Experience Inc. seeks to clear up confusion over medicaid

A change to the Medicaid service delivery system is causing confusion for some local seniors.

Experience Inc. (the Area Agency on Aging for Warren and Forest Counties) Board discussed complications this week with the new system. It is called Community Health Choices (CHC), which began on January 1, 2020, in this part of the state.

Through this new statewide system, all individuals who have both Medicaid and Medicare have to enroll with one of three state-approved managed care organizations (MCOs). The three MCOs they can choose from are AmeriHealth Caritas, PA Health & Wellness, and UPMC.

Experience Inc. is a non-profit company dedicated to meeting the needs of senior citizens in our community. It offers a variety of services and programs created for seniors to enhance their quality of life. The staff works to help, plan, and coordinate the care of our local senior citizens.

Experience, Inc. used to operate directly as a fee for service vendor with the state in what was known as the Aging Waiver program. It was responsible for coordinating care for seniors who qualify for Medicaid and are in need of long term support and services at home. All people enrolled in the Aging Waiver program were enrolled into one of the three MCOs as of January 1.

In Community Health Choices, the state contracts directly with these MCOS. The MCOs will then be able to choose who they wish to contract with for service coordination or they can keep it internally and hire their own service coordinators.

Experience, Inc. is currently under contract with each MCO through June 30. After that date, the MCOs can choose whether or not to continue to contract with them. According to Experience, Inc., things are going smoothly with PA Health & Wellness and AmeriHealth Caritas for them.

This Medicaid system change not only affects who coordinates the care of those in need of support and service at home, but also the providers of that care. This ranges from in-home care providers to area physicians and hospitals. Each type of provider has to be contracted with these MCO’s for the plans to be in-network for the consumers.

Community Health Choices is the new health insurance plan for all people who are dually-eligible for both Medicare and Medicaid. However, it does not cause any change to how a person’s Medicare works. Medicare remains their primary insurance, but their secondary insurance is no longer straight Medicaid Access. That secondary insurance is now one of the Managed Care Organizations (MCOs) mentioned above.

According to Experience, Inc. Executive Director Danell Sowers, the transition has been “exceedingly frustrating,” and the entire board is wondering if it is harming consumers. The Board agrees that not only is it a challenge for the organization, but for its workers trying to help our seniors as well.

State Rep. Kathy Rapp met with the Board this week and is concerned that CHC could be difficult in the rural communities. Staff from Senator Scott Hutchinson’s office was also in attendance to learn about the impact of this change.

In the initial weeks of the rollout, there were issues around a couple of consumers not being seen by their doctors due to the confusion around these MCOs, but that seems to be smoothing out, said Sowers.

More recently, people have gone without needed care at home because of the length of time it is taking to get things done through some of the MCOs. The Agency and its Board are not pleased, Sowers said.

“It is difficult for the Agency to be associated with some aspects of the transition to CHC because some issues associated with MCOs still reflect poorly upon Experience, Inc., even though they are no longer in control of it,” she said.

She wonders if their involvement is more of a barrier for consumers versus providing them assistance due to some of their communication issues with certain MCOs.


Today's breaking news and more in your inbox

I'm interested in (please check all that apply)