1 South Carolina Medicaid Coordinated Care and Enrollment Counselors Programs

2 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

3

4

5

6

7

8

9 SC Medicaid Matching Expenditures as a Percent of Total State General Fund Revenue 11% 14 % 19% 24% 29%. Source: South Carolina Budget and Control Board, Office of Research and Statistics

10

11 Why Coordinated Care? To establish more beneficiaries in a stable “medical home” To increase quality of care To control costs, provide budget stability Reduce DHHS’s administrative functions

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

13 Counselors update beneficiaries on plan changes, and help beneficiaries select alternative plans, if needed Counselors update beneficiaries on plan changes, and help beneficiaries select alternative plans, if needed Allowing beneficiary choice among plans will encourage plan innovation 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) Why Enrollment Counseling?

14 Coordinated Care: DHHS’ 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

15 Coordinated Care: Impact 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

16 Coordinated Care: Impact 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

17 Coordinated Care: Impact 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

18 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

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

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

21 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

22 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

23 Medical Home Network (MHN) Organization Structure MHN Governing Board Composed of Member Practices & Other Related Providers Establishes Policy & Oversees Operations 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.

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

25 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

26 SC Medicaid Coordinated Care Enrollment MCO plans112,144 MCO plans112,144 MHNs 70,292 MHNs 70,292 Total182,436 Total182,436

27 Medicaid Coordinated Care Plans in SC