South Carolina Hospital Association August 14, 2014

1. South Carolina Hospital Association August 14, 2014

2. WHAT IS PRIME? Healthy Connections Prime is a new option for individuals 65 and older with Medicare and Medicaid. Prime offers all the health care services, fully managed by a coordinated and integrated care organization (CICO). Prime aligns with the Triple Aim and offers: • Better care through a person-centered care model • Better value by focusing on quality and not quantity • Better health for the elderly population

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

4. PRIME

5. 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/

6. ELIGIBILITY Individuals may be eligible for this program if they meet the following criteria: • 65 and older, and • Full benefit dual eligible or • Meeting the above criteria and are enrolled in the following waivers: Community Choices, HIV/AIDS, and Mechanical Ventilation Waiver.

7. ELIGIBILITY SCDHHS will not enroll individuals who: • Elect the hospice benefit • Receive End-Stage Renal Disease services • Reside in a nursing facility Prime enrollees may still access the above services and remain in Prime

8. ELIGIBILITY SCDHHS will not passively enroll individuals with comprehensive health insurance (i.e., Medicare Advantage, PACE or pension coverage) When an active choice to enroll in a CICO is made, disenrollment from existing comprehensive health insurance is triggered

9. TIMELINE Original implementation schedule: July 1, 2014 Revised Timeline: No earlier than January 1, 2015

10. BENEFITS OFFERED 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 facility benefit

11. CARVED-OUT SERVICES Medicaid services carved-out under Medicaid Managed and Medicare Advantage are also carved-out under Prime (i.e., non-medical transportation, adult dental, hospice) Carved-out services will be paid FFS CICOs are responsible for coordinating and fully integrated these services into the individualized care plan

12. CICO CONTACTS Absolute Total Care, Inc. Andrew Cain, Director of Contracting (803) 587-4392 | ancain@centene.com Advicare Dell Jeter (888) 781-4371 | djeter@advicarehealth.com Molina Healthcare of South Carolina, Inc. Brian Jans, VP of Network and Operations (843) 740-1785 | brian.jans@molinahealthcare.com Select Health of South Carolina Kathy Williams, Provider Network Account Executive (843) 746-7499 | kwilliams4@selecthealthofsc.com Network Management Regional Map

13. CICO CICOs currently undergoing readiness determination including review of network adequacy CICOs, CMS and SCDHHs will enter three-way contract • Signed contract will be available on SCDHHS website • SCDHHS will share executive summary next week Prime Hospital workgroup established to address provider concerns and identify best practices for integrated models

14. Capitation Rates

15. CAPITATION RATES CICOs will receive PMPM capitation rates from CMS for Medicare services and SCDHHS for Medicaid services CICOs will then reimburse providers based upon the contract negotiated rates July 1, 2014 – December 31, 2104 Capitation Rates | Link Revised and updated rates will reflect CY2015 benefit period

16. CAPITATION RATES Capitation rates are based upon historical FFS experience Rates are budget neutral prior to application of annual percent savings • Savings percentage is applied to Medicare and Medicaid rate components regardless of whether savings accrue from reducing hospitalizations or reducing nursing facility placements

17. MEDICARE BAD DEBT Payments associated with Medicare bad debt are included baseline estimates for capitation rates Medicare FFS does not reimburse facilities for bad debt associate with Medicare Advantage enrollees Providers will not bill Medicare separately for bad debt

18. MEDICAL EDUCATION Medicare will continue to provide direct (DGME) and indirect (IME) payments to teaching hospitals for approved GME programs Both types of GME payments are calculated using fixed approaches regardless of whether Medicare beneficiaries are in FFS, Medicare Advantageor Prime Medicaid GME and Supplemental Teaching Payments will remain as it is today

19. Managing Care and Managing Cost

20. MANAGING CARE CICOs will offer care coordination services to all enrollees: • To ensure effective linkages and coordination between medical home and other providers and services; and • To coordinate the full range of medical and behavioral health services, preventive services, medications, long term services and supports and other enhanced benefits, as needed.

21. MANAGING CARE At minimum, care coordination will include the following: • Access to a single, toll-free point of contact serving as care coordinator; • Development of an individualized care plan developed by multidisciplinary team; • Disease self-management and coaching; • Medication review, including reconciliation during care transitions;

22. MANAGING CARE At minimum, care coordination will include the following (cont’d): • Utilizing data analysis to measure medical compliance and to develop strategies to influence overall health; • Collaborating with nursing facilities and other providers to promote adoption of evidence-based interventions to reduce avoidable hospitalizations and the management of chronic conditions.

23. MANAGING COSTS CICOs are expected to manage cost through defined care coordination and cost effective alternatives services Increases in primary care, outpatient, behavioral health and home and community based services and decreases in institutional care Reductions in institutional care include ambulatory care sensitive hospital admissions and emergency department visits, other avoidable admissions and readmissions, and nursing facility care

24. Service Alternatives

25. SERVICE ALTERNATIVES Prime allows CICOS to utilize Medicare and Medicaid services in a non-traditional manner Cost effective service alternative are medically appropriate services that optimize patient experience and avoid or delay more costly institutional care

26. 3-DAY QUALIFYING STAY Three-day qualifying hospital stay for nursing facility placement may be waived under Prime, when clinically appropriate TB screening is not waived for nursing facility admissions CICOs must work together with hospitals and nursing facilities to ensure a PPD is administered within 48-hours of discharge

27. HOME CARE SERVICES CICOs may authorize temporary use of services (i.e., home health or personal care) to delay admission to or facilitate transitions from acute care settings CICOs may waive homebound requirements as a prerequisite for home health Authorized use of waiver-like services to delay potential nursing facility placement for enrollees who may not be medically eligible for waiver services

28. PALLIATIVE CARE Focuses on pain management and comfort care Optimizes quality of life of individuals living with serious or chronic illness who may not meet criteria for hospice benefit Services provided earlier in disease progression; may be provided in conjunction with curative therapies Treatment options may be explored while honoring enrollee’s values and preferences

29. CARE TRANSITIONS Goals of care transitions: • To improve transitions from institutional settings to other care settings • To improve quality of care • To reduce readmissions for high risk beneficiaries Effective treatment and transition planning begins at admission to in-patient facility, including acute care, psychiatric hospitals and nursing facilities or presentation at the emergency department

30. CARE TRANSITIONS Treatment and transition planning will include, at minimum: • Establishment of transition planning protocols with network providers that identify a single point of contact for the clinical follow-up once the enrollee is transitioned; • Coordination with facility staff to build upon existing care transition models and to avoid duplication and to assure full integration of services;

31. CARE TRANSITIONS Treatment and transition planning will include, at minimum (cont’d): • Scheduling of transition/aftercare appointments; • Conducting a clinical follow up phone call or home visit within seventy-two (72) hours of transition; and • Medication monitoring using evidence-based protocols, as clinically necessary.

32. Questions?

33. Thank YouPrime Website: http://www.scdhhs.gov/primePrime E-mail Address: prime@scdhhs.gov

34. SOURCES The Henry J. Kaiser Family Foundation. (2013, May 21). 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/ South Carolina Department of Health and Human Services. (2014, July). Healthy Connections Prime Capitation Rate Report (2014). Retrieved from https://msp.scdhhs.gov/SCDue2/sites/default/files/Healthy%20Connections%20Prime%20Capitation%20Rate%20Report%20(2014).pdf