11

South Carolina South Carolina MedicaidMedicaid

Coordinated Care and Coordinated Care and Enrollment Counselors Enrollment Counselors

ProgramsPrograms

22

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

33

44

55

66

77

88

99

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

1010

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

1212

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

1313

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?

1414

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

1515

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

1616

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

1717

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

1818

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

1919

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)

2020

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

2121

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

2222

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

2323

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.

2424

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

2525

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

2626

SC Medicaid SC Medicaid Coordinated Care Coordinated Care

EnrollmentEnrollment

MCO plansMCO plans 112,144112,144 MHNsMHNs 70,292 70,292

TotalTotal 182,436182,436

2727

#

#

#

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

1

Medicaid Managed Care Plans in South Carolinaby Auto-enrollment Regions

1

1

1

1

1

Pee Dee Region

Piedmont Region

Low CountryRegion

MidlandsRegion

Medicaid Coordinated Care Plans in SC