PA HealthChoices
2024 PA HealthChoices Contract – Exhibit B(5)
Click on the image to download PACHW’s Comments about the 2024 HealthChoices Agreement.
As of January 1, 2024, Medicaid Managed Care Organizations (MCOs) are now required to include CHWs as part of their Community Based Care Management Program (CBCM) in the 2024 PA HealthChoices contract. In the past, CHWs were considered optional members of the CBCM care team. PACHW submitted recommendations to the PA Department of Human Services regarding the PA HealthChoices draft language which can be found by clicking the image to the left.
The language relating to CHWs under the CBCM program is as follows (Exhibit B5):
“The PH-MCOs must include community health workers as part of their community-based care management team […] The PH-MCO may not redirect funding from CBOs to fund positions within the PH-MCO without Department approval and must indicate in its CBCM proposal to the Department if funding to a CBO is being decreased or discontinued in order to fund a PH-MCO position.”
Medicaid Managed Care Organization Contracting
The contact information for Medicaid Managed Care Organizations (MCOs) across Pennsylvania is below. If you are a community-based organization employing CHWs, your organization can reach out to these individuals to ask about contracting for CHW services. PA Department of Human Services prepared the FAQ related to tips for Community-Based Organizations (CBOs) to contract with MCOs to fund CHW services.
MCO Contact Information
| MCO | Contact Name | Phone # | |
|---|---|---|---|
| Amerihealth Caritas and Keystone First | Kayla Clark | [email protected] | 484-496-7476 |
| Geisinger Family Health Plan | Amy Buterbaugh | [email protected] | 724-315-1168 |
| Health Partners Plans | Molly Skalina | [email protected] | |
| Highmark Wholecare | Jessica Sebastian | [email protected] | 412-255-7164 |
| UPMC for You | Christina Novotni | [email protected] | 412-454-5261 |
| United Healthcare | Lavinia Nabors | [email protected] |
MCO – CBO Contracting FAQs
- What are some general CBO qualifications that MCOs might be looking for to consider contracting?
- What data can CBOs anticipate needing to provide to help support an MCO’s decision on whether or not to contract?
- How can smaller CBOs show value to the MCOs in contracting with them?
- What technology components are MCOs looking for from a CBO standpoint for contracting consideration?
o Have an Evidenced Based Program
o Ability to supply true quality outcomes/member impact and demonstrate reporting capabilities
o Amenability to competitive reimbursement (i.e., cost) while providing results
o Geographic coverage area
o Vendor reputation and how well-known and integrated they are in the community
o Expertise in identified area
o Demonstrated ability to deliver on expectations regarding Community program implementation
o Innovative solutions offered
o Alignment with MCO mission, goals, and target populations or communities
o Being a 501(c)(3) or working with a fiscal sponsor
o Other funding sources, as this relates to the number of slots that may be available/capacity to serve more people
o Alignment with requirements of Exhibit B(5) to the HC Agreement
o Basic contact information, including provider enrollment information and details about who signs contracts, and certificates of insurance/coverage carried
o Description of services, eligibility requirements for services, demographics served, potential volume of members served/caseloads, how there will be promotion of the collaboration/programming
o Current number of individuals served, especially if you know how many are enrolled with a specific MCO
o Background on their program, including any special accreditation/certification (e.g., PAT has Blue Ribbon certification for their sites)
o Ability to track and share SDOH information, especially using platforms like PA Navigate/findhelp
o Ability to report on interventions and encounters – share current reporting that you use for other funders so MCO can leverage your current reporting structures instead of creating new ones; supply aggregate outcomes data for other clients to show your impact. Common requested metrics include:
Plan member ID
Name, DOB of member
# of visits/encounters, dates of encounters, and whether encounters were face to face, virtual or telephonic
SDOH referrals completed
o Demonstrated cost savings/ROI/rate information
o Provide outcomes of current programs the CBO provides/ROI
o Demonstrate a history and strong understanding of working with Medicaid population
o Share success stories, case studies and publications/impact reports on individual’s they have served to demonstrate real life positive impact.
o Demonstrate knowledge of the local community and health related social needs (HRSN) within that community in which they serve
o Establish a process to render services to non-English speaking participants
o Show quality over quantity and focus on your mission
o Promote what sets you apart from big organizations by sharing stories about your participant experiences or anything that makes you unique
o Address health disparities
o Close care gaps
o Show how you support special populations or focus on specific diagnoses, like HIV, asthma, diabetes, etc.
o The ability to submit data electronically, securely and timely to the MCO for reporting.
• Ability to receive referrals and track closed loop statuses through the findhelp platform
• The ability to submit invoices through the Oracle platform, if payment for services is needed
• The ability to identify and report on MCO members as a subset of the entire population they serve
o If services are telephonic, they should have the ability record and review calls for quality assurance
o Proficient use of virtual meeting platforms
o Unique email domains rather than general gmail accounts, for example
o Ability to check MCO enrollment
o Must be able to get through security clearance
• High Trust
• Soc II
• HAX third party security assessments