F. Trends and Changes with the Medicaid Program

• Library: A Practical Guide to Elder and Special Needs Law in South Carolina (SCBar) (2014 Ed.)

F. Trends and Changes with the Medicaid Program

The Medicaid program changes frequently. The elder law attorney must remain vigilant to be aware of what is changing and what the future landscape of the Medicaid program may look like. Some of the current trends which are changing how the program operates in South Carolina are highlighted here.

1. Managed Care

Traditionally Medicaid used a fee-for-service method of purchasing health care for qualified individuals. An individual on Medicaid would go to the doctor and the doctor would directly bill Medicaid for the service provided. In recent years, DHHS has followed the national trend in moving away from fee for service to purchasing health care plans for Medicaid beneficiaries. Individuals qualified for Medicaid must chose a health plan and a doctor, similar to private insurance health plans. Also, similar to private insurance, the insurance company is paid a capitated rate and accepts the risk that the need for care may be higher than the rate paid. Medicaid offers six separate health care plans.³³ In early 2014, six plans are being offered all of which are Managed Care Organizations (MCOs). DHHS had previously offered two Medical Homes Networks (MHNs).³⁴ Residents of nursing homes and individuals covered by an MCO or HMO through third-party coverage are not eligible for Medicaid MCO programs. The relevant provider manual provides a complete list at https://www.scdhhs.gov/internet/pdf/manuals/Managed%20Care%20Supplement.pdf, p. 9.

Some important requirements for MCO programs include:

• The programs provide additional benefits not available to individuals who receive services just through fee for service. Some of them include:

o 24-hour nurse advice line,
o Care coordination,
o Adult dental services.³⁵

• Eligible individuals cannot be discriminated against on the basis of health status or the need for health care. 42. C.F.R. § 438.6(d) (3).
• The contracts must provide for the beneficiary to be able to "choose his or her health professional to the extent possible and appropriate." Id. at (m).
• The relevant statutory provisions are 42 U.S.C. § 1396u-2; § 1396b(m); § 1396d(a)(25)(including primary care case managers [PCCMs] as medical assistance); § 1396d(t)(defining PCCM).

2. The Patient Protection and Affordable Care Act (ACA)

The ACA, also known as Obamacare, has provisions relating to Medicaid, provisions relating to health care availability, provisions relating to abuse and neglect of vulnerable...