First Choice VIP Care PLUS. Healthy Connections Prime Medicare Medicaid Benefits
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1 First Choice VIP Care PLUS Healthy Connections Prime Medicare Medicaid Benefits
2 Benefits Why First Choice VIP Care PLUS Was Created The Medicare Medicaid Plan, First Choice VIP Care PLUS, was created to coordinate Medicare and Medicaid services, simplify the delivery system and to streamline payment to the provider. The goals of creating this plan are: Improve health outcomes. Keep beneficiaries in the community. Provide coordination for members to improve health outcomes. 2
3 First Choice VIP Care PLUS covers all Original Medicare and SC Medicaid Medical Benefits Medicare Parts A and B benefits Medicare Part D prescription drug benefits SC Medicaid benefits Long Term Services and Supports (LTSS) benefits for the Community Choices Waiver HIV/AIDS Waiver and Mechanical Ventilation Waiver First Choice VIP Care PLUS does not charge a copayment for Original Medicare and SC Medicaid Medical Benefits to the member. 3
4 Benefits Medicare vs. Medicaid: Which Program Pays for What Service? PLAN NAME MEDICARE PARTS A & B MEDICARE PART D MEDICAID Medicaid South Carolina Department of Health and Human Services Medicare Fee for Service or Medicare Advantage (MAPD) First Choice VIP Care PLUS Medicare Medicaid Plan NA NA X X X Not applicable for non-dual Medicare beneficiaries FFS for dual eligible beneficiaries X X X 4
5 Benefits Medicare Part A and B Benefits * ** Ambulance Services Cardiac and Pulmonary Rehabilitation Services Catastrophic Coverage Chiropractic Care Dental Services Diabetes Program and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Doctor Office Visits Durable Medical Equipment Emergency Care Hearing Services Home Health Care Hospice - Initial Consultation Inpatient Hospital Care Inpatient Mental Health Care Out-of Network Catastrophic Coverage Out-of-Network Initial Coverage Outpatient Mental Health Care Outpatient Rehabilitation Outpatient Services/Surgery Outpatient Substance Abuse Care Pharmacy LTC Pharmacy Mail Order Prescriptions Out-of-Network catastrophic Prescriptions Outpatient Prescription Drugs Podiatry Preventive Services and Wellness/Education Prosthetic Devices Skilled Nursing Facility Urgent Care *Exceptions may apply, see provider manual for full list of benefits. ** Referral or prior authorization may be required. 5
6 Benefits Medicaid Benefits Adult Day Health Transportation Skilled Nursing Facility Home Health Services Durable Medical Equipment Prosthetics/Medical Supplies Family Planning Personal Care Services (Personal Care I and II) Private Duty Nursing Institution for Mental Disease Pharmacy Services Dialysis for End-Stage Renal Disease (ESRD) Medicaid Targeted Case Management Health Education Behavioral Health Services (Rehabilitative Behavioral Health) Outpatient Mental Health Services (Community mental health services) Infusion Centers/Services Nursing Home Transition Services (Home Again) Tele-psychiatry *Exceptions may apply, see provider manual for full list of benefits. ** Referral or prior authorization may be required. 6
7 Carved Out Medicare and Medicaid Benefit Non-emergent Transportation Services. Adult Dental. Hospice Services. 7
8 Long Term Services and Supports (LTSS) Benefits
9 Medicaid Waivers Waivers are state specific Medicaid programs that allow for services to be provided outside of nursing homes. To avoid confusion, it is worth mentioning that waivers are also referred to as 1915 waivers (for the Social Security Act), home and community based services (HCBS) waivers, waiver services, waiver programs and by any number of other state-specific names. Healthy Connections Prime will include three of the nine waiver programs in the Long Term Services and Supports benefits. 9
10 What are Long Term Services and Supports (LTSS) benefits LTSS benefits are a variety of services and supports that help elderly individuals and/or individuals with disabilities meet their daily needs for assistance and improve the quality of their lives. Examples include assistance with bathing, dressing and other basic activities of daily life and self-care, as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over an extended period, predominantly in homes and communities, but also in facility-based settings such as nursing facilities. 10
11 Adult Day Health Care. Case Management. Personal Care (I and II). Adult Care Home Services. Adult Companion Care. Adult Day Health Care Transportation. Attendant Care. Community Residential Personal Assistance (CRPA). Home Accessibility Adaptations. Home delivered meals. Nursing Home Transition Service. Personal Emergency Response System. Specialized Medical Equipment and Supplies. Telemonitoring. Benefits Community Choices Waiver 11
12 Case Management. Personal Care (I and II). Benefits- HIV/Aids Waiver Prescription Drugs, except drugs furnished to participants who are eligible for Medicare Part D benefits. Adult Companion Care. Attendant Care Services. Home Accessibility Adaptations. Home Delivered Meals. Private Duty Nursing. Specialized Medical Equipment and Supplies. 12
13 Personal Care (I and II). Respite. Prescription Drugs, except drugs furnished to participants who are eligible for Medicare Part D benefits. Attendant Care. Home Accessibility Adaptations. Personal Emergency Response System. Pest Control. Private Duty Nursing. Specialized Medical Equipment and Supplies. Benefits- Mechanical Ventilator Dependent Waiver 13
14 Personal Care I and II Personal Care I This assistance includes assistance with instrumental activities of daily living: Light housework. Laundry. Meal preparation. Grocery shopping. Using the telephone. Personal Care II This assistance may take the form of hands-on assistance (performing a task for the person) or cuing to prompt the participant to perform a task. Such assistance may include assistance in activities of daily living: Bathing. Dressing. Toileting. Transferring. Maintaining continence. 14
15 Benefits 24/7/365 Nurse Line If members are unable to reach their PCP s office, registered nurses are available 24/7days to assist members through the Nurse toll-free Call Line First Choice VIP Care Nurse Call Line:
16 Benefits Additional Information For additional information on benefits, please refer to the Provider Manual or call Provider Services at
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