How Pennsylvania’s Community HealthChoices (CHC) and Medicaid Works with Medicare
Understanding how CHC works alongside Medicare is key to maximizing your benefits and minimizing out-of-pocket costs.
April 22, 2025
Navigating the complexities of healthcare can be challenging—especially when juggling multiple programs like Medicare and Medicaid. In Pennsylvania, individuals who qualify for both benefit from a coordinated system through the Community HealthChoices (CHC) program. Understanding how CHC works alongside Medicare is key to maximizing your benefits and minimizing out-of-pocket costs.
What is Dual Eligibility?
If you qualify for both Medicare and Medicaid, you're considered dual eligible. In this case:
Medicare pays first. It covers hospital stays, doctor visits, preventive care, and prescriptions.
Medicaid, through the CHC program, acts as secondary payer, helping cover remaining costs and services Medicare doesn't pay for.
What Is Community HealthChoices (CHC)?
Pennsylvania’s Community HealthChoices (CHC) program is a Medicaid managed care program for individuals who are:
21 or older,
Dual eligible (have both Medicare and Medicaid), or
Receiving long-term services and support (LTSS).
CHC is designed to improve coordination of care for physical health and long-term services.
How Medicare and CHC Work Together
Here’s how Medicare and CHC coordinate benefits:
Medicare Pays First
When you receive Medicare-covered services, Medicare is the primary payer. Providers should always bill Medicare first.
CHC Covers the Gaps
After Medicare pays, your CHC plan pays for cost-sharing like deductibles, coinsurance, and copayments—so you typically pay little or nothing out of pocket.
CHC Covers What Medicare Doesn’t
CHC also provides coverage for services not covered by Medicare, such as:
Long-term services and supports (LTSS)
Home and community-based services (HCBS)
Nursing facility care
Personal assistance services
Coordinated Managed Care
You’ll choose from a CHC Managed Care Organization (MCO) such as:
UPMC Community HealthChoices
These MCOs manage both physical health and LTSS services to ensure continuity and coordination of care.
What About Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs)?
If you’d prefer to have your Medicare and Medicaid services managed by one plan, you may consider enrolling in a Dual-Eligible Special Needs Plan (D-SNP). These are Medicare Advantage plans specifically designed for people with both Medicare and Medicaid. Benefits often include:
Combined Medicare and Medicaid coverage
Care coordination
Extra services like transportation or dental
One ID card and one plan to manage
Enrollment in a D-SNP is optional, but many dual eligibles find the simplified experience helpful, plus they typically provide extra benefits such as Healthy Foods allowance card, Dental and Vision Coverage, Gym Memberships, and more.
Does CHC Change My Medicare?
No. CHC does not replace or alter your Medicare benefits. You still keep Medicare, and it continues to cover your usual services. CHC just adds extra coverage and support, especially for long-term care.
Key Takeaways
Medicare or Medicare Advantage D-SNP plans pay first; CHC pays what Medicare doesn’t.
CHC adds benefits like long-term care, home services, and personal assistance.
You must still enroll in Medicare—CHC does not replace it.
Medicare Advantage D-SNPs are a convenient option if you want everything managed under one plan, plus they typically provide extra benefits such as Healthy Foods allowance card, Dental and Vision Coverage, Gym Memberships, and more.
Learn More
For more information, visit these official resources:
PA Department of Human Services – Community HealthChoices
Medicare.gov – Coordination with Medicaid
CMS – D-SNP Overview
If you have questions about how to enroll in a CHC plan or D-SNP in Pennsylvania—or want help understanding your dual-eligible benefits—Contact us today and our licensed insurance experts will guide you every step of the way.