Pennsylvania

Pennsylvania delivers Medicaid managed care through three separate programs. Physical HealthChoices, mandatory statewide since 2013 across five geographic zones, covers acute, primary, specialty, and dental care through seven contracted MCOs. Behavioral HealthChoices is carved out to county-administered behavioral health MCOs rather than the physical health plans. Community HealthChoices (CHC), overseen by the Office of Long-Term Living, is a separate statewide program for dual-eligible and LTSS-qualifying adults 21 and older, delivered through three dedicated CHC MCOs; the LIFE program (Pennsylvania's PACE model) is a voluntary alternative for frail seniors 55 and older, and intellectual disability/autism waivers are administered separately by the Office of Developmental Programs, outside HealthChoices entirely.

• AmeriHealth Caritas Pennsylvania: statewide
• Geisinger Health Plan: Lehigh/Capital, Northeast, and Southwest zones
• Highmark Wholecare: multiple zones
• Jefferson Health Plans (Everwell): multiple zones
• Keystone First: Southeast zone
• UnitedHealthcare Community Plan: multiple zones
• UPMC for You: statewide

Long-term services and supports for dual-eligible and nursing-facility-eligible adults are fully integrated with physical health care through Community HealthChoices' three dedicated MCOs; a 2024 award of new CHC contracts was later voided by a court, and the state is repeating the procurement, with the same three incumbent MCOs continuing to serve members while the rebid proceeds. Intellectual disability and autism waiver services, however, remain outside managed care entirely, administered separately by the Office of Developmental Programs. The LIFE program is a separate voluntary PACE-model alternative to CHC for adults 55 and older. The Office of Developmental Programs also runs the Adult Community Autism Program, a small managed care program serving close to 200 adults with autism in Cumberland, Dauphin, Chester, and Lancaster counties, which combines physical health, behavioral health, and community supports in one plan.

Partially integrated into managed care

• AmeriHealth Caritas Pennsylvania: branded Keystone First Community HealthChoices in the Southeast zone
• Pennsylvania Health & Wellness (Centene): statewide
• UPMC Community HealthChoices: statewide

Behavioral health is carved out of Physical HealthChoices entirely and administered through county-based behavioral health MCOs under contracts overseen by the Office of Mental Health and Substance Abuse Services, rather than through the physical health MCOs; for example, Community Behavioral Health (CBH) serves Philadelphia County.

Carved out

Dental care is included as a covered benefit under Physical HealthChoices, delivered through each MCO's own contracted dental network rather than a single statewide dental vendor.

Pharmacy benefits are carved into Physical HealthChoices; each MCO manages its own pharmacy benefit through its own contracted PBM, rather than a statewide fee-for-service carve-out. Pennsylvania has required pass-through PBM pricing (prohibiting spread pricing) for several years and enacted anti-patient-steering legislation. Legislation has been introduced to transition the pharmacy benefit to a statewide fee-for-service model, but it has not been enacted.

Non-emergency medical transportation is delivered through the Medical Assistance Transportation Program (MATP), administered locally through County Assistance Offices rather than a single statewide broker contract.

The PROMISe Medicaid Management Information System, which processes Medicaid fee-for-service claims and provider enrollment, is operated by Gainwell Technologies as the state's fiscal agent (formerly DXC Technology, and originally Electronic Data Systems/HP Enterprise Services, under the same continuously-amended contract originally awarded in 2008).