Healthy Connections Prime Passive Enrollment Scheduled to Begin April 2016; Seniors in South Carolina now have a new health care option

PROVIDER ALERT

 

Healthy Connections Prime is a new program for South Carolina seniors age 65 and older with Medicare and Medicaid. This demonstration program is jointly administered by the Centers for Medicare and Medicaid Services (CMS) and the South Carolina Department of Health and Human Services (SCDHHS) and is designed to integrate all the services of Medicare, Medicare Part D and Medicaid under a single Medicare-Medicaid plan. In South Carolina these Medicare-Medicaid plans are offered by Coordinated and Integrated Care Organizations (CICO).

Healthy Connections Prime currently has almost 2,000 members who have voluntarily selected a CICO and enrolled for coverage during 2015. In April 2016, Wave 1 of passive enrollment for eligible beneficiaries who have not actively chosen to participate will be conducted using a passive enrollment process that auto-assigns each eligible enrollee to a CICO. Wave 2 of passive enrollment will begin in July 2016 (see chart below for the timeline and page 3 for the county breakdown by wave). SCDHHS will utilize an intelligent assignment algorithm to identify the CICO that will best meet the needs of the enrollee and will promote continuity of care. Factors considered in the assignment include existing provider relationships, previous history with the plan and household members currently enrolled with the CICO. Passive enrollment will be conducted in two waves based on county and relative acuity levels of eligible beneficiaries. Newly eligible beneficiaries, throughout the entire state, will be auto-assigned monthly on an on-going basis beginning July 1, 2016. CICOs in your county will notify you if any of your patients have been auto-assigned.

Program Details

Healthy Connections Prime is a voluntary program. Individuals who enroll in Healthy Connections Prime can change health plans, or disenroll from the program at any time and receive their Medicare and Medicaid benefits just like they do now.

 

Providers are encouraged to be part of this important initiative by joining one or more of the four CICO networks: Absolute Total Care, Advicare Advocate, First Choice VIP Care PLUS and Molina Dual Options.  As a network provider, you will be able to provide care to new and existing patients while benefiting from the following:

·         One card(verify eligibility/coverage for only one program)

·         One party to bill(no sequential billing – submits to one entity, payment comes from one entity)

·         One point of contactregardless of service type. (i.e., Medicare, Medicaid, Part D)

·         Support from an integrated, team-based approach to care, including the member’s care coordinator. Coordination of all member medical and non-medical needs.

·         Continuity of care(new members can keep their existing providers for six months while the plan contacts out-of-network providers about joining the network)

·         $0 copay for drugs

·         No coinsurance feesfor Medicare Part A and B related services. Provider reimbursement from Medicare-Medicaid plans constitute payment in full regardless of the type of service.  

Can I continue to see my patients who join Healthy Connections Prime even if I am not participating?

If you do not wish to participate as a Healthy Connections Prime provider, you may continue seeing your Healthy Connections Prime enrolled patients as a non-participating provider for up to six months after they enroll in the program. This continuity of care provision is offered to all individuals newly enrolled in a CICO. During the transition period, the member’s CICO will also offer a contract or single-case agreement to non-participating providers.  After the six months, the CICO will work with the member to identify an appropriate provider within the network.

 

During the transition period, members may continue their course of treatment with their current provider(s) at existing service authorization levels. Service authorization levels must be maintained for all direct care home and community based service providers during the transition period, unless a significant change has occurred and is documented in the member’s long term care assessment and/or reassessment.  

 

What counties are included in each wave of passive enrollment?

Please see the chart below for the listing of counties by wave.

 

Wave 1

(Earliest effective date: April 1, 2016)

Wave 2

(Earliest effective date: July 1, 2016)

Abbeville

Anderson

Bamberg

Barnwell

Cherokee

Chester

Edgefield

Fairfield

Greenville

Kershaw

Laurens

Lexington

McCormick

Newberry

Oconee

Pickens

Richland

Saluda

Spartanburg

Union

Allendale

Beaufort

Berkeley

Calhoun

Charleston

Chesterfield

Clarendon

Colleton

Dillon

Florence

Georgetown

Greenwood

Hampton

Jasper

Lee

Marion

Marlboro

Orangeburg

Williamsburg

 

 

Note: Aiken and Dorchester counties areeligible for “choice only” enrollment. Eligible beneficiaries in choice only counties must actively choose to participate and cannot be auto-enrolled into the program. In addition, the following counties are not participating in Healthy Connections Prime: Lancaster, Horry, Darlington, Sumter and York.

 

 

Who do I contact if I have other questions about Healthy Connections Prime?

If you need assistance with helping your patients understand Healthy Connections Prime, please visit www.scdhhs.gov/primefor more information or call SC Thrive at (800) 726-8774 to schedule an in-person education session. 

If you have other questions about Healthy Connections Prime, please visit www.scdhhs.gov/primeor email primeproviders@scdhhs.govfor help with a specific question or concern. 

  
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

Tags: 
Report Fraud