Provider FAQs

Provider FAQs

Healthy Connections Prime has ended. The material reference in this page is designed to help continue answer questions during the program run out period in the event that you may have unresolved claims or billing questions for services rendered prior to December 31, 2025.

What were Healthy Connections Prime Medicare-Medicaid Plans?

Healthy Connections Prime was an enhanced program that allows Coordinated and Integrated Care Organizations (CICO) to offer insurance coverage through Medicare-Medicaid Plans (MMP). The plans combined all of a member's health care and prescription drug benefits under a single set of benefits.

How was this different from Medicare Advantage?

Medicare-Medicaid plans offered a seamless experience for both members and providers. Under Healthy Connections Prime there was no beneficiary coinsurance fees for Medicare Part A and B related services. There was no traditional crossover claims. Provider reimbursement from Medicare-Medicaid Plans constituted payment in full regardless of the type of service.

How was this different from other programs?

Healthy Connections Prime was an enhanced program that offered the following benefits to providers who have dual-eligible patients:

1. One card (verify eligibility/coverage for only one program)
2. One party to bill (no sequential billing - submit claim to one entity, payment comes from one entity)
3. One point of contact regardless of service type (i.e., Medicare, Medicaid, Part D)
4. Coordination of all member medical and non-medical needs
   • Leverage member's integrated care team, including member's care coordinator
   • Address psychosocial needs through community referrals and home and community-based services (e.g., home-delivered meals, support for caregivers, minor home repairs or modifications)
   • Provide continuity of care (new members can keep their existing providers for six months while the plan reaches out to out-of-network providers about joining the network)
   • Provide data to better understand member circumstances
5. Zero-dollar copays for covered prescription drugs, doctor visits and hospital stays
6. Value-based payment opportunities for better health outcomes (pay for performance)

What was covered?

Participating members would receive all of their Medicare, Medicare Part D and Healthy Connections Medicaid coverage from a new plan type called a Medicare-Medicaid Plan.

Members still had access to current services such as:

• Doctor visits
• Hospital care
• Prescription drugs, Medicaid over-the-counter drugs
• Adult dental*
• Durable medical equipment (DME)
• Emergency and non-emergency medical transportation services (NEMT)*
• Nursing home and community long-term care (CLTC)

*Adult dental and non-emergency medical transportation are still covered and are available for members under Healthy Connections Medicaid.

Members also had new benefits such as:

• One health plan;
• One health care card;
• One number to call;
• No insurance premiums and no copays for Medicare Part A and B services;
• A care team;
• A personalized care plan that fits the member's needs; and
• Help transitioning home from the hospital or nursing home

Who was eligible for this program?

In general, individuals who met all of the following criteria would have been eligible for Healthy Connections Prime:

• Age 65 years old or older and live in the community at the time of enrollment;
• Entitled to Medicare Part A and enrolled in Parts B and D;
• Eligible for full Medicaid benefits;
• Not currently in hospice or receiving treatment for end stage renal disease;
• Not living in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or nursing facility

Members who met the above criteria and were enrolled in the Community Choices Waiver, HIV/AIDS Waiver, or Mechanical Ventilator Dependent Waiver were also eligible to enroll.

Was enrollment in Healthy Connections Prime mandatory?

Healthy Connections Prime was a voluntary program. Individuals could have cancelled, disenrolled, or opted out of the program at any time and received their Medicare and Medicaid benefits just like they would normally. Individuals who cancelled, disenrolled, or opted out from Healthy Connections Prime would continue to receive Medicaid services through Healthy Connections Medicaid, and they would continue to have a choice of original Medicare or Medicare Advantage and a prescription drug plan.

As a provider could you have continued to see your patients who joined Healthy Connections Prime even if you were not participating?

Providers were encouraged to join the multiple Healthy Connections Prime networks in order to provide continuous care to existing patients and to be part of the important initiative to coordinate care.

If you did not wish to participate as a Healthy Connections Prime provider, you could have continued seeing your Healthy Connections Prime enrolled patients as a non-participating provider for up to six months after they enrolled in the program. This generous continuity of care provision was offered to all individuals newly enrolled in a Medicare-Medicaid Plan. During the transition period, the Medicare-Medicaid Plan was also offered a contract or single-case agreement to non-participating providers. After the six months, the Medicare-Medicaid Plan would work with the member to identify an appropriate provider within its network.

During the transition period, members could have continued their course of treatment with their current provider(s) at existing service authorization levels. Service authorization levels were maintained for all direct care home and community-based service providers during the transition period, unless a significant change had occurred and was documented in the member's Long Term Care Assessment and/or reassessment.

How did the billing process change under Healthy Connections Prime?

With Healthy Connections Prime, you would bill one entity (the member's plan) and receive payment from one entity (the member's plan). After your claim was processed, you would receive one or two remittance advices and payments, depending on the plan.

Your office would receive one remittance advice and one payment from:

• First Choice VIP Care Plus
• Molina Dual Options

Your office would receive two Remittance Advices and two payments (one representing Medicare services, one representing Medicaid services) from:

• Wellcare Prime by Absolute Total Care

Click on the image below to download our brochure on the claims and payment process.

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

You can email PrimeProviders@scdhhs.gov for help with a specific question or concern

Provider Toolkit

https://www.scdhhs.gov/providers/managed-care/healthy-connections-prime-mmp/provider-information/provider-toolkit