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SCDuE South Carolina Dual Eligible Demonstration. Hospice and the Demonstration Wednesday, July 10, 2013 10am – 11am. Goals For This Session HOSPICE AND THE DEMONSTRATION. To provide an overview of the Demonstration and South Carolina’s health reform strategies for Medicaid;

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scdue south carolina dual eligible demonstration

SCDuESouth CarolinaDual Eligible Demonstration

Hospice and the Demonstration

Wednesday, July 10, 2013

10am – 11am

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

goals for this session hospice and the demonstration
Goals For This SessionHOSPICE AND THE DEMONSTRATION
  • To provide an overview of the Demonstration and South Carolina’s health reform strategies for Medicaid;
  • To describe how the hospice benefit will operate in the Demonstration;
  • To describe the payment structure for hospice providers under the Demonstration; and
  • To identify next steps for care coordination and training discussions.

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

presenters for this session hospice and the demonstration
Presenters For This SessionHOSPICE AND THE DEMONSTRATION

South Carolina Department of Health and Human Services Staff:

  • Teeshla Curtis – Program Manager
  • Sam Waldrep– Senior Advisor
  • Christine Raper – Program Coordinator

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

purpose of scdue demonstration purpose and goals of the demonstration
Purpose of SCDuE DemonstrationPURPOSE AND GOALS OF THE DEMONSTRATION

The Demonstration will provide a new option for older South Carolinians with Medicare and Medicaid. This program will make it easier for consumers to get all the services they need, including all Medicare and Medicaid benefits, fully managed by a single entity.

  • Purpose
    • To integrate and coordinate care for beneficiaries with both Medicare and Medicaid
    • To purchase quality health outcomes through a person-centered model that delivers care at the right time and in the most appropriate setting.

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

purpose of scdue demonstration goals and purpose of the demonstration
Purpose of SCDuE DemonstrationGOALS AND PURPOSE OF THE DEMONSTRATION

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

  • Medicaidservices, including:
    • Behavioral health
    • Home and community based services
    • Nursing facility services
  • Medicare services, including primary care
  • Medicare Part D (prescription drugs)

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

status update
Status Update
  • The SCDuE team is in the process of negotiating the Memorandum of Understanding (MOU) between the State and CMS.
  • The MOU will outline the final details of the Demonstration including changes the State has incorporated since the initial submission of its proposal in May 2012 (i.e., transition of core components of home and community based service authority to the CICOs).
  • Participating health plans will be selected once the MOU is finalized and fully executed.

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

overview background state demonstrations to integrate care for dual eligible individuals
Overview & BackgroundSTATE DEMONSTRATIONS TO INTEGRATE CARE FOR DUAL ELIGIBLE INDIVIDUALS

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

other state demonstration models examples of hospice in approved memorandums of understanding
Other State Demonstration ModelsEXAMPLES OF HOSPICE IN APPROVED MEMORANDUMS OF UNDERSTANDING
  • 5 states have approved MOUs with CMS (capitated model)
  • Virginia: Hospice beneficiaries must disenroll from Demonstration health plans
  • California, Illinois, Massachusetts, and Ohio - Other MOU approved states: Hospice benefit paid under Medicare FFS; beneficiary remains enrolled in participating plan
  • Formal communication/coordination between hospice providers and Demonstration health plans is not detailed in approved MOUs

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

health reform in south carolina
Health Reform in South Carolina

3 Pillar Strategy

Clinical

Integration

Payment

Reform

Hot Spots

&

Disparities

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

scdue enrollment
SCDuE Enrollment
  • Demonstration target population includes full-benefit non-institutionalized dual eligible individuals age 65 and older
  • Excluded populations:
    • Currently residing in nursing facility or other institution
    • Current ESRD (End-Stage Renal Disease) population
    • Currently enrolled in Hospice
    • Enrollees in the Program of All-Inclusive Care for the Elderly (PACE)
    • Members enrolled in Department of Disabilities and Special Needs (DDSN) waivers (undecided)
  • Enrollment in demonstration will have voluntary enrollment followed by passive enrollment

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

scdue enrollment process hospice
SCDuE Enrollment Process - Hospice
  • Persons who have elected the hospice benefit will be excluded from both voluntary and passive enrollment.
  • Demonstration consumers who meet the hospice criteria may elect the hospice benefit without disenrolling.
  • Enrollment and options counseling will be conducted by the state and/or its agent.

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

payment for hospice services in scdue
Payment for Hospice Services in SCDuE
  • CMS determined that Hospice would not be a part of the capitated rate.
  • Hospice will continue to be reimbursed under Medicare FFS. There are no anticipated changes to the rate structure.
  • Health plan will no longer receive Medicare Part C for enrollees who elect the hospice benefit.
  • Health plans (CICOs) are responsible for coordinating all care included in their capitated payment. This includes primary care, nursing facility services, HCBS, behavioral health services and any other benefits offered by the health plan.

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

hospice and waiver services
Hospice and Waiver Services
  • SCDHHS will use the same protocol as is currently followed for Medicaid only beneficiaries and duals who received Medicaid LTC services.
  • Policies regarding duplication and overlap between the hospice benefit and HCBS will remain unchanged regardless of payor (Medicare or Medicaid).
  • A Medicaid bulletin has been drafted for hospice and waiver providers to update overlap information previously communicated and will reflect changes with the addition of waiver and Medicaid state plan services.

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

medicaid hospice diagnoses discussion of the need for care coordination
Medicaid-Hospice DiagnosesDISCUSSION OF THE NEED FOR CARE COORDINATION

What common hospice diagnoses may indicate the need for additional care coordination?

  • What other conditions or diagnoses outside the terminal diagnoses may co-occur?
  • Which of these diagnoses would there be a secondary diagnosis or related condition that would indicate the need for primary care?
  • Example 1: Diabetic with hospice diagnoses of End-Stage Renal Disease
  • Example 2: Consumer with breast cancer with unrelated hip fracture

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

medicaid hospice length of stay 3
Medicaid-Hospice Length of Stay3
  • Average length per span of hospice enrollment (combined community and nursing facility):6.2 months
  • Average length per span of hospice enrollment (community): 3.9 months

With increased care coordination, what is the potential for earlier referral for hospice?

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

health plan care coordination
Health Plan Care Coordination
  • Hospice providers will be financially responsible for benefits covered under the hospice diagnosis.
  • Health plans will be financially responsible for services that are not related to the hospice diagnosis.
  • Health plans will coordinate care with hospice providers.
  • The goal is to avoid the provision of care in silos.

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

hospice health plan communication
Hospice & Health Plan Communication
  • Hospice providers will have a role in CICO’s multidisciplinary team.
  • Formal communication protocol will be developed by SCDHHS with collaboration from hospice associations and selected CICOs.
  • The goal of these communications is to improve end of life care coordination, thereby improving quality of life.

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

scdue consumers and hospice
SCDuE Consumers and Hospice
  • How will this impact consumers?
    • Freedom to choose hospice providers remains
    • Consumers subject to the network of primary care and LTC providers from their CICO
    • Prior authorizations for services applies
    • Ombuds (will monitor trends related to disenrollment from both CICO and Hospice)

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

hospice and demonstration consumers in nursing facilities
Hospice and DemonstrationCONSUMERS IN NURSING FACILITIES
  • There is a strong need for better care coordination between primary care and long term care
  • Hospice team will be included in the Demonstration’s Multidisciplinary Team (MDT)
  • Hospice will continue to share information with nursing facility about patient prognosis or decline
  • Avoidance of unncessary hospital re-admissions and/or emergency department admissions is a shared goal
  • CMS Federal Register Notice | Link2

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

hospice and demonstration consumers in assisted living in patient settings
Hospice and DemonstrationCONSUMERS IN ASSISTED LIVING & IN-PATIENT SETTINGS
  • The DHEC Level of Care Waiver policy (08/31/09) remains in effect1
  • SCDHHS has an assisted living waiver service pending CMS approval
  • IPC is no longer a service effective 7/1/13; service is replaced by Optional Supplemental Care for Assisted living Participants service (OSCAP)
  • In-patient criteria and FFS reimbursement will remain unchanged

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

palliative care demonstration benefit
Palliative CareDEMONSTRATION BENEFIT
  • Palliative care is a Demonstration-only service to be offered in South Carolina’s plan benefit package (PBP).
  • This service will focus on pain management and comfort care.
  • Other services such as medications or DME must be accessed through the Medicare-Medicaid benefit.
  • CICOs will establish a network of providers.
  • The addition of this service is considered a component of the end-of-life continuum.
  • The Demonstration will test cost-effectiveness of this new Medicaid-sponsored benefit while improving quality of life.
  • Benefit can be offered by qualified provider (e.g., hospice agency or other entity meeting qualifications) for persons in the community, NFs, and ALFs.

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

next steps
Next Steps

Hospice - CICO Forum

Submit any questions to scdue@scdhhs.gov

SCDHHS will compile FAQs to share with hospice providers and stakeholders.

Frequently Asked Questions

  • This will occur after CICOs are selected.
  • The forum will be held to:
    • Discuss communication and coordination of care; and
    • Educate CICOs about the end-of-life care, hospice benefit and the palliative care service.

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

questions
Questions?

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

slide28

Thank You

Special Thank You to the Carolinas Center for Hospice

and End of Life Care and Heather Jones for their support of this

training session regarding Hospice and the Demonstration

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

contact information
Contact Information

Nicole Mitchell-Threatt

Andrew Lowder

Medicaid-Hospice

SC Dept. of Health & Human Services

1801 Main Street

Columbia, SC 29201

(803) 898-2590 | Office

(803) 255-8209 | Fax

mitcheln@scdhhs.gov

andrew.lowder@scdhhs.gov

________________________________

SCDuE Website

http://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

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

sources
Sources
  • Department of Health and Environmental Control [DHEC]. Level of care waiver. Retrieved from http://www.scdhec.gov/health/licen/PS-R084-20090831.pdf
  • Federal Register. (2013, June 27). Medicare and Medicaid programs: Requirements for long term care facilities; hospice services. Retrieved from https://www.federalregister.gov/articles/2013/06/27/2013-15313/medicare-and-medicaid-programs-requirements-for-long-term-care-facilities-hospice-services
  • The Carolinas Center for Hospice and End of Life Care. (2013, June 20). 2012 calendar year South Carolina hospice data & trends.
  • 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/

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