1 South Carolina Medicaid Coordinated Care and Enrollment Counselors Programs.
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Transcript of 1 South Carolina Medicaid Coordinated Care and Enrollment Counselors Programs.
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South Carolina South Carolina MedicaidMedicaid
Coordinated Care and Coordinated Care and Enrollment Counselors Enrollment Counselors
ProgramsPrograms
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South Carolina Medicaid South Carolina Medicaid FactsFacts
Provides benefits for over 20% of Provides benefits for over 20% of populationpopulationPays for 60% of all birthsPays for 60% of all birthsCovers over 40% of all childrenCovers over 40% of all childrenCovers 30% of all seniorsCovers 30% of all seniorsNearly $5 billion total annual budgetNearly $5 billion total annual budgetAccounts for 20% of General Fund Accounts for 20% of General Fund budgetbudget
Updated 1/17/2007
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SC Medicaid Matching Expenditures as a SC Medicaid Matching Expenditures as a Percent of Total State General Fund Percent of Total State General Fund
RevenueRevenue
11% 14 %19%
24%29%
.Source: South Carolina Budget and Control Board, Office of Research and Statistics
$0
$1,000,000,000
$2,000,000,000
$3,000,000,000
$4,000,000,000
$5,000,000,000
$6,000,000,000
$7,000,000,000
$8,000,000,000
1995 2000 2005 2010 2015
General Fund Revenue Medicaid Match
1111
Why Coordinated Why Coordinated Care?Care?
To establish more beneficiaries in To establish more beneficiaries in a stable “medical home”a stable “medical home”
To increase quality of careTo increase quality of care To control costs, provide budget To control costs, provide budget
stabilitystability Reduce DHHS’s administrative Reduce DHHS’s administrative
functionsfunctions
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Why Enrollment Why Enrollment Counseling?Counseling?
Counselors help beneficiaries select Counselors help beneficiaries select appropriate Medicaid medical homeappropriate Medicaid medical home
Beneficiaries will not have to find Beneficiaries will not have to find providers and manage health care providers and manage health care needs on their ownneeds on their own
Counselors conduct health Counselors conduct health assessments to match beneficiaries to assessments to match beneficiaries to appropriate Medicaid plan, using rating appropriate Medicaid plan, using rating system to ensure proper placementsystem to ensure proper placement
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Counselors update beneficiaries on Counselors update beneficiaries on plan changes, and help beneficiaries plan changes, and help beneficiaries select alternative plans, if neededselect alternative plans, if needed
Allowing beneficiary choice among Allowing beneficiary choice among plans will encourage plan innovationplans will encourage plan innovation
(Note: Certain eligibility groups, like (Note: Certain eligibility groups, like pregnant women, the aged, and pregnant women, the aged, and disabled, are not included in the disabled, are not included in the Enrollment Counseling program)Enrollment Counseling program)
Why Enrollment Counseling?Why Enrollment Counseling?
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Coordinated Care:Coordinated Care:DHHS’ Role DHHS’ Role
Evaluate coordinated care plansEvaluate coordinated care plansProvide consultation and Provide consultation and technical assistancetechnical assistanceServe as liaison between plans Serve as liaison between plans and various DHHS departmentsand various DHHS departmentsServe as liaison between DHHS Serve as liaison between DHHS and CMS regarding all and CMS regarding all coordinated care planscoordinated care plans
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Coordinated Care:Coordinated Care:Impact on Service Impact on Service
DeliveryDeliveryImproved continuity of careImproved continuity of care
Decreased pharmaceutical costsDecreased pharmaceutical costs
Decreased emergency room utilizationDecreased emergency room utilization
Increased efforts in targeting chronically Increased efforts in targeting chronically ill beneficiariesill beneficiaries
Improved physician collaboration Improved physician collaboration
Wiser use of network resources Wiser use of network resources including staff, data, and best practicesincluding staff, data, and best practices
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Coordinated Care:Coordinated Care:Impact on ProvidersImpact on Providers
Improved service delivery due to Improved service delivery due to an increased use of data and an increased use of data and physician collaborationphysician collaborationMore time to practice medicine More time to practice medicine due of better utilization of due of better utilization of resourcesresourcesIncreased satisfaction with the Increased satisfaction with the Medicaid Program among the Medicaid Program among the provider community provider community
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Coordinated Care:Coordinated Care:Impact on Medicaid Impact on Medicaid
BeneficiariesBeneficiaries
Better continuity of careBetter continuity of care
Increased access to national best Increased access to national best practicespractices
Increased attention on care coordinationIncreased attention on care coordination
Extended service hoursExtended service hours
Better educated about healthcare issuesBetter educated about healthcare issues
Established medical homeEstablished medical home
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DHHS’ Expectations of DHHS’ Expectations of Expanding Coordinated Expanding Coordinated
CareCareMore informed beneficiaries and More informed beneficiaries and physiciansphysiciansMore fiscally sound behavior by More fiscally sound behavior by beneficiaries and physiciansbeneficiaries and physiciansGreater emphasis on preventive careGreater emphasis on preventive careImproved health states for those with Improved health states for those with chronic diseaseschronic diseasesDecreased emergency room utilizationDecreased emergency room utilizationMedicaid beneficiaries will have a true Medicaid beneficiaries will have a true medical homemedical home
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Types of Coordinated Care Types of Coordinated Care Programs in South CarolinaPrograms in South Carolina
Managed Care Organizations Managed Care Organizations (MCOs)(MCOs)
Medical Home Networks Medical Home Networks (MHNs)(MHNs)
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Medicaid Managed Care Medicaid Managed Care Organization (MCO) Organization (MCO)
StructureStructure$$ Premium
Operations
Administration
Reserves
Earnings
Support
Services
Care Coordination
Case Management
Disease Management
Pharmacy Management
Data Management
Utilization ManagementPatient/Client
Clinical ServicesPayments to Providers
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MCO Payment MCO Payment StructureStructure
DHHS pays MCO a “per member DHHS pays MCO a “per member per month” (PMPM) fee for per month” (PMPM) fee for provision of health services for provision of health services for enrolleesenrolleesThe MCO contracts with and pays The MCO contracts with and pays providersprovidersMCO retains profit from PMPM fee MCO retains profit from PMPM fee not required to pay for services not required to pay for services for network enrolleesfor network enrollees
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South Carolina Medicaid South Carolina Medicaid Managed Care Managed Care OrganizationsOrganizations
There are currently two There are currently two Managed Care Organizations Managed Care Organizations in South Carolina:in South Carolina:
Select Health of South Carolina Inc.Select Health of South Carolina Inc. Unison Health PlanUnison Health Plan
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Medical Home Network Medical Home Network (MHN) Organization (MHN) Organization
StructureStructureMHN Governing
Board
Composed of Member Practices & Other Related
Providers
Establishes Policy & Oversees Operations
Practice Practice Practice Practice
Administrative Services Organization (ASO)
Care Coordination
Case Management
Disease Management
Pharmacy Management
Data Management
Utilization Management
Hospitals, Specialists, DME, Podiatrists, Chiropractors, Home Health, etc.
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MHN Payment MHN Payment StructureStructure
DHHS pays MHN Board/ASO PMPM fee DHHS pays MHN Board/ASO PMPM fee (MHN board is comprised of one doctor (MHN board is comprised of one doctor from each participating practice plus from each participating practice plus ASO)ASO)
Participating PCP’s receive PMPM fee Participating PCP’s receive PMPM fee plus FFS reimbursementplus FFS reimbursement
MHN and State share cost savings based MHN and State share cost savings based upon meeting quarterly indicators and upon meeting quarterly indicators and reduction in overall expendituresreduction in overall expenditures
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Medical Home Network Medical Home Network Programs in SCPrograms in SC
There are currently three Medical There are currently three Medical Home Networks in South Carolina:Home Networks in South Carolina:
PhyTrust of South CarolinaPhyTrust of South Carolina South Carolina SolutionsSouth Carolina Solutions Palmetto Medical Home NetworkPalmetto Medical Home Network
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SC Medicaid SC Medicaid Coordinated Care Coordinated Care
EnrollmentEnrollment
MCO plansMCO plans 112,144112,144 MHNsMHNs 70,292 70,292
TotalTotal 182,436182,436
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#
#
#
Medically FragileChildren's Program
#
SC Solutions/CHS
Unison Health Plan
Select Health/First Choice
Current as of April, 2007.
PhyTrust
1 Only One Practice
Palmetto MHLN/Physicians Choice
Legend
Created by the University of South Carolina, Institute for Families in Society, April 2007.
Auto-enrollment Regions
Midlands
Low Country
Pee Dee
Piedmont
Managed Care Plans
S
N
EW
25 0 25 50 Miles
Pickens
Anderson
Cherokee
Laurens
McCormick
Oconee
Greenville
Greenwood
Abbeville
Union
LancasterChester
Fairfield
Edgefield
Spartanburg
Kershaw Darlington
Lee
York
Florence
Marlboro
Dillon
Berkeley
Sumter
Chesterfield
Lexington
Richland
Orangeburg
Newberry
Bamberg
Barnwell
Saluda
Jasper
AikenClarendon
Calhoun
Allendale
Hampton
Beaufort
Marion
Georgetown
Horry
Charleston
Williamsburg
Colleton
Dorchester
Charleston
Easley
Palmetto1
1
1
1
1
1
1
1
1
1
1
1
1
1
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Medicaid Managed Care Plans in South Carolinaby Auto-enrollment Regions
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1
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1
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Pee Dee Region
Piedmont Region
Low CountryRegion
MidlandsRegion
Medicaid Coordinated Care Plans in SC