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UPMC has one of three managed care organizations chosen for new state program

Darrell Sapp/Post-Gazette

UPMC has one of three managed care organizations chosen for new state program

Older or disabled Pennsylvanians relying on government-subsidized services will have a choice of three managed care organizations starting next summer to arrange help with long-term care needs.

The Wolf administration announced Tuesday that it had chosen UPMC for You, AmeriHealth Caritas of Philadelphia and Pennsylvania Health and Wellness (part of Centene Corp. of St. Louis) to serve some 450,000 Medicare and/​or Medicaid beneficiaries in the new Community HealthChoices program.

The three health insurers were selected from among 14 organizations submitting proposals to coordinate the home assistance and medical care that people receive in a more vigorous, efficient way than is currently provided, with the idea it will reduce unnecessary and costly use of hospitals and nursing homes.

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Starting on July 1 in 13 southwestern counties — and subsequently in other parts of the state — individuals who have been part of Medicaid-funded aging or disability waiver programs or certain other types of aid will need to pick one of the three MCOs and be assigned a new service coordinator to oversee what help they get. During a transition period of at least 180 days, consumers won’t have to change any of the services they are currently receiving, if they are satisfied with them.

Pennsylvania Department of Human Services Secretary Ted Dallas said the three selected MCOs showed a broad understanding of issues beyond “just what happens in the doctor’s office” that will help frail individuals live safely in the community longer. He said having three such competing organizations should give consumers the necessary range of options instead of forcing them to use providers they don’t want for home or health services.

The MCOs in coming months will be setting up provider networks of home care agencies, adult day care services, nursing homes and more that they negotiate contracts with and allow their service coordinators to offer to clients as options. The MCOs will receive a per-person fixed rate from the government to cover costs, known as “capitation,” which benefits the organizations when they meet clients’ needs in less expensive forms, such as home help instead of institutional care.

UPMC for You president John Lovelace said that if the program works as intended, a service coordinator for a client who has been hospitalized would be in touch with both medical professionals and home care services who are part of the MCO’s network, to ensure necessary services are properly provided after the discharge.

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“It will be in our interest that you have a seamless transition to the next thing you need, because otherwise you’ll wind up back in the hospital, and we have to pay for that, too,” Mr. Lovelace said.

The state anticipates sending information about Community HealthChoices to affected individuals locally in early 2017, including guidance on how to choose an MCO before the July 1 enrollment arrives.

Gary Rotstein: grotstein@post-gazette.com or 412-263-1255.

First Published: August 30, 2016, 5:10 p.m.
Updated: August 31, 2016, 3:18 a.m.

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 (Darrell Sapp/Post-Gazette)
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