Medical Billing Company in Pennsylvania | HealthChoices Expertise

Pennsylvania delivers Medicaid through HealthChoices, split across two separate geographic zone maps. HealthChoices Physical Health covers acute and primary care across five zones, Southeast, Southwest, Lehigh/Capital, Northeast, and Northwest, with behavioral health carved out entirely to separate BH-MCOs overseen by the state's Office of Mental Health and Substance Abuse Services. Community HealthChoices (CHC), a separate mandatory long-term services and supports program, uses its own five-zone map covering all 67 counties, currently through three MCOs, AmeriHealth Caritas, PA Health & Wellness, and UPMC, with new contracts taking effect January 2025. Pennsylvania has pushed capitation spending from 48 to 78 percent of total Medicaid expenditures between 2013 and 2024, one of only nine states above 70 percent.

On the commercial side, Pennsylvania is effectively split between two regional Blues plans: Highmark, dominant in western and central Pennsylvania and based in Pittsburgh, and Independence Blue Cross, dominant in the Philadelphia region with as much as 82 percent of the local ACA market. In 2009, Pennsylvania's Insurance Commissioner rejected a proposed merger between the two after a 21-month review, the longest in state history, concluding it would have created too dominant a single insurer. UPMC, based in Pittsburgh, is also both an insurer and an integrated health system in its own right.