Coordinating Care for Duals

In October, CMS and the State of South Carolina Department of Health and Human Services (SCDHHS) announced plans to test a new pilot to provide care for individuals who are both Medicare-Medicaid enrollees. The intent is to provide a better model of care for dual eligibles that is more coordinated and person-centered.

Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, insurance cards, and providers. Many dual enrollees suffer from multiple or severe chronic conditions and need to receive care better care that is coordinated and managed to suit their needs.

The new program called “Healthy Connections Prime” will enable beneficiaries that enroll in the pilot program to receive both Medicare and Medicaid and receive additional behavioral health and community support services through one health plan that promotes clinically integrated patient-centered care.

The demonstration was approved under the CMS Financial Alignment Initiative. One of the Initiative’s two models is referred to as the Managed Fee-for-Service Model where the state would be eligible to benefit from savings. The Capitated Model enables the state and CMS to contract with health plans or other qualified entities to receive a prospective blended payment when providing enrolled duals with coordinated care. South Carolina is operating under the capitated model for the new pilot demonstration.

SCDHHS is preparing to serve about 53,600 dual eligibles 65 and older in a fully integrated system by December 2015. To begin, the state and CMS will contract with health plans known as “Coordinated and Integrated Care Organizations” (CICO) to oversee the delivery of covered Medicare and Medicaid service for dual enrollees.

South Carolina’s capitated demonstration will leverage the state’s existing “Phoenix” and “Care Call” systems that currently provide automated support for Home and Community-Based Services waiver operations.

These systems provide electronic records for all waiver assessments, care plans, service authorizations, provider information, service delivery documentation, caregiver support systems, real-time monitoring of service provisions, and numerous other components to support case management activities. Under the demonstration, providers and case managers will have access to these systems and be able to access a single database containing all care and notifications related to the care beneficiaries received.

Medicare-Medicaid enrollees enrolled in the demonstration will maintain access to full Medicare and Medicaid benefits throughout the demonstration including Home and Community-based Services (HCBS).

In order to provide CICO plans with additional time to fully integrate HCBS services, responsibility for providing these services will be transferred from the state to the plan over an 18 month period. Throughout that time, beneficiaries will maintain seamless access to all HCBS services through close collaboration between CMS and the state.

The State has been and is going to continue to work with providers, health plans, nursing facilities, hospitals, state agencies advocacy groups, associations, and other individuals for thoughts on whether the project is achieving the goals set out in the demonstration project proposal.

For more information go to www.scdhhs.gov.