HealthChoice Managed Care Organization

Program Location: 
Harrisburg, PA
Payer Type: 

HealthChoices, Pennsylvania’s premier Medicaid Managed Care program, serves over 1.2 million of the Commonwealth’s most vulnerable low-income and disabled citizens.All members have a Primary Care Provider (PCP) who provides a Medical Home for the member and manages their medical care. The PCP makes referrals to specialists for care when medically necessary. Members have access to a wide range of specialists, hospitals, dentists, laboratory sites, therapists, home health providers, pharmacies, and other medical providers.

MCOs assist the PCPs and the members to obtain necessary care and receive preventive screenings and immunizations. The MCOs employ nurse case managers and social workers to provide Disease and Comprehensive Case Management to members with serious and/or chronic medical conditions so that they can maintain the best possible health status.

The HealthChoices Program has dramatically increased access to care from levels prevalent under the previous fee-for-service model. Active provider participation has been achieved through innovative payment practices and initiatives, regularly performing and acting upon provider network analysis, cultivating relationships with providers, and performing provider training and education. This program description was found on the the PA Coalition of Medical Assistance MCO's website.

Payment Model: 

HealthChoices MCOs incorporate the following payment model:

  • HealthChoices MCOs are paid on a capitated, risk-adjusted PMPM basis which provides incentives to effectively manage the cost of care.
  • These MCOs participate in a pay-for-performance (P4P) program under which they can earn up to an additional 1.5% of total premium payments with higher performance levels earning higher payments.
  • Recognizing the need to apply value-based purchasing at the provider level, DPW has implemented provider P4P program through its HealthChoices MCOs.
  • DPW has followed CMS’s Medicare policy direction and does not pay for related readmissions within 30 days of discharge and reduces or denies payment for preventable serious adverse events.
  • DPW has implemented an efficiency adjustment program104 that reduces MCO payments related to inappropriate use of health care services based on ambulatory care-sensitive condition preventable admissions, readmissions, pharmacy, and low-acuity non-emergent emergency department visits
Last updated May 2014
Go to top