South Carolina – Medical Homes

In early 2011, the Centers for Medicare & Medicaid Services (CMS) approved South Carolina’s request to expand its Healthy Connections Choices program to require that most beneficiaries enroll in managed care. Healthy Connections Choices enrollees have the option to join a managed care plan or a primary care case management program known as the Medical Homes Network Program. In the Medical Homes Network Program, South Carolina Department of Health and Human Services (SCDHHS) (the South Carolina Medicaid agency) contracts with Care Coordination Service Organizations (CSOs) to provide medical home services to Medicaid beneficiaries. The CSOs individually contract with primary care physicians to create the medical home network. Palmetto Physician Connections and South Carolina Solutions are the current CSOs.

The goals of the Medical Homes Network Program include:

  1. Providing accessible, comprehensive, family centered, coordinated care (including 24/7 telephonic patient access);
  2. Providers that manage the patient’s health care, perform primary and preventive care services, arrange for any additional needed care, and focus on the physician-patient relationship; and
  3. Patient education regarding preventive and primary health care, utilization of the medical home and appropriate use of the emergency room.

More information, including specific provider requirements, can be found in the network contract and policy and procedure guide, as well as the provider manual for Palmetto Physician Connections.

Federal Support: South Carolina has received a duals demonstration grant from CMS to “coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals.”

Last Updated: January 2014

Aligning Reimbursement & Purchasing
Care Coordination Service Organizations (CSO), administrative entities that contract with primary care physicians in a Medical Home Network, receive two payments for their services:
  1. Monthly Care Coordination Fees: Networks receive monthly care coordination fees equal to $10 per member per month (PMPM).
  2. Shared Savings: Networks that save money can earn shared savings payments of 50 percent of the actual savings (up to a maximum of five percent of the total fee for service payments incurred by network enrollees). The South Carolina Department of Health and Human Services calculates costs and savings quarterly.
Networks that do not achieve savings risk a penalty that would require the network to return a portion (or all) of their prospective care coordination fees.
It is up to each CSO to determine specific care coordination fees and shared savings payments made to the participating primary care providers in their network. Care coordination fees to providers are paid out of the network’s $10 PMPM payment.
Participating providers continue to receive fee for service reimbursement from South Carolina Medicaid; the Medical Home Networks do not pay any claims.
Supporting Practices
Under the Medical Homes Network Program, the South Carolina Department of Health and Human Services contracts with Care Coordination Service Organizations to provide care coordination, disease management and data management support.
Measuring Results
The South Carolina Department of Health and Human Services requires participating medical home networks to work with the department to establish outcome measures relevant to the program.
Furthermore, an external quality review organization conducts an annual quality assurance evaluation for each medical home network. This process includes:
  • A quality of care study that includes data on prenatal and newborn care, childhood immunizations, asthma, emergency room utilization, and Early and Periodic Screening Diagnosis & Treatment (EPSDT) examinations;
  • A service access study focusing on emergency room service and utilization; appointment availability and scheduling, referrals, follow up care provided, and the timeliness of services;
  • A medical record survey to ensure compliance with medical record uniformity of format, legibility and documentation; and
  • An administrative survey of administrative policies and procedures.