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Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared – Appendix – South Carolina – 8426-06 « » The Henry J. Kaiser Family Foundation

Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS

South Carolina

MOU Signed: Oct. 25, 2013
3-way contract not yet available
Demonstration Duration: 3 years
July 1, 2014 to Dec. 31, 2017
Target Group: Includes:  an estimated 53,600 full benefit dual eligible beneficiaries ages 65 and older who reside in the community at the time of enrollment (includes Community Choices (elderly/disabled) waiver, HIV/AIDS waiver, and Mechanical Ventilation waiver participants) are eligible to enroll; Medicare Advantage and PACE enrollees may enroll in the demonstration if they disenroll from their current program; beneficiaries who transition from an ICF/DD or nursing facility to the community may elect to enroll and also may be eligible for passive enrollment; beneficiaries already enrolled in the demonstration who later enter a nursing facility or hospice program or begin receiving ESRD services may remain in the demonstration

  dual eligible beneficiaries with other comprehensive coverage, residents of an ICF/DD or nursing facility and beneficiaries receiving hospice or ESRD services at the time of demonstration eligibility determination, those on a Medicaid spend down, and those receiving Medicaid HCBS through a waiver other than the 3 listed above
Geographic Area: Statewide, divided into two regions:

-Region 1/Upstate:  Abbeville, Aiken, Anderson, Bamberg, Barnwell, Cherokee, Chester, Edgefield, Fairfield, Greenville, Kershaw, Lancaster, Laurens, Lexington, McCormick, Newberry, Oconee, Pickens, Richland, Saluda, Spartanburg, Union, and York counties

-Region 2/Coastal:  Allendale, Beaufort, Berkeley, Calhoun, Charleston, Chesterfield, Clarendon, Colleton, Darlington, Dillon, Dorchester, Florence, Georgetown, Hampton, Horry, Jasper, Lee, Marion, Marlboro, Orangeburg, Sumter, and Williamsburg counties
Enrollment: Initial enrollment period is voluntary, followed by three passive enrollment periods in which the remaining beneficiaries in the target population will be automatically enrolled

Voluntary enrollment will begin no sooner than July 1, 2014 and extend through Dec. 31, 2014.  Passive enrollment will be phased in as follows:  enrollment effective Jan. 1, 2015 for beneficiaries in the Upstate Region (Region 1) who are not served through HCBS waivers; enrollment effective March 1, 2015 for beneficiaries in the Coastal Region (Region 2) who are not served through HCBS waivers; and enrollment effective May 1, 2015 for beneficiaries statewide who receive HCBS waiver services.  Beneficiaries subject to Medicare reassignment effective Jan. 1, 2015 will be eligible for passive enrollment no earlier than Jan. 1, 2016.  Beneficiaries will receive enrollment notices 60 days and 30 days prior to passive enrollment

Beneficiaries may opt out of the demonstration until the last day of the month prior to enrollment and thereafter on a monthly basis

South Carolina must submit a § 1932 Medicaid state plan amendment and concurrent authority for the 3 affected § 1915(c) waivers prior to Jan. 1, 2014

Passive enrollment will be based on an “intelligent assignment” algorithm that will consider existing provider relationships, including HCBS providers; previous history with another Medicare Advantage or Medicaid managed care plan within the past year; household members currently assigned to a demonstration plan; and relative case mix of each demonstration plan
Financing: Capitated with savings percentage (1% in year one, 2% in year two, 4% in year three) applied upfront to baseline Medicare and Medicaid contributions; capitation rate qualify withhold same as in California (1% in year 1, 2% in year 2, 3% in year 3); the state and health plans will provide financial incentives to providers that achieve NCQA patient centered medical home certification

Plans may receive up to $3,000 per enrollee as a one-time enhanced transition coordination fee for successfully moving a beneficiary from a nursing facility to the community for at least 12 months through SC’s Money Follows the Person program.
Medicare baseline for capitated payments:  Same as California1
Medicare risk adjustment:  Same as California
Medicaid baseline for capitated payments:  Historical state FFS spending for state plan and HCBS waiver services trended forward
Medicaid risk adjustment: Rating categories with financial incentive for 90 days following transition to community from nursing facility and financial penalty for 90 days following transition from community to nursing facility2
Risk sharing: MLR of 85% required beginning in CY 2015
Care Delivery Model: Coordinated and Integrated Care Organizations (CICOs) must offer providers that are medical homes and will offer care coordination of medical and behavioral health, preventive services, prescription drugs, LTSS, social supports, and enhanced benefits.

The HCBS waiver case manager will be a member of the multidisciplinary care team, responsible for advocating for LTC in the care coordination process.

HCBS authority will be transitioned from the state to plans over the course of the demonstration:  in phase I (July 1 to Dec. 31, 2014), the state will maintain contractual relationships with HCBS providers, and plans will receive payment for those services and process provider payments.  The state will develop the waiver care plan and recommended service authorizations with concurrence by the plan in a three-way conference between the state reviewer, waiver care manager, and plan designee.  If there is disagreement, the plan may request review from the demonstration ombudsman which has authority to make a final decision.  The waiver case manager will work with the plan care coordinator to integrate HCBS into the single overall care plan.  In phase II (2015), plans that have completed the benchmark review will assume responsibility for case management services and most HCBS.  Plans will perform LOC reassessments, contract with HCBS providers, set provider rates subject to state minimum levels, develop HCBS care plans and service authorizations with state concurrence, and subcontract with the University of SC’s Center for Disability Resources for self-direction services.  In phase III (2016), plans that have completed the final benchmark review will assume all responsibility needed to adequately coordinate HCBS, including self-direction, and may elect to assume responsibility for provider credentialing and monitoring.  A readiness review will precede each phase.
Participating Health Plans: Absolute Total Care, Advicare, Molina Healthcare of South Carolina, Select Health of South Carolina, WellCare Health Plans3
Benefits: Plans will provide all Medicare and Medicaid benefits, other than Medicare hospice.  Includes home and community-based waiver services for Community Choices (elderly/disabled), HIV/AIDS, and Mechanical Ventilation waivers. All enrollees who meet the level of care criteria for HCBS will access waiver services without a waiting list

Plans must provide a new palliative care benefit for enrollees with a serious, chronic or life-threatening illness who may not meet hospice criteria.  Plans have discretion to offer flexible benefits as appropriate to beneficiary needs
Continuity of Care: Beneficiaries must be able to maintain a current course of treatment with an out-of-network provider, including behavioral health and LTSS, and must maintain current service authorization levels for all direct care waiver services during a 180 day transition period unless significant change has occurred and is documented during the LTC LOC assessment.
Ombuds Program: State intends to support an independent ombuds program outside of the state Medicaid agency to advocate and investigate on behalf of demonstration enrollees, safeguard due process, identify systematic problems, and provide arbitration between the state and plans as needed during the HCBS transition
Stakeholder Engagement: Same as California
Appeals: Notice:  Same as California (single integrated notice)

Timeframe to request initial appeal:
  Same as Illinois (60 days)

Internal health plan appeal:
  Same as Illinois (initial appeal must be filed with health plan) except that expedited appeals are to be resolved within 72 hours

External Medicare appeals:
  same as California except that Office of Medicare Hearing and Appeals review not mentioned in MOU

External Medicaid appeals:
  Same as Illinois except that beneficiary has 30 days from internal appeal decision to request fair hearing for Medicaid-only services and expedited appeals are to be resolved within 72 hours

Appeals where Medicare and Medicaid services overlap:
  if plan upholds denial of overlapping Medicare-Medicaid services, appeal will be automatically forwarded to IRE.  Beneficiary then has 30 days from notice of right to fair hearing following IRE adverse disposition to request fair hearing for Medicare-Medicaid overlapping services.

Continued benefits pending appeal: 
Medicare services will be required to continue pending resolution of internal plan appeal.  Medicaid services and Medicare-Medicaid overlapping services will continue pending internal plan appeal if internal plan appeal is filed within 10 days of notice.  Medicaid services continue pending fair hearing disposition if fair hearing is requested within 10 days of internal appeal decision.  Medicare-Medicaid overlapping services continue pending IRE decision and then during subsequent fair hearing if requested within 10 days.

Medicare Part D appeals:
  Same as California (existing Medicare Part D appeals process continues to apply)


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