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Overview of Prime

HEALTHY CONNECTIONS PRIME:  BETTER CARE. BETTER VALUE. BETTER HEALTH.

GOALS OF HEALTHY CONNECTIONS PRIME

  • Improve health outcomes
  • Reduce avoidable emergency department visits and hospital readmissions
  • Continued emphasis on delaying the need for nursing facility care by increasing access to home and community-based services

CURRENT SYSTEM:  WITHOUT INTEGRATED CARE.

  • Three ID cards:  Medicare, Medicaid, and prescription drugs
  • Three different sets of benefits
  • Poor communication among providers
  • Health care decisions uncoordinated and not made from a person-centered perspective
  • Incomplete knowledge of patient's condition, medical records, prescriptions, etc.
  • Limited time, staff resources, or financial incentives to coordinate services
  • Lack of appropriate incentives to provide care at the right time and in the least restrictive setting

Medicare and Medicaid were not initially designed to integrate and coordinate services for individuals served by both programs. 

Increased health care spending has not been proven to improve health outcomes. 

Dual eligibles, individuals who receive both Medicare and Medicaid benefits, represent a disproportionate share in health care costs.  Roughly 15% of the population are dual eligibles, accounting for 30% of costs.

PURPOSE OF HEALTHY CONNECTIONS PRIME

Healthy Connections Prime will provide a new health care option for South Carolina's seniors with Medicare and Medicaid.  This program will make it easier for our seniors to get all the health care services they need, fully managed by a single entity.

Healthy Connections Prime proposes:

  • To integrate and coordinate care for beneficiaries with both Medicare and Medicaid; and
  • To purchase quality health outcomes through a person-centered model that delivers care at the right time and in the most appropriate setting.

CMS and SC signed a Memorandum of Understanding (MOU) on October 25, 2013 approving this new pilot program.

ADVANTAGES OF HEALTHY CONNECTIONS PRIME

Healthy Connections Prime promotes integrated care to address inefficiencies in the current system, including:

  • Communication between providers;
  • Transitions between care settings;
  • Delivery of care at the right time and in the most appropriate setting;
  • Documentation requirements and administrative processes;
  • Health disparities; and
  • Cost shifting between Medicare and Medicaid.

BENEFITS OFFERED AND PROVIDER NETWORKS

Health plans participating in Prime, known as CICOs (Coordinated and Integrated Care Organizations), will be required to provide all Medicare and Medicaid services, either directly or through subcontracts.

Medicaid services under Prime include:

  • Behavioral health
  • Home and community-based services
  • Nursing facility services

Medicare services under Prime include:

  • Primary and acute care
  • Part D (prescription drugs)
  • Skilled nursing facilities

Hospice services will still be reimbursed as fee-for-service (FFS) directly from Medicare.

The Centers for Medicare and Medicaid Services (CMS), South Carolina Department of Health and Human Services (SCDHHS), and the Coordinated and Integrated Care Organizations (CICOs) will ensure beneficiaries have access to an adequate network of medical and support services.  SCDHHS will validate network adequacy through review and analysis of CICO reports.

Pending upon successful completion of the joint federal and state readiness review, the CICOs participating in Healthy Connections Prime will be:

  • Absolute Total Care, Inc.
  • Advicare
  • Molina Healthcare of South Carolina, Inc.
  • Select Health of South Carolina
  • WellCare of South Carolina

ELIGIBILITY OVERVIEW

Healthy Connections Prime population inclusion criteria:

  • Individuals >= 65
  • Full-benefit dual eligible
  • Individuals receiving Home and Community-Based Services (HCBS) CLTC waivers (i.e., HIV, Vent, and Community Choices)

Excluded populations (only applicable to individuals enrolled in the following services at the time of initial enrollment):

  • Residing in a nursing facility
  • Enrolled in hospice
  • Receiving End-Stage Renal Disease (ESRD) services
  • Enrolled in a Program of All-Inclusive Care for the Elderly (PACE), or
  • Enrolled in Department of Disabilities and Special Needs (DDSN) operated waiver serving adults (ID/RD, HASCI, and Community Supports)

Enrollment includes an opt-in period starting July 1, 2014, followed by passive enrollment to begin January 1, 2015.  Healthy Connections Prime is voluntary; beneficiaries can opt-out as well as change plans at any time.

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