent agreement, which covers the period from January 1, 2018, through December 31, 2018, includes several important changes that beneficiaries should be aware of.

New MCOs

One of the biggest changes in the 2018 agreement is the addition of new MCOs. In addition to the incumbents (AmeriHealth Caritas, Keystone First, and UPMC for You), the DHS has added three new MCOs: PA Health & Wellness, Geisinger Health Plan, and Community HealthChoices.

These new MCOs will be responsible for providing services to enrollees in certain counties, based on geographical location. It is important for beneficiaries to check which MCO serves their area and ensure that their healthcare providers are in-network.

Provider Directories

Another change in the 2018 agreement is the requirement for MCOs to provide accurate and up-to-date provider directories to enrollees. This is intended to help beneficiaries choose healthcare providers that are in-network and reduce the likelihood of surprise medical bills.

Enrollees should review the provider directory for their MCO and confirm that their healthcare providers are listed. If a provider is not listed, they may need to switch to an in-network provider to avoid paying out-of-pocket costs.

Pharmacy Benefits

The 2018 agreement also includes changes to pharmacy benefits for HealthChoices enrollees. Starting in 2018, MCOs will be required to provide certain prescription drugs without prior authorization if the medication is on the DHS`s Preferred Drug List.

Enrollees should check to see if their medications are on the Preferred Drug List and confirm that their pharmacy is in-network. If a medication is not on the list, patients may need to seek prior authorization from their MCO before the medication will be covered.

Out-of-Pocket Maximums

Finally, the 2018 agreement includes changes to out-of-pocket maximums for HealthChoices enrollees. Starting in 2018, the maximum amount that an enrollee can be required to pay for healthcare services in a calendar year is $250 for individuals and $500 for families.

Enrollees should keep track of their healthcare expenses throughout the year to ensure that they do not exceed their out-of-pocket maximums. Once the maximum is reached, the MCO will be responsible for covering the cost of any additional healthcare services.

In conclusion, the PA HealthChoices agreement for 2018 includes several important changes that beneficiaries should be aware of. These changes include new MCOs, more accurate provider directories, changes to pharmacy benefits, and out-of-pocket maximums. By staying informed and following these guidelines, HealthChoices enrollees can ensure that they receive the healthcare coverage they need without unexpected costs.