HealthChoices is the name of Pennsylvania’s managed care program, which serves the healthcare needs of the clinically and most economically challenged Pennsylvanians.
Program history
Serving Pennsylvania since 1972
MCOs have worked with the commonwealth of Pennsylvania for decades, helping to deliver a higher standard of healthcare to millions of Pennsylvanians.
1972
Voluntary managed care program introduced1
1997
HealthChoices launched for Medicaid1
2015
Pennsylvania expands Medicaid to more individuals experiencing low incomes2
Program population
In Pennsylvania, MCOs are responsible for program administration, including network management, claims payment, care coordination, and utilization management.
HealthChoices covers approximately 2.2 million people in the commonwealth and utilizes MCOs to provide coverage for its members.3
2-in- 1
nursing home residents covered by HealthChoices4
Reduced costs
Billions saved through managed care since 2016
Our healthcare system requires the innovation, expertise, and capital of the private sector.
MCOs are uniquely positioned to combine these resources with public funding, accountability, and oversight.
With the costs of healthcare rising, states need a way to plan and manage their budgets while ensuring that Medicaid recipients get the high-quality healthcare they deserve.
Between 2016 and 2020, HealthChoices is projected to save as much as $4.4 billion in state funds through the use of managed care.5
MCOs use a range of strategies to run cost-effective programs, including helping patients receive preventive services, providing supportive care for members with complex conditions, and managing the provider network.
In 2017, thousands of Pennsylvanians accessed preventive screenings and checkups through Medicaid, including: 104,000 breast cancer screenings, 68,000 colon cancer screenings and 153,000 cervical cancer screenings.6
Improved population health
MCOs in Pennsylvania integrate behavioral and physical health services to address the holistic needs of a person to ensure they are healthy.
In Pennsylvania, MCOs are addressing the opioid crisis by coordinating care and working with providers on prescribing practices as well as introducing safety measures to curb the abuse of opioids among Medicaid enrollees.8
Patient experience
Coordinated care for Pennsylvanians
MCOs coordinate care and provide a single point of contact for Pennsylvanians.
MCOs serve as the glue that binds community resources with a unified health strategy, integrating physical and mental health services.
In 2018, 79% of HealthChoices members said they were satisfied with their health plan, and 87% of enrollees said that they were satisfied with their child’s health plan.9
Provider experience
Under Medicaid managed care, MCOs provide a cohesive service platform that helps to efficiently process payments and offer provider training.
MCOs use value-based payment models that incentivize, empower, and reward providers for the quality of care they deliver, not the quantity. The focus is on keeping individuals healthy and delivering better outcomes; over time, this improves overall population health and reduces the total cost of care.
Sources
- “Managed Care in Pennsylvania,” Medicaid.gov, 2011.
- “Medicaid Expansion in Pennsylvania: Transition from Waiver to Traditional Coverage,” Kaiser Family Foundation, 2015.
- “Monthly Physical Health Managed Care Program Enrollment Report,” Pennsylvania Department of Human Services, 2020.
- “Fact Sheet: Medicaid in Pennsylvania,” Kaiser Family Foundation, 2019.
- “An Evaluation of Medicaid Savings from Pennsylvania’s HealthChoices Program,” The Lewin Group, 2011.
- “Access & Spending,” Open Data Pennsylvania, 2017.
- HEDIS, 2012 & 2018.
- “Pennsylvania Tightens Medication Rules to Help Combat Opioid Crisis,” Commonwealth of Pennsylvania, 2017.
- “Physical HealthChoices Plan Selection,” www.dhs.pa.gov.