MedicaidCoverageMedium impact
Changes to Managed Care Coverage of Nursing Facility Services MAB 03-18-20
Pennsylvania Medicaid (DHS)·PA · Geriatrics·Eligibility
Effective date
Nov 21, 2018
We identified it
Jun 20, 2026
Summary
In Pennsylvania HealthChoices zones where Community HealthChoices (CHC) is implemented, Medicaid beneficiaries in nursing facilities will remain enrolled in their Physical Health MCO beyond the traditional 30-day limit until CHC eligibility is determined. Physical Health MCOs are now responsible for nursing facility coverage during this extended eligibility determination period.
Action Required
Immediately: Billing teams at nursing facilities in Pennsylvania CHC zones must verify beneficiary eligibility in the Eligibility Verification System (EVS) before submitting claims to ensure claims are sent to the correct entity (PH-MCO vs CHC-MCO). Stop requesting PH-MCO coverage end-dates at 30 days for beneficiaries in CHC zones. Contact appropriate PH-MCO for questions about payment and claim submission during the CHC Eligibility Determination Period.