Community HealthChoices (CHC) in Pennsylvania: 3 Plans, Who Enrolls

In Pennsylvania, almost everyone who has both Medicare and Medicaid, lives in a Medicaid-paid nursing home, or receives Medicaid home care gets that care through Community HealthChoices (CHC). CHC is the Commonwealth's mandatory Medicaid managed care program for dually eligible people and adults with physical disabilities, and it is the capitated program through which Pennsylvania delivers managed long-term services and supports (MLTSS); enrollment is not optional for the people it covers. Community HealthChoices Pennsylvania runs through three managed care organizations (MCOs) that each cover all five of the program's zones, and the plan a family chooses decides which case manager, provider network, and extra benefits come with the coverage.

This guide explains who must enroll, who is carved out, how the three plans differ, how to get paid to care for a relative through Services My Way, how to enroll, and what to do when a plan denies a service.

Key Takeaways

CHC is mandatory managed long-term care for adults 21 and older who are dually eligible, live in a Medicaid-paid nursing facility, or receive Medicaid home and community-based services (HCBS). It is the capitated Medicaid managed care program through which the Pennsylvania Department of Human Services (DHS) Office of Long-Term Living (OLTL) administers MLTSS.
Three MCOs run CHC: AmeriHealth Caritas, PA Health & Wellness, and UPMC Community HealthChoices. Each of the five CHC zones is covered by all three plans, and you can choose a new MCO at any time.
CHC is not the same as HealthChoices. HealthChoices (no leading word) is the physical-health Medicaid managed-care program; Community HealthChoices is the long-term-care program. Behavioral health is carved out to a separate county behavioral-health MCO.
You can hire most relatives as a paid caregiver through Services My Way, but a spouse cannot be paid. A Direct Care Worker cannot be the participant's spouse, legal guardian, representative payee, or power of attorney. Tempus Unlimited handles the payroll.
The front door for enrollment is the Pennsylvania Independent Enrollment Broker (PA IEB) at 1-877-550-4227. The IEB schedules the in-home assessment and sends the plan-selection packet.

CHC vs. HealthChoices: Telling the Two Programs Apart

Pennsylvania runs two Medicaid managed-care programs with almost the same name, and the overlap confuses families, hospital discharge planners, and out-of-state writers daily.

HealthChoices (no leading word) is the physical-health Medicaid managed-care program for the non-long-term-care population: most working-age adults, parents and children, and pregnant women on Medicaid. Community HealthChoices is the long-term-services-and-supports program this guide covers, for adults 21 and older who are dually eligible, in a Medicaid-paid nursing facility, or receiving Medicaid home care.

Both are administered by PA DHS and both are mandatory for their populations, but they are different programs with different rules. When a hospital social worker says "pick a HealthChoices plan," ask whether they mean physical-health HealthChoices or Community HealthChoices, because the answer changes which phone number you call. Behavioral health is a third track entirely: mental-health and substance-use treatment are carved out of CHC and delivered through a county-based behavioral-health MCO (BH-MCO), so most CHC members carry two plans at once, a CHC-MCO and a BH-MCO.

Who Must Enroll in Community HealthChoices (and Who Is Carved Out)

You are enrolled in CHC if you are 21 or older and any one of the following is true: you receive both Medicare and Medicaid; you receive long-term services and supports through the former Attendant Care, Independence, COMMCARE, or Aging waivers; you are in the OBRA waiver and determined nursing facility clinically eligible; you receive Medicaid-paid nursing-home care; or you are an Act 150 participant who is dually eligible.

CHC delivers Medicaid long-term services and supports through capitated managed care, an arrangement federal law allows a state to build on any of several managed-care authorities (a 1915(a) voluntary program, a 1932(a) state plan amendment, a 1915(b) waiver, or a Section 1115 demonstration), which can in turn be paired with state-plan home and community-based benefits or an HCBS waiver under Section 1915(c).

Several groups are deliberately left out, and getting the boundary wrong sends a family to the wrong program:

Intellectual-disability and autism waivers (the Consolidated, Person/Family Directed Support, Community Living, and Adult Autism waivers) run under the Office of Developmental Programs, not CHC.
The LIFE program is Pennsylvania's name for Programs of All-Inclusive Care for the Elderly (PACE), a voluntary alternative for people 55 and older who meet nursing-facility level of care, live in a LIFE provider's service area, and can be served in a community setting at enrollment without jeopardizing their health or safety. It is an alternative to CHC rather than an addition to it: LIFE covers the whole care package through the LIFE provider. Enrollment is never locked in, because federal PACE rules let a participant disenroll without cause at any time (42 CFR 460.162(b)).
Act 150 attendant care is a state-funded (non-Medicaid) program, so its participants are not in CHC unless they are also dually eligible.
Behavioral health, state psychiatric facility residents, ICF/ID residents, and adults under 21 are all outside CHC.

The Three Community HealthChoices Plans in Pennsylvania

All three CHC-MCOs cover every one of the five CHC zones, so the choice is a real one everywhere in Pennsylvania. Where the plans differ in practice is in supplemental benefits, provider-network depth by region, and service-coordinator practice, so compare on those rather than assuming the plans are interchangeable.

Plan	Member-services line DHS lists	Zones covered
AmeriHealth Caritas	1-855-235-5115 (DHS lists a separate Keystone First line, 1-855-332-0729)	All five CHC zones
PA Health & Wellness	1-844-626-6813	All five CHC zones
UPMC Community HealthChoices	1-844-833-0523	All five CHC zones

DHS lists AmeriHealth Caritas and Keystone First as separate entries on its CHC contact page, each with its own member-services line, so check which name is on your parent's plan card before you call. Because all three MCOs cover all five zones, where you live never narrows the list for you: every CHC-eligible Pennsylvanian chooses among the same three plans.

When you compare plans, the questions that matter are whether your parent's current doctors and specialists are in network, which plan contracts with the home-care or nursing-facility provider you want, and what supplemental benefits (dental, vision, over-the-counter allowance, transportation) each adds. Call each plan's member-services line to confirm a specific provider participates before you choose.

What Community HealthChoices Covers

Because CHC is a capitated managed-care program, the CHC-MCO is the entity responsible for the Medicaid services a participant qualifies for, and for members who meet nursing-facility level of care that includes the long-term services and supports Medicaid delivers through its home and community-based authorities. For a member living in a Medicaid-paid nursing home, the CHC-MCO is the payer for that facility care. The home and community-based side typically includes personal assistance services (agency-directed or self-directed), home health, adult day services, home-delivered meals, personal emergency response systems, home modifications, respite, and service coordination; your plan's member handbook is the controlling list of what that specific plan covers and at what limits, so ask the service coordinator for it in writing.

When a plan must decide whether to authorize a service, federal managed-care rules set the clock. For Medicaid managed-care rating periods beginning on or after January 1, 2026, a standard service-authorization decision must be made within 7 calendar days of the request under 42 CFR 438.210, tightened by the federal CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F); the prior 14-day cap still governs rating periods that started before that date. An expedited decision, used when the standard clock could seriously jeopardize the enrollee's life, health, or ability to regain maximum function, is due within 72 hours. Either clock can be extended by up to 14 more calendar days if you or your provider request it, or if the plan justifies needing more information and the delay is in your interest.

Getting Paid to Care for a Family Member: Services My Way

Services My Way is CHC's self-directed option for Personal Assistance Services. It lets a participant who meets nursing-facility level of care hire, train, and schedule their own Direct Care Workers (DCWs) instead of receiving care through an agency. For a family weighing whether the adult child already providing the care can be paid for it, this is the central question.

Most relatives can be paid: adult children, siblings, in-laws, grandchildren, and friends can all serve as paid DCWs. The hard limit is that a DCW cannot be the participant's spouse, legal guardian, representative payee, or power of attorney, so a spouse cannot be paid to provide care. Tempus Unlimited is the Financial Management Services (FMS) vendor for CHC self-direction; it runs payroll, files employment taxes, and handles the worker paperwork while the participant remains the employer.

A live-in family caregiver can usually exclude their pay from federal income tax under the Difficulty of Care exclusion in IRS Notice 2014-7, which treats qualified Medicaid waiver payments to a care provider living in the same home as the person they care for as difficulty-of-care payments excluded from gross income.

How to Enroll in Community HealthChoices in Pennsylvania

The Pennsylvania Independent Enrollment Broker (PA IEB) is the front door. Call the IEB helpline at 1-877-550-4227 (TTY 1-877-824-9346) or start online at paieb.com. The IEB schedules the in-home assessment and sends the plan-selection packet; once you are enrolled, the CHC participant helpline is 1-844-824-3655.

A family helping a parent into CHC from scratch generally moves through these steps:

Step 1

Rule out LIFE first

If your parent is 55 or older, lives in a LIFE provider's service area, and meets nursing-facility level of care, weigh the integrated LIFE/PACE alternative before choosing CHC.

Step 2

Apply for Medicaid

File through COMPASS at compass.dhs.pa.gov, by phone at the Consumer Service Center (1-866-550-4355), or at the County Assistance Office.

Step 3

Clear the financial test

For 2026, Pennsylvania uses an income limit of $2,982 per month for a single long-term-care applicant, which is 300 percent of the federal benefit rate. If income is at or below that limit, the countable-resource limit is $2,000 with an additional $6,000 resource disregard; if income is above it, the resource limit is $2,400. DHS publishes those two components separately and does not publish a single combined resource figure. The home is exempt up to the Medicaid home-equity limit, which for 2026 is $752,000 unless the state elects a higher amount, up to a maximum of $1,130,000. That equity cap does not apply at all when the applicant's spouse, a child under 21, or a blind or permanently and totally disabled child of any age is lawfully living in the home; in that case the home is exempt regardless of its equity, which is the common situation when one spouse enters a facility and the other stays home. An applicant whose income is over the limit can still qualify through Pennsylvania's medically-needy spend-down, which DHS computes over a six-month budget period.

Step 4

Complete the functional assessment

The IEB arranges an in-home assessment to determine whether the applicant meets nursing-facility clinical eligibility, the standard for the home and community-based and nursing-facility tracks.

Step 5

Choose a plan

The IEB sends a packet listing the three MCOs; compare on provider networks, supplemental benefits, and service-coordinator reputation. If you do not choose, the IEB assigns one, and you can switch at any time.

Continuity of Care in CHC: What Actually Carries Over

Pennsylvania built transition protections into CHC, and the nursing-facility one is narrower than it is usually described. It is a rollout protection tied to the CHC Implementation Date in each zone: January 1, 2018 in the Southwest, January 1, 2019 in the Southeast, and January 1, 2020 in the Northwest, Lehigh-Capital, and Northeast. A participant who was already living in a nursing facility on that date must keep receiving nursing-facility services from that same facility until the earliest of three things happens: the stay ends, the participant is disenrolled from CHC, or the facility stops being enrolled in Medical Assistance. Switching CHC-MCOs, a temporary hospitalization, and therapeutic leave do not cut that period short while the person is still a resident.

Because those implementation dates are all in the past, this is a closed group. If your parent entered a nursing home after CHC came to their zone, they are not in it, and the protection that applies instead is the general continuity of care in Section C.3 of the CHC agreement, not a right to stay in one facility indefinitely. What does apply to anyone moving into or between CHC plans is this: the long-term services and supports written into the person-centered service plan stay in place until a reassessment is completed. The 180-day period in which participants could keep their existing HCBS providers and service coordinators was likewise a rollout-era provision, and it is not restated in the current CHC agreement, so ask a new plan in writing which of your providers it will keep and for how long rather than assuming a fixed window.

If a Plan Denies or Cuts a Service: Appeals

When a CHC-MCO denies, reduces, or ends a service, you have a layered appeal path, and the deadlines are federal.

Appeal to the plan first. You have 60 calendar days from the date on the adverse-benefit-determination notice to file an appeal with the CHC-MCO, and the plan offers one level of internal appeal.
The plan must decide on a clock. A standard appeal must be resolved within 30 calendar days; an expedited appeal, used when waiting would seriously jeopardize the participant's health, must be resolved within 72 hours. Either clock can be extended by up to 14 calendar days if you request the extension, or if the plan shows the state it needs more information and the delay is in your interest, so ask in writing what the plan's deadline actually is.
Then request a State fair hearing. After the plan upholds its decision, you have at least 90 calendar days to request a fair hearing through the DHS Bureau of Hearings and Appeals. Federal rules set a 90-to-120-day band and each state picks its own number inside it, so treat 90 days as the floor and confirm Pennsylvania's exact deadline on the plan's notice of resolution.
Ask for aid pending to keep services running. If you request the hearing before the date the change takes effect (the required advance notice is normally 10 days) and ask that benefits continue, services stay at the current level until a decision is rendered. Two limits are worth knowing before you rely on it: a request made after the effective date does not trigger continuation, and if the decision ultimately goes against you, the agency may recoup the cost of the services furnished solely by reason of that continuation.

The Pennsylvania Health Law Project (PHLP) at 1-800-274-3258 is the free legal-aid resource for Pennsylvania Medicaid, CHC, and Medicare. It represents consumers in eligibility disputes, service denials, and fair hearings, and is independent of DHS and the MCOs. It is the first call to make when something has gone wrong with a CHC plan.

Paying for the Nursing Home: What the Family Actually Owes

When a CHC member lives in a nursing facility, the CHC-MCO pays for the facility care and the resident contributes most of their monthly income toward the cost. The resident keeps a Personal Needs Allowance of $60 per month, raised from $45 effective January 1, 2025. If one spouse stays in the community, that community spouse's protected share is one-half of the couple's total countable resources, but never less than $32,532 and never more than $162,660 for 2026., Read the ceiling carefully: a couple with modest savings protects half of what they have, not $162,660.

Gifts or transfers made in the five years before a long-term-care Medicaid application can trigger a penalty. Pennsylvania divides the value transferred by its average daily private-pay nursing-facility rate to set the length of ineligibility, and because that divisor is a daily rate, the penalty period is measured in days. The rate applied is the one in effect when the county assistance office determines the penalty period, not the one in effect on the day the application was filed, so a case filed in one year can be penalized at the next year's rate. Effective January 1, 2026 the divisor is $421.20 per day, up from $399.80. The look-back and the penalty attach to Medicaid long-term-care eligibility generally, not only to nursing-home coverage, so do not assume a gift is safe because the care will be delivered at home. Ask the County Assistance Office or an elder-law attorney before transferring anything.

What's Changing in 2026

HCBS waivers run on a renewal clock, not an expiration date. The home and community-based services CHC delivers are furnished under Medicaid's Section 1915(c) waiver authority, and under 42 CFR 441.304 such a waiver runs in fixed terms: three years for a newly approved waiver, then extendable for additional five-year periods when the state asks. So a waiver term coming to an end starts a renewal, not a cutoff.
Faster authorization decisions. The 7-day standard service-authorization clock under the federal prior-authorization rule applies to CHC plans for 2026 rating periods.
Medicaid provider-tax changes. The federal One Big Beautiful Bill Act (P.L. 119-21, enacted July 4, 2025) limits how states use provider taxes to fund the state share of Medicaid for fiscal years starting on or after October 1, 2026, which may affect managed-care financing over time. The participant-facing benefit package is not changed by this.

Frequently Asked Questions

Who has to enroll in CHC?

Adults 21 and older who are dually eligible for Medicare and Medicaid, who live in a Medicaid-paid nursing facility, or who receive Medicaid home and community-based services through the former Attendant Care, Independence, COMMCARE, or Aging waivers (or the OBRA waiver with nursing-facility clinical eligibility). Adults under 21, intellectual-disability and autism waiver participants, LIFE participants, and state psychiatric facility residents are not in CHC.

What is the difference between Community HealthChoices and HealthChoices?

HealthChoices (no leading "Community") is the physical-health Medicaid managed-care program for the non-long-term-care population. Community HealthChoices is the long-term-services-and-supports program for adults 21 and older who are dually eligible, in a Medicaid-paid nursing facility, or receiving Medicaid home care. Both are run by PA DHS, but the populations and rules differ.

Can I be paid to care for my parent through CHC?

Yes, through Services My Way, with one major exception: a spouse cannot be paid. Adult children, siblings, in-laws, grandchildren, and friends can all be paid as Direct Care Workers, but a DCW cannot be the participant's spouse, legal guardian, representative payee, or power of attorney. Tempus Unlimited runs the payroll and tax filings.

How is CHC different from LIFE?

LIFE is Pennsylvania's name for the federal PACE model. It is voluntary and requires age 55 or older, nursing-facility level of care, residence in a LIFE provider's service area, and the ability to live in a community setting at enrollment without jeopardizing health or safety. LIFE participants get all their care through the LIFE provider and do not have a CHC-MCO. CHC is mandatory for the populations it covers and uses managed-care plans. A person can switch between LIFE and CHC at any time.

How do I appeal a denial?

File an appeal with your CHC-MCO within 60 days of the notice. The plan must resolve a standard appeal within 30 days, or 72 hours if expedited. If the plan upholds the denial, request a State fair hearing through the DHS Bureau of Hearings and Appeals, where you have at least 90 days. Appeal before the change takes effect and ask for aid pending to keep services running. The Pennsylvania Health Law Project (1-800-274-3258) helps for free.,

Who pays for the nursing home if my parent is on CHC?

The CHC-MCO pays for the facility care, and your parent contributes their income toward the cost, keeping a $60 monthly Personal Needs Allowance. Medicare stays primary for short-stay rehabilitation; CHC pays for long-stay care. The five-year look-back and transfer penalty attach to Medicaid long-term-care eligibility generally, so they are not something home-based care lets a family skip.

Learn More

Find personalized help comparing Pennsylvania's Community HealthChoices plans at brevy.com.

References

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