CMS and South Carolina Partner to Coordinate Care for Medicare-Medicaid Enrollees
Overview
On October 25, 2013, the Centers for Medicare & Medicaid Services (CMS) announced that the State of South Carolina will partner with CMS to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience.
Under the demonstration, known as “Healthy Connections Prime,” South Carolina and CMS will contract with Medicare-Medicaid Plans to coordinate the delivery of covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees.
Medicare-Medicaid Enrollees
Improving the care experience for low-income seniors and people with disabilities who are Medicare-Medicaid enrollees – sometimes referred to as “dual eligibles” – is a priority for CMS.
Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, insurance cards, and providers (Medicare Parts A and B, Part D, and Medicaid). Many Medicare-Medicaid enrollees suffer from multiple or severe chronic conditions and could benefit from better care coordination and management of health and long-term supports and services.
The Financial Alignment Initiative – Partnerships to Provide Better Care
Through the demonstrations approved under the Financial Alignment Initiative (Initiative), CMS seeks to provide Medicare-Medicaid enrollees with a better care experience by offering a person-centered, integrated care initiative that provides a more easily navigable and seamless path to all covered Medicare and Medicaid services.
In July 2011, CMS announced the opportunity for states to partner with CMS through one of two models:
- Managed Fee-for-Service Model in which a state and CMS enter into an agreement by which the state would be eligible to benefit from savings resulting from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid;
- Capitated Model in which a state and CMS contract with health plans or other qualified entities that receive a prospective, blended payment to provide enrolled Medicare-Medicaid enrollees with coordinated care.
South Carolina is the ninth state to establish a memorandum of understanding (MOU) with CMS to move forward with a demonstration. CMS continues to work with other states to develop their demonstration models. All demonstrations will be evaluated to assess their impact on the beneficiary’s care experience, quality, coordination, and costs.
The South Carolina Demonstration
Under this capitated model demonstration, an estimated 53,600 Medicare-Medicaid enrollees in South Carolina, age 65 and over and living in the community at the time of enrollment, will have an opportunity for more coordinated care. South Carolina and CMS will contract with health plans known as Coordinated and Integrated Care Organizations (CICOs) that will oversee the delivery of covered Medicare and Medicaid services for Medicare-Medicaid enrollees in South Carolina.
All participating plans must first meet core Medicare and Medicaid requirements, state procurements standards and state insurance rules (as applicable). Every selected Medicare-Medicaid Plan must also pass a comprehensive joint CMS-state readiness review.
Enrollment will be phased in over several months. Eligible beneficiaries will begin opting into the demonstration no earlier than July 1, 2014. Beginning no earlier than January 1, 2015, eligible beneficiaries who have not made a choice to opt in or out will be assigned to a CICO.
Electronic Records
South Carolina’s capitated demonstration, known as Healthy Connections Prime, will leverage the state’s existing Phoenix and Care Call systems which currently provide automated support for Home and Community Based Services (HCBS) waiver operations. Together, 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 provision, and numerous other components to support case management activities. Under the demonstration, providers and case managers will also have access to these systems providing a single database of all care and notifications provided to beneficiaries related to care they receive.
Home and Community Based Services (HCBS)
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). 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.
Putting the Beneficiary First
Care Coordination
Under the demonstration, care coordination services will be available to all enrollees. CICO plans will offer a multidisciplinary care team to ensure the integration of the member’s medical, behavioral health, long-term services and supports, and social needs. The team will be person-centered and built on the enrollee’s specific preferences and needs.
Quality Measures
The new demonstration includes beneficiary protections to ensure that enrollees receive high-quality care. CMS and South Carolina have established quality measures relating to the beneficiary overall experience, care coordination, and fostering and supporting community living, among many others.
Other Protections
The demonstration also includes continuity of care requirements to ensure that beneficiaries can continue to see their current providers during transitions into the CICO plans. Ombudsman services will support individual advocacy and independent systematic oversight for the demonstration, with a focus on compliance with principles of community integration, independent living, and person-centered care.
Comprehensive Evaluation
CMS is funding and managing an external evaluation of each state. The evaluation for South Carolina’s demonstration will measure quality, including overall beneficiary experience of care, care coordination, care transitions, and support of community living. CMS will develop a unique, South Carolina-specific evaluation using a comparison group to analyze the impact of the demonstration.
A Transparent Process Supporting Public Input
The South Carolina demonstration is the product of an ongoing planning and development process through which the public helped shape the demonstration’s design. South Carolina:
- Worked with a diverse group of stakeholders including providers, health plans, nursing facilities, hospitals, state agencies, advocacy groups, associations, and individuals.
- Established public workgroups with external stakeholders to inform demonstration development and policy.
- Created and maintained a website to facilitate public participation in the demonstration design and planning process: https://msp.scdhhs.gov/scdue/.
- Posted its draft proposal for public comment and incorporated the feedback into its demonstration proposal before officially submitting it to CMS. The proposal was then posted by CMS for public comment.
Additional Information
The demonstration will be administered under the Center for Medicare and Medicaid Innovation authority.
Additional information about the South Carolina demonstration, including the MOU, is publicly available at:
Additional information on the ongoing development and implementation of the South Carolina demonstration is available at: https://msp.scdhhs.gov/scdue/.