What is a Healthy Connections Prime Medicare-Medicaid Plan?
Healthy Connections Prime is an ehanced program that allows Coordinated and Integrated Care Organizations (CICO) to offer insurance coverage through Medicare-Medicaid Plans (MMP). The plans combine all of a member's health care and prescription drug benefits under a single set of benefits.
How is this different from Medicare Advantage?
Medicare-Medicaid plans offer a seamless experience for both members and providers. Under Healthy Connections Prime there are no beneficiary coinsurance fees for Medicare Part A and B related services. There are no traditional crossover claims. Provider reimbursement from Medicare-Medicaid Plans constitute payment in full regardless of the type of service.
How is this different from other programs?
Healthy Connections Prime is an ehanced program that offers the following benefits to providers who have dual-eligible patients:
- One card (verify eligibility/coverage for only one program)
- One party to bill (no sequential billing - submit claim to one entity, payment comes from one entity)
- One point of contact regardless of service type (i.e., Medicare, Medicaid, Part D)
- 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
- Zero-dollar copays for covered prescription drugs, doctor visits and hospital stays
- Value-based payment opportunities for better health outcomes (pay for performance)
What is covered?
Participating members will receive all of their Medicare, Medicare Part D and Healthy Connections Medicaid coverage from a new plan type called a Medicare-Medicaid Plan.
Members will still have 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 will also have 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 is eligible for this program?
In general, individuals who meet all of the following criteria will be 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 meeting the above criteria and enrolled in the Community Choices Waiver, HIV/AIDS Waiver, or Mechanical Ventilator Dependent Waiver are also eligible to enroll.
How can individuals enroll in Healthy Connections Prime?
Potential members will receive notification about their enrollment options. Individuals can then contact South Carolina Healthy Connections Choices at (877) 552-4642, TTY: 711) to speak with an enrollment counselor Monday through Friday from 8 a.m. - 6 p.m. TTY users should call (877) 552-4670.
If an eligible members does not choose a particular Medicare-Medicaid Plan, SCDHHS will take into consideration the most frequently used providers, family relationships and previous coverage in order to pick a Medicare-Medicaid Plan for the eligible member. If they want to switch to a different plan, they can call South Carolina Healthy Connections Choices at the number listed above.
Is enrollment in Healthy Connections Prime mandatory?
Healthy Connections Prime is a voluntary program. Individuals can cancel, disenroll, or opt out of the program at any time and receive their Medicare and Medicaid benefits just like they do today. Individuals who cancel, disenroll, or opt out from Healthy Connections Prime will continue to receive Medicaid services through Healthy Connections Medicaid, and they will continue to have a choice of Original Medicare or Medicare Advantage and a prescription drug plan.
How can my patients get help understanding their coverage options under Healthy Connections Prime?
Help with understanding coverage options is available for all potential enrollees. Please visit the member section of the website for more information or call SC Thrive at (800) 726-8774, Monday - Friday, 8:30 a.m. - 5 p.m. to schedule an education session. TTY users call 711. This call is free.
Can I continue to see my patients who join Healthy Connections Prime even if I am not participating?
Providers are encouraged to join the multiple Healthy Connections Prime networks in order to provide continuous care to existing patients and to be part of this important initiative to coordinate care.
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 generous continuity of care provision is offered to all individuals newly enrolled in a Medicare-Medicaid Plan. During the transition period, the Medicare-Medicaid Plan will also offer a contract or single-case agreement to non-participating providers. After the six months, the Medicare-Medicaid Plan will work with the member to identify an appropriate provider within its 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 will 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.
How can I, or my patients, find out which providers are in each health plan's network?
Refer to the online searchable provider directories or the printed directories for each plan:
- Wellcare Prime by Absolute Total Care: Provider Directory
- First Choice VIP Care Plus: Provider Directory
- Molina Dual Options: Provider Directory
How does my billing process change under Healthy Connections Prime?
With Healthy Connections Prime, you bill one entity (the member’s plan) and receive payment from one entity (the member’s plan). After your claim is processed, you will receive one or two remittance advices and payments, depending on the plan.
Your office will receive one remittance advice and one payment from:
- First Choice VIP Care Plus
- Molina Dual Options
Your office will 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.
How do I join a Healthy Connections Prime provider network?
Providers are encouraged to join the multiple Healthy Connections Prime networks in order to provide continuous care to existing patients and to be part of this important initiative to coordinate care. Please contact the representatives listed on the Plan Contact information page to learn more about how you can become a Healthy Connections Prime network provider.
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