SCDuE South Carolina Dual Eligible Demonstration

1. SCDuESouth Carolina Dual Eligible Demonstration Integrating Care for Medicare-Medicaid Enrollees Tuesday, October 15, 2013 4pm Presenters: Teeshla Curtis, Program Manager; Sam Waldrep, Senior Consultant; and Dr. Michael Musci

2. GOALS FOR THIS SESSION To provide an overview of the South Carolina Department of Health and Human Services’ (SCDHHS) South Carolina Dual Eligible Demonstration (SCDuE) To describe how the Demonstration aligns with South Carolina’s health reform strategies for clinical integration

3. History and Background

4. HISTORY Medicare and Medicaid programs signed into law July 30, 1965 1965 “three-layer cake” – Medicare Part A hospital services; Medicare Part B physician and other outpatient services; and Medicaid expanding federal support for health care services for poor elderly, disabled, and families with dependent children Not initially designed to integrate and coordinate services for individuals served by both program

5. HISTORY During the first year of Medicare, superior health care has been provided for millions of aged Americans, and health standards have been raised for all Americans. This has come about because of cooperation between the federal government, physicians, insurance carriers, and the states. It would not have been possible without the strong support of each of these groups. We have forged a partnership for a healthier America. Statement By the President on the First Anniversary of Medicare – July 1, 1967

6. DUAL ELIGIBLES 10.2 million Americans are eligible for Medicare and Medicaid (known as Medicare-Medicaid enrollees or “dual eligibles”) 7.4 million are “full duals” 17.7% increase, from 8.6 million to 10.2 million between 2006 and 2011 (One in five Medicare enrollees) In comparison, the number of Medicare-only beneficiaries grew by only 12.5% Sources: Data Analysis Brief Medicare-Medicaid Dual Enrollment from 2006 through 2011, Prepared by Medicare-Medicaid Coordination Office, February 2013.

7. The face of South Carolina’s Medicare-Medicaid enrollees 65+ is: 75% Female51% African-American1-2 chronic conditionsMost common conditions: diabetes and heart disease75% not using LTSS Source: Centers for Medicare & Medicaid Services. (n.d.). Medicare-Medicaid enrollee state profile. Retrieved from http://www.integratedcareresourcecenter.com/PDFs/StateProfileSC.pdf

8. STATE PROFILE Chronic Disease Prevalence by Enrollment Group Source: Centers for Medicare & Medicaid Services. (n.d.). Medicare-Medicaid enrollee state profile. Retrieved from http://www.integratedcareresourcecenter.com/PDFs/StateProfileSC.pdf

9. FULL BENEFIT MEDICARE-MEDICAID ENROLLEES’ USE OF FEE-FOR-SERVICE MEDICAID-FUNDED LTSS Source: Centers for Medicare & Medicaid Services. (n.d.). Medicare-Medicaid enrollee state profile. Retrieved from http://www.integratedcareresourcecenter.com/PDFs/StateProfileSC.pdf

10. PURPOSE OF SCDUE This Demonstration will provide a new health care option for South Carolina’s seniors with both Medicare and Medicaid. This program will make it easier for Medicare-Medicaid enrollees to receive all Medicare and Medicaid services through a single entity that is accountable for the quality and cost of these services. The Demonstration proposes: • To integrate and coordinate care for beneficiaries with both Medicare and Medicaid; and • To purchase quality health outcomes through a person-centered model that delivers care at the right time and in the most appropriate setting.

11. PURPOSE OF SCDUE Goals • Improve health outcomes • Delay the need for nursing facility care • Reduce avoidable emergency department visits and hospital readmissions • Increase access to home and community based services Covered Services • Medicaid services, including: • Behavioral health • Home and community based services • Nursing facility services • Medicare services, including: • Primary and acute care • Part D (prescription drugs) • Skilled nursing facilities

12. Status Update and Overview

13. STATUS UPDATE The SCDuE team is in the process of finalizing the Memorandum of Understanding (MOU) between the State and CMS. The MOU will outline the operational details of the Demonstration including changes the State has incorporated since the initial submission of its proposal in May 2012. Participating health plans will be selected later this fall.

14. Healthy Connections Mission:…to purchase the most health for our citizens in need at the least possible cost to the taxpayer.

15. Health Reform in South Carolina 3 Pillar Strategy Clinical Integration Payment Reform Hot Spots & Disparities

16. https://msp.scdhhs.gov/scdue/

17. https://msp.scdhhs.gov/scdue/

18. https://msp.scdhhs.gov/scdue/

19. “At the core of our mission are seniors and persons with living disabilities.”- Anthony Keck, SCDHHS Director

20. CURRENT SYSTEM Fragmented Not Coordinated Complicated Difficult to Navigate Not Focused on the Individual Gaps in Care https://msp.scdhhs.gov/scdue/

21. INTEGRATED CARE One set of comprehensive benefits: primary & acute care , prescription drug, and long-term supports and services One ID card Single and coordinated care team Health care decisions based on beneficiary needs and preferences Provide flexible, non-medical benefits that help individuals stay in the community

22. PERSON-CENTERED Improve both the quality of care and the quality of life Foster patient-provider communication and relationships Enhance health literacy to support informed decision making Participant’s strengths, capacities, preferences, and personal outcomes are identified and documented

23. PERSON-CENTERED I decide where and with whom I live. I make decisions regarding my supports and services. I work or do other activities that are important to me. I have relationships with family and friends I care about. I decide how I spend my day. I am involved in my community. My life is stable. I am respected and treated fairly. I have privacy. I have the best possible health. I feel safe. I am free from abuse and neglect. Source: (Ingram, 2013). Integrated Care Transformation: State Accomplishments, Challenges and Opportunities for the Future [PowerPoint Slides]. Improving New Systems of Innovation for Dual Eligibles.

24. Care Coordination

25. CARE COORDINATION Patient Center Medical Home model, lead by primary care provider Multidisciplinary team structure with provider input and/or direct involvement Transition planning (e.g., transitions between acute care settings and the community or nursing facilities) Bi-directional communications between health plans and providers Person-centered approach

26. CARE COORDINATION Universal Assessment Tool Individualized care plan involving participant and/or her caregiver Designated care coordinator linking participant, PCP, family/caregiver ensuring care coordination and the communication of barriers and needs

27. CARE COORDINATION Access to a single, toll-free point of contact for all questions; Development of an Individualized Care Plan that is periodically reviewed and updated; Disease self-management and coaching; and Medication review, including reconciliation during transitions of care setting.

28. Provider Reimbursement Structure

29. RATE STRUCTURE Blended capitation rate: Medicare Part A, Part B, Part D, Medicaid Medicaid Rate Cells • Nursing Facility • Home and Community Base Services Plus • Home and Community Base Services • Community

30. PAYMENTS Provider reimbursements negotiated by provider with contracted health plans Pay for Performance Care transition related incentives Reimbursements should not be identical to FFS model Shared goals based on outcomes

31. Eligibility and Enrollment

32. Overview & Background The Henry J. Kaiser Family Foundation. (2013, August 1). State demonstration proposals to integrate care and align financing for dual eligible beneficiaries. Retrieved from http://kff.org/medicaid/fact-sheet/state-demonstration-proposals-to-integrate-care-and-align-financing-for-dual-eligible-beneficiaries/

33. ELIGIBILITY OVERVIEW Demonstration population inclusion criteria: • Individuals 65 years and older • Full-benefit dual eligible • Individuals receiving Home and Community Based Services (HCBS) waivers (i.e., HIV, Vent, and Community Choices) Excluded populations (at time of enrollment): • Residing in a nursing facility; • Enrolled in hospice; • Receiving End-Stage Renal Disease (ESRD) services; • Enrolled in a Program of All-Inclusive Care for the Elderly (PACE); or • Enrolled in Department of Disabilities and Special Needs (DDSN) operated waiver serving adults (ID/RD, HASCI, and Community Supports). Enrollment includes an opt-in period following by passive enrollment. The Demonstration is voluntary; beneficiaries can opt-out as well as change plans at any time.

34. ENROLLMENT Opt-in statewide enrollment: July 1, 2014 - December 31, 2014 Passive enrollment: Wave 1 – January 1, 2015 Wave 2 – March 1, 2015 Wave 3 – May 1, 2015

35. NEXT STEPS Signing of MOU Release of Demonstration name New SCDuE website launch Provider forums – November 2013 Start of Readiness Review Process

36. NEXT STEPS Integrated Care Workgroup Meeting Thursday, October 17 10am – 12noon Lexington Richland Alcohol and Drug Abuse Council (LRADAC) 2711 Colonial Drive, Columbia, SC 29203

37. Questions?

38. Thank You

39. CONTACT INFORMATION Nathaniel J. Patterson, MHA Director, Health Services SC Dept. of Health & Human Services 1801 Main Street Columbia, SC 29201 (803) 898-2018 | Office (803) 255-8209 | Fax pattnat@scdhhs.gov ________________________________ SCDuE Website https://msp.scdhhs.gov/scdue/ Teeshla Curtis SCDuE Program Manager SC Dept. of Health & Human Services 1801 Main Street Columbia, SC 29201 (803) 898-0070 | Office (803) 255-8209 | Fax curtist@scdhhs.gov ________________________________ SCDuE E-mail Address scdue@scdhhs.gov