South%20Carolina%20Medicaid

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South Carolina Medicaid
Coordinated Care and Enrollment Counselors
Programs
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South Carolina Medicaid Facts

• Provides benefits for over 20 of population
• Pays for 60 of all births
• Covers over 40 of all children
• Covers 30 of all seniors
• Nearly 5 billion total annual budget
• Accounts for 20 of General Fund budget

Updated 1/17/2007
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SC Medicaid Matching Expenditures as a Percent of
Total State General Fund Revenue
29
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14
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Source South Carolina Budget and Control Board,
Office of Research and Statistics
.
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Why Coordinated Care?

• To establish more beneficiaries in a stable
  medical home
• To increase quality of care
• To control costs, provide budget stability
• Reduce DHHSs administrative functions

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Why Enrollment Counseling?

• Counselors help beneficiaries select appropriate
  Medicaid medical home
• Beneficiaries will not have to find providers and
  manage health care needs on their own
• Counselors conduct health assessments to match
  beneficiaries to appropriate Medicaid plan, using
  rating system to ensure proper placement

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Why Enrollment Counseling?

• Counselors update beneficiaries on plan changes,
  and help beneficiaries select alternative plans,
  if needed
• Allowing beneficiary choice among plans will
  encourage plan innovation
• (Note Certain eligibility groups, like pregnant
  women, the aged, and disabled, are not included
  in the Enrollment Counseling program)

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Coordinated CareDHHS Role

• Evaluate coordinated care plans
• Provide consultation and technical assistance
• Serve as liaison between plans and various DHHS
  departments
• Serve as liaison between DHHS and CMS regarding
  all coordinated care plans

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Coordinated CareImpact on Service Delivery

• Improved continuity of care
• Decreased pharmaceutical costs
• Decreased emergency room utilization
• Increased efforts in targeting chronically ill
  beneficiaries
• Improved physician collaboration
• Wiser use of network resources including staff,
  data, and best practices

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Coordinated CareImpact on Providers

• Improved service delivery due to an increased use
  of data and physician collaboration
• More time to practice medicine due of better
  utilization of resources
• Increased satisfaction with the Medicaid Program
  among the provider community

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Coordinated CareImpact on Medicaid Beneficiaries

• Better continuity of care
• Increased access to national best practices
• Increased attention on care coordination
• Extended service hours
• Better educated about healthcare issues
• Established medical home

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DHHS Expectations of Expanding Coordinated Care

• More informed beneficiaries and physicians
• More fiscally sound behavior by beneficiaries and
  physicians
• Greater emphasis on preventive care
• Improved health states for those with chronic
  diseases
• Decreased emergency room utilization
• Medicaid beneficiaries will have a true medical
  home

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• Types of Coordinated Care Programs in South
  Carolina
• Managed Care Organizations (MCOs)
• Medical Home Networks (MHNs)

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Medicaid Managed Care Organization (MCO) Structure
Premium
Administration Reserves Earnings
Operations
Care Coordination Case Management Disease
Management Pharmacy Management Data
Management Utilization Management
Support Services
Patient/Client Clinical Services
Payments to Providers
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MCO Payment Structure

• DHHS pays MCO a per member per month (PMPM) fee
  for provision of health services for enrollees
• The MCO contracts with and pays providers
• MCO retains profit from PMPM fee not required to
  pay for services for network enrollees

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South Carolina Medicaid Managed Care Organizations

• There are currently two Managed Care
  Organizations in South Carolina
• Select Health of South Carolina Inc.
• Unison Health Plan

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Medical Home Network (MHN) Organization Structure
MHN Governing Board Composed of Member Practices
Other Related Providers Establishes Policy
Oversees Operations
Administrative Services Organization (ASO) Care
Coordination Case Management Disease
Management Pharmacy Management Data
Management Utilization Management
Practice
Practice
Practice
Practice
Hospitals, Specialists, DME, Podiatrists,
Chiropractors, Home Health, etc.
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MHN Payment Structure

• DHHS pays MHN Board/ASO PMPM fee (MHN board is
  comprised of one doctor from each participating
  practice plus ASO)
• Participating PCPs receive PMPM fee plus FFS
  reimbursement
• MHN and State share cost savings based upon
  meeting quarterly indicators and reduction in
  overall expenditures

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Medical Home Network Programs in SC

• There are currently three Medical Home Networks
  in South Carolina
• PhyTrust of South Carolina
• South Carolina Solutions
• Palmetto Medical Home Network

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SC Medicaid Coordinated Care Enrollment

• MCO plans 112,144
• MHNs 70,292
• Total 182,436

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