Changes outlined for S.C. Medicaid

Ultimate goal is to pair assigned or chosen physician with patient for ongoing care

By RODDIE A. BURRIS

rburris@thestate.com

Online | Learn about the plan

After months of evaluation, state health officials Friday unveiled a new, long-term plan to change South Carolina’s $5 billion Medicaid program.

Heavily based on consumer choice, the plan seeks to pair each of the state’s more than 800,000 Medicaid recipients with a managed care organization or physician-led medical home network.

It replaces changes to Medicaid that Gov. Mark Sanford aimed to make through a sweeping federal waiver, a path the state says it no longer will pursue.

Key changes the plan establishes, in addition to managed care, include:

• Co-payments. All recipients — except children, pregnant women, those in institutions, and those in home and community-based waiver programs — would have co-payments.

• No coverage limits. There would be no caps, or limits of care, for recipients under a managed care organization or medical home network.

n Protected coverage. Recipients would not be dropped due to high treatment costs.

n Quality ratings. The state would compile and publicize a score card (based on claims data) on how well a health plan performs, so consumers can use the information in making choices.

n More information. Consumers could access electronic personal health records to get a snapshot of their expenditures. Details then could be compared to alternative choices.

Much of the new plan is still conceptual, so officials have not set timetables to implement it.

The Department of Health and Human Services is not sure yet whether they will need permission from the Centers for Medicare and Medicaid Services to begin carrying out all phases.

Overall, the state projects managed care could be about 5 percent less expensive than the current fee-for-services system.

The push to change S.C.’s health care system for poor and young residents follows previously outlined goals of trimming the growth in costs by changing how residents get medical care.

Health officials say their aim is to achieve greater efficiency by fostering an overall healthier group of Medicaid recipients. That, over time, would help lower costs and slow Medicaid’s rate of growth, they said.

Managed care differs from existing care under Medicaid by tying recipients to an organized plan, with accountability both for care and expenditures.

Right now, recipients simply access Medicaid-covered services, which are then billed to the state. Fee-for-service medical care, which is how S.C. Medicaid currently functions, also will remain an option, an official said.

The new plan will require a high level of consumer education. That will be carried out by an independent group of enrollment counselors the state is seeking to hire.

Ultimately, the health department said it wants either a self-chosen or state-assigned physician to attend to every Medicaid recipients’ ongoing medical care.

Health officials are aiming to adopt these new changes without obtaining a federal waiver, a step they think is unnecessary due to changes adopted earlier this year.

Sanford said many of the changes he wanted to effect in the state Medicaid program are allowed under the congressional act. Sanford initially had sought to make Medicaid changes through a controversial waiver.

While many of the newly proposed changes are conceptual, some are under way.

Nearly 11,000 Medicaid recipients in two counties, Orangeburg and Marion, have been enrolled in managed care plans since January, according to the Department of Health and Human Services.

The state is developing plans to introduce managed care as a preferred choice for Medicaid recipients in other S.C. counties, too.