A longstanding barrier to coordinating care for Medicare-Medicaid enrollees has been the financial misalignment between Medicare and Medicaid. To begin to address this issue, the Centers for Medicare & Medicaid Services (CMS) will test models with States to better align the financing of these two programs and integrate primary, acute, behavioral health and long-term services and supports for their Medicare-Medicaid enrollees.
On October 25, 2013, CMS announced that the State of South Carolina will partner with them 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 contracted with Medicare-Medicaid Plans to coordinate the delivery of covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees.
Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, insurance cards, and providers (Medicare Parts A, B, 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.
Under the 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 contracted with health plans known as Coordinated and Integrated Care Organizations (CICOs). These plans are: Absolute Total Care, First Choice VIP Care Plus, and Molina Dual Options.
The Ombudsman services provided by the South Carolina Department on Aging are part of the demonstration exclusively for Healthy Connections Prime members. These services 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. The advocate for the Healthy Connections Prime Program is called the Healthy Connections Prime Ombudsman. This is the designated government official appointed to receive and investigate complaints in a fair and impartial manner for the benefit of the Healthy Connections Prime member.
Contact the Healthy Connections Prime Ombudsman at the South Carolina Department on Aging for more information, toll free: 1-844-477-4632.