PowerPoint Presentation

South Carolina Healthy Connections Choices

Helping Your Patients Make the Most of Their Medicaid Benefits#Good morning. My name is Tom Dalik and I am a Sr. Provider Representative for South Carolina Healthy Connections Choices, the enrollment broker for South Carolinas Medicaid program. Thank you all for coming today.

The purpose of this training is to equip you to help your patients make the most of their Medicaid Benefits. Patients trust their doctor and often turn to their doctors office for help navigating the healthcare system. We want to equip you to help themUnderstand the program and the benefits it offersUnderstand the enrollment process and timeline and how to enrollSo members canAccess available preventive and primary care services to ensure regular care and early detection of health issues, andAccess health management and other programs to help them manage and improve their overall health

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AgendaOverview of South Carolina Healthy Connections and South Carolina Healthy Connections ChoicesBenefits of Joining a Health PlanSouth Carolina Healthy Connections Choices GoalsReview the Health Plan Enrollment ProcessYour Role in the Enrollment ProcessQuestionsSC Healthy Connections Choices

#The Agenda for our presentation today will be >>To Overview South Carolina Healthy Connections and South Carolina Healthy Connections Choices>>To Show the Benefits of Joining a Health Plan>>To Discuss the Goals of South Carolina Healthy Connections Choices>>To Review the Health Plan Enrollment Process>>To Look at the Role You Can in the Enrollment Process and How You Can Help>>To Answer any Questions you may have about the enrollment process

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South Carolina Healthy Connections is South Carolinas Medicaid program.

Currently there are just under one million members in SCHC (2/2013).

In SC Healthy Connections there are three Medicaid Eligibility CategoriesAssignable (Managed Care Only)Regular Medicaid (Fee-for-Service) Non-Assignable (can choose to be in Managed Care or regular Medicaid)

SCHCC is the part of SCHC that helps Medicaid members in choosing a managed care health plan.

SCHCC serves Medicaid members in the Assignable and Non-Assignable Eligibility Categories.

835k Medicaid members are eligible for Managed Care participation (7/2013)

637k of those are enrolled in a Health PlanSouth Carolina Healthy Connections (SCHC)South Carolina Healthy Connections Choices (SCHCC)

Overview of SC Healthy Connections Choices#What is South Carolina Healthy Connections? >>South Carolinas Medicaid program is called South Carolina Healthy Connections. >>Currently there are just under 1 million members in SCHC. That represents:>>21% of South Carolinians, >>Over 45% of all children in SC and >>and over half of all births in SC

>>When someone is determined to be eligible for Medicaid, they are placed into one of three Eligibility Categories:

>>The largest eligibility category is Managed Care Assignable. If someone is in this category, they are required to participate in a Medicaid Managed Care Health Plan. Managed Care health plans that offers the same services traditional fee-for-service provides as well as additional services and benefits (different drug formularies).

>>The second category is Regular Medicaid This is the traditional Medicaid model. Patients use services as needed, not necessarily in a coordinated way. However, there are some definitive drawbacks to this model.It is difficult for patient to navigate the complex health system, services, and specialists and there is greater possibility for duplication of services and unnecessary use of ER,This results in higher costs and inefficient care Because of these drawbacks, typically only members who have long term health care needs and some members in short term waiver programs fall into this category.

>>The last category is Managed Care Non-Assignable this means members can choose to be in either a Managed Care Health Plan or in regular Medicaid.

>>What is South Carolina Healthy Connections Choices? >> South Carolina Healthy Connections Choices is a program within SC Healthy Connections that assists Medicaid members in choosing and enrolling into a managed care health plan.

>>SCHCC serves Medicaid members in the Assignable and Non-Assignable Eligibility Categories.

>>Approx. 835k members are eligible to participate in a Managed Care Health Plan (7/2013)

>>637k of those are enrolled in a Managed Care Health PlanNext Slide

Benefits of Health Plans

Some of the benefits of being in a health plan are:Members have a medical home that provides accessible, comprehensive, family-centered care led by a primary care physician who knows them and their medical history.The same core services as regular Medicaid plus they have access to additional and enhanced services.Greater access to preventive and primary care services. An ally to help them navigate the complex medical system providing better coordination of care, including finding the appropriate specialist when one is needed. Improved understanding of how to access services and the appropriate use of the emergency room.Access to a live voice 24 hours a day, 7 days a week.

As a results members have:Better health care and health outcomesGreater investment in their own health careOther BenefitsReduced use of the emergency room for non-emergenciesLower overall costs by reducing acute medical care and disease-related conditions#Some of the benefits of being in a health plan are:>>Members have a medical home that provides accessible, comprehensive, family-centered care led by a primary care physician who knows them and their medical history.The Medical Home terminology is often misunderstood by members and can cause confusion. However, it is a very important concept. In the simplest terms a Medical Home is the primary care doctor a patient goes to for well visits and when you are sick. Many of the health centers here today are already certified patient-centered medical homes or will be one soon.When a member has a relationship with a primary care doctor, the doctor can deliver more effective and consistent care, arrange and track any additional services needed, and help manage chronic conditions. >>The same core services as regular Medicaid plus they have access to additional and enhanced services.As mentioned, health plans offer an array of additional services that help keep the members healthy such as health management programs - like Asthma, Diabetes, Hypertension, COPD (Chronic obstructive pulmonary disease), and CHF (congestive heart failure), as well as Prenatal and postpartum care programs. Some also offer Gift cards for meeting specific wellness criteria, Discounts on fitness programs and weight-loss programs, and/or Adult dental and vision services. >>Greater access to preventive and primary care services. A medical home doctor not only has office hours that make them more accessible than the traditional Monday through Friday 9-5 schedule, but they also actively outreach to health plan members to remind them that they are due for preventive and wellness visits. >>An ally to help them navigate the complex medical system providing better coordination of care, including finding the appropriate specialist when one is needed. Figuring out which specialist to go to and how to coordinate care can be complicated. With a medical home doctor and a health plan that help coordinates care, members are able to get the right health services they need at the right time. >>Improved understanding of how to access services and the appropriate use of the emergency room.Because we educate beneficiaries how to access services during the enrollment process and health plans promote those services, members can take greater advantage of the services that health plans offer.>>Access to a live voice 24 hours a day, 7 days a week.Health plans and medical home doctors both have nurses and other staff available 24 hours a day, 7 days a week to help health plan members with their questions and concerns when they are needed.>>As a result, members have: Better health care and health outcomes Greater investment in their own health care>> Other Benefits include Reduced use of the emergency room for non-emergencies Lower healthcare costs by reducing acute medical care & disease-related conditionsNext Slide

SC Healthy Connections Health Plans

Absolute Total Care803-933-3638Advicare (formerly PPC)888-781-4371BlueChoice Medicaid Health Plan800-327-3183, ext. 25151First Choice by Select Health843-569-4872South Carolina Solutions888-793-0006WellCare(Effective 9/1/2013)888-588-9842Health Plans after the Transition from MHNs to MCOs is CompleteCurrent Health PlansMCOsAbsolute Total CareBlueChoice Medicaid Health PlanFirst Choice by Select HealthUnited Healthcare Community PlanMHNsCarolina Medical HomesPalmetto Physician ConnectionsSouth Carolina Solutions#>>In SC Medicaid Managed Care there are currently two types of health plans >>Managed care organizations (MCOs) and Medical home networks (MHNs)SCDHHS has asked all MHN Health Plans to convert to an MCO model by the end of 2013, so we will only discuss issues based upon the MCO structure today.

>>There are currently 4 MCOs and 3 MHNsMCOs: Absolute Total Care, BlueChoice Medicaid Health Plan, 1st Choice by Select Health, & United Healthcare Community Plan.MHNs: Carolina Medical Homes, Palmetto Physician Connections, & South Carolina Solutions

>> When the transition from MHNs to MCOs is complete, their will be six MCOsAbsolute Total Care, Advicare (formerly PPC), BlueChoice Medicaid Health Plan, First Choice by Select Health, South Carolina Solutions, and WellCare (effective 9/1/2013). * Carolina Medical Homes membership was purchased by WellCare and will be moved to that HP later this year.

As mentioned earlier, all Managed Care Health Plans offer the same core services as the traditional fee-for-service Medicaid, AND they also offer additional services and benefits like health management programs, care coordination, and they promote prevention services to help patients get the best care for their specific needs.

Managed Care Organizations issue an identification card that is different then the members SC Healthy Connections card. Members should bring both cards with them to all doctor appointments and to the hospital.

Next SlideSC Healthy Connections Choices GoalsWe want to help members:Understand benefits of health plans and various plan optionsChoose a health plan that their doctor of choice accepts Enroll in a health plan by making the process easy Take an active role in their health care byChoosing their own Primary Care Provider (Medical Home)Getting preventive and primary health careTaking children to well-child visitsGoals of SCHCCIncreased voluntary enrollment rate (minimize auto assignment)Decreased churn from one health plan to anotherGreater satisfaction with health care servicesImproved access to and use of preventive and primary careImproved overall health outcomesImproved efficiency and effectiveness of the program

#SCHCC wants to help members find the right health plan for their health care needs and to maximize their health coverage. We do this by helping members:>>Understand the benefits of health plans and the various plan options they have>>Choose a health plan their doctor of choice accepts and that best meet their health needs>>Enroll in a health plan by making the process easy>>Take an active role in their health care by>> Choosing their PCP>> Getting preventive and primary health care>> Taking children to well-child visits>>Ultimately the goals of SCHCC >>To see an increase in members selecting a health plan and voluntarily enrolling, thus minimizing auto-assignments. This begins a greater personal investment in their health care and increases the likelihood they are seeing the doctor they want to see and in the right health plan for their needs.

>>This will hopefully result in a decrease the churn from one health plan to another. This not only simplifies their insurance, but it makes it easier on you and your staff.

>>As a result, patients will have greater satisfaction with their health care, >>improved access to and use of preventive and primary care, >>and improved overall health outcomes. >>Put together, this improves efficiency and effectiveness of the Medicaid program, their health coverage, and your administrative workload.

Next SlideHealth Plan Enrollment ProcessInitial Enrollment Period (at least 30 days)

An enrollment packet is mailed to all Assignable Medicaid members who are required to select a Managed Care Health Plan.We send out reminders to encourage members to make their choice.If members do not choose a plan by the end of the Initial Enrollment Period they will be automatically assigned to a plan. An outreach packet is mailed to all Non-Assignable Medicaid members who can choose to select a Managed Care Health Plan or regular Medicaid.If the member does not choose a health plan they remain in regular Medicaid.Members in regular Medicaid, can switch to a health plan at any time.

#So how does a member enroll in a health plan? The process is straightforward, although it is easy for new members to feel overwhelmed in the process. We try to make it as easy as possible for members and are always looking for ways to improve the process. In your handouts there is a page called The Enrollment Process and Timeline that covers this material as well.Each month, SCDHHS completes their eligibility determination process and tells us who is eligible to enroll in a health plan. >>The new members enter their Initial Enrollment Period. We mail these members an information packet containing enrollment instructions based on their individual circumstances. They have at least 30 days to respond after they receive their information packet. There are two type of packets:>>Enrollment Packets. These packets get mailed to Medicaid Managed Care Assignable members. Members in this group have to choose a health plan. Enrollment packets contain information about the program, available health plans, and how they can enroll in a plan. >>We send out regular reminders during the Initial Enrollment Period to encourage members to make their own choice. >>If members do not choose a plan by the end of the Initial Enrollment Period they will be automatically assigned to a plan. There is also a sample of what members receive in their packet in your handouts.

>>Outreach Packets. These packets get mailed to Medicaid Managed Care Non-Assignable members. The decision to join a health plan is optional for these members; they can choose to stay in regular Medicaid if they want to. Outreach packets also contain information about the program, available health plans, and how they can enroll in a plan. We encourage these members to join a health plan so that they can get better, coordinated care. >>These members can join a health plan at any time. If they do not choose a health plan by the deadline, again at least 30 days, they remain in the regular Medicaid automatically. >>If they choose regular Medicaid, they can change their mind and join a health plan at any time. Next SlideHealth Plan Enrollment ProcessOnce enrolled, members stay in their health plan for 12 months unless one of the following happens:They become ineligible for Medicaid and/or Managed Care enrollment.They requests transfer within the first 90 daysThey make a written For Cause Transfer Request after the Choice Period

Annual Right to ChangeManaged Care Health Plan members will receive an enrollment packet 30 to 60 days prior to their anniversary date for their Annual Right to Change. At this time, they can remain in their current health plan or they can transfer to a different health plan. On the day after their Anniversary Date, they are transitioned to a 90 Day Annual Right to Change Period.#>>The next stage in the Enrollment Process is the One Year Continuous Enrollment Period.

>>Once enrolled, members stay in their health plan for one year unless one of the following happens:

>>They become ineligible for Medicaid and/or Managed Care enrollment. If a Medicaid beneficiary enrolled in a managed care plan loses Medicaid eligibility, but regains it within 60-days, he or she will be automatically reassigned to the same plan and will forego a new 90-day choice period.

>>They requests transfer within the first 90 days from the time of their HP selection. In the 90 Day Choice Period, members can transfer to another HP one time during the 90 days following their initial enrollment. After the 90 Day Choice Period ends, or when the member makes their one health plan change, the member enters a For Cause Transfer Period.

>>Thirdly, They make a written For Cause Transfer Request after the Choice Period. In the for Cause Transfer Period, the member can request that DHHS consider a special circumstance that warrants a health plan change. An example of a For Cause transfer request might be if a member moves to a different county in SC where their current health plan does not participate. Members can request a For Cause Transfer Request form from SCHCC and they return it to DHHS, who will accept or deny the request.

>>Finally, the last stage of the enrollment process is the Annual Right to Change period. Every year members get the opportunity to change their health plan.>>Members will receive an enrollment packet from us 60 days prior to their anniversary date for their Annual Right to Change. >>The Health Plan that the member is enrolled in will also send the member a reminder letter prior to their annual review date.

>>At this time, they can remain in their current health plan or they can transfer to a different health plan. On the day after their Anniversary Date, they are transitioned to a 90 Day Annual Right to Change Period.

Note: The Medicaid WebTool lists the members Anniversary Date under the Beneficiary Special Program Data and it can be used to determine when a member is eligible to make a health plan change if necessary (we have included a screenshot of this in your handouts)

Next SlideHealth Plan Enrollment ProcessEnrollment Process: NewbornsIf the mother has Medicaid, her baby is automatically eligible.In the MCO structure the baby is enrolled in the same health plan as her/his mother.The baby enters the 90 Day Choice Period and her/his health plan can be changed one time within the first 90 days after birth.

Primary Care ProvidersMembers can change their PCP at any time by contacting the Member Services Department of their Health Plan.#Newborn Enrollment ProcessMothers-to-be and new mothers are another group we want to make sure understand the benefits of enrolling in a health plan. >>If the mother has Medicaid, her newborn is automatically eligible.>>In the MCO structure, the baby is enrolled in the same health plan>>The baby enters the 90 Day Choice Period and her/his health plan can be changed one time within the first 90 days after birth.

Primary Care ProvidersMembers can change their PCP at any time by contacting the Member Services Department of their Health Plan.

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Enrolling in a Health PlanThere are three ways a member can enroll in a health plan:Online: www.SCchoices.comAvailable in English and SpanishTakes 5-10 minutesEasy, step-by-step instructionsWe also have a webinar explaining how to use the website for online enrollments.

Mail or fax the completed health plan selection form to SCHCMailing AddressSC Healthy Connections ChoicesPO Box 8691Columbia, SC 29202-9255Fax: 1-877-552-4672

Call our Customer Service Center at 1-877-552-4642

#Members have three ways they can enroll in a health plan>>The fastest and easiest way is online at www.SCchoices.com>>Web site is available in both English and SpanishThe enrollment process only takes about 5 minutes.Members simply click on the Enroll Now button to get started. For each step of the process, there are instructions and embedded videos that walk the member through that step. This continues throughout the enrollment process until the member has enrolled all eligible members of their family.We also can provide training on how to use the website for online enrollments.>>In the enrollment and outreach packets, members receive a Health Plan Selection form. Members can also fill out this form and mail or fax it back to our office.

>>Members can also call the Customer Service Center at 1-877-552-4642. Members can be helped in the language of their choice.

Next SlideYour Role in the Enrollment ProcessTalk with your patients about the benefits of enrolling in a health plan, especially:Newly eligible membersNon-Assignable Medicaid members who have chosen regular MedicaidMothers of newborns

Encourage Members to enroll in a planProcess is easyOnline step-by-step instructions

Tell Members which plans you participate withUse the Prescription for Better Health Care sheetPut up SCHCC posters in your waiting room and other high traffic locations

#Your participation in the education process is extremely important. Things you can do to help your patients make the best health choices for themselves and their family members include:

>>Talk with your patients about the benefits of enrolling in a health plan, >>especially those who are newly eligible, >>non-assignable members who have chosen regular Medicaid, >>and mothers of newborns. >>Encourage Members to enroll in a plan you may want to consider dedicating a computer or phone in your office for use by patients to contact us to enroll in a health plan and choose you office as their PCP. Many of you have out-stationed Medicaid eligibility workers who can help in this process. If we have to auto-assign them to a plan, there is a good chance it might be to a plan you dont accept.>>Process is easy>>There are step-by-step instructions online>>Tell Members which plans you participate with>>Use the Prescription for Better Health Care sheet >>Put up SCHCC posters in your waiting room and other high traffic locations

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Your Role in the Enrollment Process

#Here is a copy of the Prescription for Better Health Care Plan. It has a place for you to write in the practice or their individual doctors name, the practice phone number, as well as an opportunity to check off boxes for the health plans you participate with. On the back there will be quick and easy steps on how to enroll online. Once all the HP conversion changes take place, we will make this into a tear off pad. For now, we are able to customize these with your practice name, phone number, and only the plans you participate with.

Some examples of how your practice can use the Prescription for Better Health Care sheets as an educational tool are:

To help new and current patients update their health plan and PCP selection if they are enrolled in a Medicaid health plan your practice does not accept or if the patient was auto-assigned to a different PCP.

If your practice has doctors who have hospital rotations for newborns, the doctors can give a sheet to mothers who are Medicaid members to let them know which plans you participate with so they can update the childs health plan if necessary and choose your practice as their childs PCP.

To remind Medicaid patients of the health plans you participate with as their anniversary date approaches. If an established patient needs to see a specialist that does not participate with their health plan or the doctor wants them to try a new medicine that is not on their health plans formulary, you can discuss the option of changing health plans as their anniversary date approaches.

To help educate your patients who are in regular Medicaid that there are extra benefits in the Managed Care health plans and that generally it is a good idea to be in a health plan instead of being in traditional Medicaid.

To educate self-pay patients that you think might be eligible for Medicaid. If they gain eligibility, you want them to know which health plans you work with so they can choose one of those.

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Your Role in the Enrollment Process

#Hang up educational posters in your officeWe also have posters you can hang up in your office to help educate members.

>>The first poster is an 8.5x11 poster that lets Medicaid patients know which Medicaid Managed Care Health Plans you participate with. We can send this to you in MS Word so you can add your practice name and/or logo and choose the plans you participate with.

>>The second is an 11x17 poster that reviews the benefits of joining a health plan, how to enroll, and has a place for you to check off which plans you participate with. Please hang these in your lobby and/or patient rooms. We are still waiting for DHHS approval on this one.

Our Provider Outreach Team contact information is on the last slide and they will be happy to send you any of these materials. Just contact the representative for your area and let them know what you need.In addition, we realize that you are on the front line and if you have an idea that will help with the enrollment process, contact your outreach representative and share it with them.

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#These materials come in the members enrollment packet. You can also have them available in the lobby or in patient rooms.

>>health plan comparison chart, >>a decision guide that helps members understand how to go about choosing their health plan and PCP, >>and informational brochures on pregnancy and >>well child visits.

You can find them on our website, www.scchoices.com, and I have some with me today.

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Your Role in the Enrollment Process

Consider participating with all the health plans available in your county as it makes your practice more flexible for patients. When a Medicaid member calls for an appointment ask for their Medicaid ID # (MAID) and check the Medicaid WebTool to verify that they are in a health plan your practice participates with AND that you are their Primary Care Provider (PCP). If you are a Pediatric practice, make sure to take the SCHCC Prescription for Better Health sheet to the hospital when doing newborn visits.Consider providing opportunity for your patients to contact us while at your office via our website, www.scchoices.com. Make use of the Medicaid Managed Care Educational Classes that the Provider Services Center makes available to your staff. You can find classes on the Provider Services website, www.MedicaidELearning.com.Maximizing Your Participation in Medicaid Managed Care#Tips for Maximizing Your Participation in Medicaid Managed CareThe SCHCC Provider Outreach Team is here to help support you to equip your patients to understand their health coverage and to make the right choice for their family when choosing a health plan. As mentioned earlier, we want to maximize member choice by minimizing auto-assignments and decrease the number of Medicaid patients who are eligible to be in a Managed Care health plan, but are still in regular Medicaid. Minimizing auto-assignments directly helps your practice as their will be fewer time-consuming enrollment issues that your staff have to correct.

>>Consider participating with all the health plans available in your county as it makes your practice more flexible for patients. Participating with all the plans means you will not lose your patients because they changed plans or were assigned to a plan you do not participate with. We can get you in touch with your local provider reps for the HPs you do not participate with currently.

>>When a Medicaid member calls for an appointment ask for their Medicaid ID # (MAID) and check the Medicaid WebTool to verify that they are in a health plan your practice participates with AND that you are their Primary Care Provider (PCP). As mentioned earlier, the WebTool now shows their Anniversary Date. Be aware of well visit and preventive service schedules and contact patients to schedule their appointments. Patients can often forget that well visits and preventive services are covered in their health plan. Use your staff to make outreach calls to them in order to schedule appointments for these services. >>If you are a Pediatric practice and your doctors have hospital rotations, make sure they take the Prescription Tear-off pad to the hospital when doing newborn visits. Newborns enrolled in a health plan that your practice does not participate with is a huge issue for pediatricians, so we are repeating this for emphasis.

>>Provide access for your patients to contact us while at your office via our website, or by phone. Many patients do not have internet access at home and have a hard time enrolling or transferring. By providing them access at your office, you are giving them the opportunity to enroll/transfer into a plan you participate with and establish you as their Primary Care Physician. This helps solidify you as their trusted medical home and helps ensure they can get the medical care they need.

>>Make use of the Medicaid Managed Care Educational Classes that the Provider Services Center makes available to your staff. You can find classes on the Provider Services website, www.MedicaidELearning.com.

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Tom DalikPhone: 843-754-8322 Email: TDalik@mximus.comAllendale, Bamberg, Beaufort, Berkeley, Calhoun, Charleston, Chesterfield, Clarendon, Colleton, Darlington, Dillon, Dorchester, Florence, Georgetown, Hampton, Horry, Jasper, Lee, Marion, Marlboro, Orangeburg, Sumter, and Williamsburg CountiesMichelle LeMoinePhone: (803) 834-9956 Email: MLemoine@maximus.comAbbeville, Aiken, Anderson, Barnwell, Cherokee, Chester, Edgefield, Fairfield, Greenville, Greenwood, Kershaw, Lancaster, Laurens, Lexington, McCormick, Newberry, Oconee, Pickens, Richland, Saluda, Spartanburg, Union, and York CountiesSCHCC Provider Outreach Team

Questions?#We want to make sure you have all of the information you need to help you educate your patients about their enrollment choices. Please dont hesitate to contact us for additional information. Were here to support you.There are a lot of materials available on the website at www.scchoices.com or you can contact the call center at 877-552-4672.In addition, we have listed the contact information for our Provider Outreach Team - myself and Michelle LeMoine, and the areas of the state we each work in.