Health Care Reform - What's Happening in Pennsylvania?

In February 2015 Pennsylvania transitioned to the HealthChoices, the state’s Medical Assistance managed care program.
Health Care Reform - What's Happening in Pennsylvania? - Articles

Updated: August 8, 2017

In This Article
Health Care Reform - What's Happening in Pennsylvania?

In February 2015, Pennsylvania Governor Tom Wolf announced that Pennsylvania would transition to the HealthChoices program, the state's Medical Assistance (or Medicaid) mandatory managed care program. Under the program, all existing and newly eligible beneficiaries were moved into a single benefit package for adults, effective September 30, 2015. This transition mostly affected newly eligible adults between the ages of 21 to 64 in Pennsylvania with incomes up to 138 percent of the federal poverty level (FPL, $11,770 per year for an individual in 2015).

The HealthChoices program is administered by the Pennsylvania Department of Human Services (DHS) and has the following goals.

  • To improve access to health care services for Medical Assistance recipients;
  • To improve the quality of health care available to Medical Assistance recipients; and
  • To stabilize Pennsylvania's Medical Assistance spending.

Through Physical Health Managed Care Organizations, recipients receive medical care and access to all appropriate physical health services, whether the services are delivered on an inpatient or outpatient basis. The Department of Human Services Office of Medical Assistance Programs oversees the Physical Health component of the HealthChoices Program.

Through Behavioral Health Managed Care Organizations, recipients receive medical care and access to appropriate mental health and/or drug and alcohol services. This component is overseen by the Department of Human Services Office of Mental Health and Substance Abuse Services.

HealthChoices serves approximately 1,600,000 recipients in the following zones:

  • Southeast Zone - Bucks, Chester, Delaware, Montgomery and Philadelphia counties
  • Southwest Zone - Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Green, Indiana, Lawrence, Somerset, Washington and Westmoreland counties
  • Lehigh/Capital Zone - Adams, Berks, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Lancaster, Lebanon, Lehigh, Northampton, Perry and York counties
  • Northwest Zone - Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Potter, Venango and Warren counties
  • Northeast Zone - Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne and Wyoming counties

Pennsylvania uses the federal health insurance exchange rather than a state-run exchange. The Federally-Facilitated Marketplace (FFM) is the online option to buy health insurance for individuals and small businesses that provide insurance for their employees. Through the FFM, individuals and small businesses can compare health plans, get answers to questions, determine eligibility for lower out-of-pocket costs and enroll in health plans. Visit HealthCare.gov for more information.

Enrolling through the Federally-Facilitated Marketplace

The 2017 open enrollment period runs from December 1, 2016 to January 31, 2017. When you enroll (purchase insurance) determines when your policy becomes effective. See the chart below. If you miss open enrollment, you may have to wait until the 2018 open enrollment period unless you have a special circumstance such as getting married or becoming age 26 and can no longer be insured under your parents' health insurance policy. However, health insurance may be available to you in Pennsylvania's private health insurance market (i.e., through companies that are not listed on healthcare.gov.)

Open enrollment on healthcare.gov: December 1, 2016 to January 31, 2017

Enroll/Purchase by
Policy Effective Date
December 15, 2016January 1, 2017
December 16-31, 2016February 1, 2017
January 1-15, 2017March 1, 2017
January 16-31, 2017April 1, 2017

Visit HealthCare.gov to learn more, or to sign up for email or text alerts or to find out what you may qualify for through the FFM.

Navigators are trained, nonbiased professionals who can explain the health care options on The Health Insurance Marketplace (healthcare.gov) and assist you with completing the eligibility and enrollment forms.

To find the nearest navigator (in-person assistance) go to healthcare.gov and search localhelp using your zip code. You can search within 5-50 miles of your zip code.

A listing of federally-funded organizations that can provide assistance with The Health Insurance Marketplace.

Federally Funded Organizations

These organizations are funded by the federal government to provide in-person assistance for those who purchase health insurance on The Health Insurance Marketplace.

To find the nearest navigator (in-person assistance) go to healthcare.gov and search localhelp using your zip code. You can search within 5-50 miles of your zip code.

Consumer Health Coalition

415 East Ohio Street
Pittsburgh, PA 15212

Telephone: 412-456-1877, Ext. 200
E-mail Address: lbachurski@consumerhealthcoalition.org
Website: consumerhealthcoalition.org

Penn Asian Senior Services

Fallon Every, Health Care Insurance Navigator
6926 Old York Road
Philadelphia, PA 19126

Telephone: 215- 572-1234, Ext. 12
E-mail Address: Fallon.Every@passi.us
Website: passi.us

Pennsylvania Association of Community Health Centers

Statewide Director, Outreach and Enrollment
1035 Mumma Road, Suite 1
Wormleysburg, PA 17043-1159

Telephone: 717-761-6443 or 1-866-944-CARE
Website: www.pachc.com

Pennsylvania Mental Health Consumers' Association

in consortium with Mental Health Association in PA, Mental Health America of Westmoreland County and The Advocacy Alliance
4105 Derry Street
Harrisburg, PA 17111

Telephone: 717-564-4930

Email: lynn@pmhca.org

Public Health Management Corporation

1500 Market Street #1500
Philadelphia, PA 19102

Telephone: 267-4342
Email: pgriffin@phmc.org

Young Women's Christian Association of Pittsburgh

6907 Frankstown Avenue
Pittsburgh, PA 15208

Telephone: 412-255-1253

Email: esheppard@ywcapgh.org
Website: www.ywcapgh.org