What is Healthy Connections Prime?
Healthy Connections Prime is an enhanced option for South Carolina seniors 65 and older with Medicare and Healthy Connections Medicaid. It is designed to integrate all the services of Medicare, Medicare Part D, and Medicaid into a single set of benefits fully managed by a Coordinated and Integrated Care Organization (CICO). Healthy Connections Prime is a demonstration project jointly administered by the Centers for Medicare and Medicaid Services (CMS) and the South Carolina Department of Health and Human Services (SCDHHS). This program aligns with South Carolina's overall efforts to support the Institute for Healthcare Improvement's IHI Triple Aim.
How is this different from other programs?
Healthy Connections Prime is an enhanced 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 Multidisciplinary Care Team (MDT), 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 6 months while the plan reaches out to out-of-network providers about joining the network)
- Provide data to better understand member circumstances.
- $0 copays for covered prescription drugs, doctor visits, and hospital stays.
- Value-based payment opportunities for better health outcomes (pay for performance).
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 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 I find out more information?
Visit the Provider Frequently Asked Questions (FAQ) page and learn more details about the program and how you can participate. Additionally, you can email PrimeProviders@scdhhs.gov for help with a specific question or concern.
You can also view the interactive e-Learning training module.