Scdue south carolina dual eligible demonstration
1 / 39

SCDuE South Carolina Dual Eligible Demonstration - PowerPoint PPT Presentation

  • Uploaded on

SCDuE South 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. GOALS FOR THIS SESSION.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about ' SCDuE South Carolina Dual Eligible Demonstration' - laurence-lemaitre

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Scdue south carolina dual eligible demonstration
SCDuESouth Carolina Dual Eligible Demonstration

Integrating Care for Medicare-Medicaid Enrollees

Tuesday, October 15, 2013


Presenters: Teeshla Curtis, Program Manager;

Sam Waldrep, Senior Consultant; and

Dr. Michael Musci


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


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


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


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.

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


Chronic Disease Prevalence by Enrollment Group

Source: Centers for Medicare & Medicaid Services. (n.d.). Medicare-Medicaid enrollee state profile. Retrieved from


Source: Centers for Medicare & Medicaid Services. (n.d.). Medicare-Medicaid enrollee state profile. Retrieved from


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.



  • 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

  • Status update and overview


    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.

    Healthy Connections Mission: FEE-FOR-SERVICE MEDICAID-FUNDED LTSS…to purchase the most health for our citizens in need at the least possible cost to the taxpayer.

    Health reform in south carolina
    Health Reform in South Carolina FEE-FOR-SERVICE MEDICAID-FUNDED LTSS

    3 Pillar Strategy





    Hot Spots



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

    CURRENT SYSTEM living disabilities.”


    Not Coordinated


    Difficult to Navigate

    Not Focused on the Individual

    Gaps in Care

    INTEGRATED CARE living disabilities.”

    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

    PERSON-CENTERED living disabilities.”

    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

    PERSON-CENTERED living disabilities.”

    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.

    Care coordination
    Care Coordination living disabilities.”

    CARE COORDINATION living disabilities.”

    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

    CARE COORDINATION living disabilities.”

    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

    CARE COORDINATION living disabilities.”

    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.

    Provider reimbursement structure
    Provider Reimbursement Structure living disabilities.”

    RATE STRUCTURE living disabilities.”

    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

    PAYMENTS living disabilities.”

    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

    Eligibility and enrollment
    Eligibility and Enrollment living disabilities.”

    Overview & Background living disabilities.”

    The Henry J. Kaiser Family Foundation. (2013, August 1). State demonstration proposals to integrate care and align financing for dual eligible beneficiaries. Retrieved from

    ELIGIBILITY OVERVIEW living disabilities.”

    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.

    ENROLLMENT living disabilities.”

    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

    NEXT STEPS living disabilities.”

    Signing of MOU

    Release of Demonstration name

    New SCDuE website launch

    Provider forums – November 2013

    Start of Readiness Review Process

    NEXT STEPS living disabilities.”

    Integrated Care Workgroup Meeting

    Thursday, October 17

    10am – 12noon

    Lexington Richland Alcohol and Drug Abuse Council (LRADAC)

    2711 Colonial Drive, Columbia, SC 29203

    Questions living disabilities.”?

    Thank you
    Thank You living disabilities.”

    CONTACT INFORMATION living disabilities.”

    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

    [email protected]


    SCDuE Website

    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

    [email protected]


    SCDuE E-mail Address

    [email protected]