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Presentation on theme: "1 Start. How to view this presentation: Click to view the previous slide or go back to the top level slide. Click to view the next slide. Whenever you."— Presentation transcript:

1 1 Start

2 How to view this presentation: Click to view the previous slide or go back to the top level slide. Click to view the next slide. Whenever you see a link like this you can get further information. Click on the link to access the information. 2 Glossary of Acronyms Quick Contact Reference Other Resources

3 County-Based Purchasing (CBP) allows county governments to become local buyers of health care for county residents eligible for state and federal health care programs. County-Based Purchasing Established as a County-Based Purchasing plan in 2001, South Country Health Alliance strives to integrate social services, public health, and medical services so members receive the right services, at the right time, in the right setting. 3

4 More than just a health plan, South Country is a partner to the counties we serve. Through County Integration, we work together with the County toward:County Integration Promoting and improving our members current state of health and well-being with Member Programs and Services.Member Programs and Services Creating partnerships with county Public Health and Social Services as demonstrated with the Community Care Connector.Community Care Connector 4

5 South Country Health Alliances mission is to empower and engage our members to be as healthy as they can be, build connections with local agencies and providers who deliver quality services, and be an accountable partner to the Counties we serve. 5

6 6 South Country administers Medicare and Medicaid programs in 11 Member Counties and 1 Non- Member County.11 Member Counties and 1 Non- Member County To meet the needs of residents eligible for state and federal health care programs within its service area, South Country offers seven programs.seven programs

7 South Country is governed by a Joint Powers Board made of one county commissioner and one alternate from each member county.Joint Powers Board MN Department of Human Services (DHS) and Centers for Medicare and Medicaid Services (CMS) contract with South Country to administer government health care programs. MN Department of Health regulates insurance companies to ensure laws and rules are followed related to: Financial solvency Quality of care Access to services Complaints and Appeals 7

8 8 South Country is committed to preventing fraud, waste, and abuse, and encourages physicians, providers, and the community to help by reporting suspected activity. Phone: 1-877-778-5463 – Username (SCHA), Password (Owatonna) Website: www.reportit.net – Username (SCHA), Password (Owatonna)www.reportit.net Email: Rhonda Seefeld – rseefeld@mnscha.orgrseefeld@mnscha.org Mail: South Country Health Alliance, Attn: Compliance Officer, 2300 Park Dr., Suite 100, Owatonna, MN 55060

9 South Country was initially funded by an equity contribution by member counties and receives monthly capitation payments from DHS and CMS. capitation payments 9

10 10 Member Services: 1-866-567-7242 Fraud & Abuse: Internet: www.reportit.netwww.reportit.net Username: SCHA Password: Owatonna Telephone: Toll-free hotline 1-877-788-5463 Provide username and password (above) Write to: Compliance Officer at the address below Grievances & Appeals: Call Member Services Marketing: marketing@mnscha.org marketing@mnscha.org Website: www.mnscha.org – much information is here! www.mnscha.org South Country Health Alliance 2300 Park Dr., Suite 100 Owatonna, MN 55060 Mail to:

11 11

12 Counties recognize overall physical health and well-being of their government program enrollees is closely correlated with services provided by: County Public Health. County Social Services Non-profit Community-Based Resources Managed Care Organizations Private Health Care Providers CBPs strive to bring all these service providers together into a local, single care delivery model. 12 Our History

13 Formed by MN Statute 256B.692MN Statute 256B.692 A CBP plan can be an individual county or several counties joined through a Joint Powers Board. CBPs in Minnesota have been successfully operating in since 1997: CBPs in Minnesota Itasca Medical Care since 1997 South Country Health Alliance since 2001 PrimeWest Health Since 2003 13 Our History

14 Coordination with county social services, public health, housing, and corrections Proactive focus on prevention and healthy habits Improved public accountability with greater emphasis on Cost Benefit versus Cost Containment or Cost Shifting, thereby protecting local taxpayers and community providers from being forced to pay higher health costs of deferred careCost Benefit versus Cost Containment or Cost Shifting 14 Our History

15 County Integration is the process where the counties and South Country work together toward common goals. This process is performed through: Committees Community Care Connector Model of Care Delegation Agreements County Connection Newsletter 15 A Health Plan Plus

16 16 Member Services assists members, county staff, or providers with problems or questions regarding members access to health care. Member Services Take Charge! Health Promotions are value-added incentive programs used to encourage preventive care and provide health education. Take Charge! Health Promotions Disease Management provides education and telephonic support for members with chronic conditions to help them follow their doctors plan of care. Disease Management A Health Plan Plus

17 17 Restricted Recipient Program identifies and assists members who have used services at a frequency or amount that is not medically necessary. Restricted Recipient Program South Country and the County provide Medical Case Management, Care Management, and Care Coordination to assist members in meeting their health care needs. A Health Plan Plus

18 A county employee in either the public health or social services department, serving as the primary link between South Country and the county. Leads the countys role in a care team focusing on the South Country member-centered philosophy Helps build fluid communication among members, providers, county staff, South Country staff, and other outside organizations 18 A Health Plan Plus

19 Connectors help South Country and the county work together toward: Improving members health and well-being Ensuring appropriate utilization of services Accurately administering benefits Coordinating medical care and/or behavioral health with county services for high-risk individuals 19 A Health Plan Plus

20 South Country keeps frequent communication with the Community Care Connector staff through: A monthly Question & Answer conference call Facilitated by South Country Direct dialogue with Care Coordinators and their supervisors Monthly Community Care Connector meetings South Country staff and Community Care Connectors Provides new information and updates regarding job duties 20 A Health Plan Plus

21 21 Member County Non-Member County Service Area and Programs

22 22 CBP in Minnesota

23 South Country provides coverage for these Minnesota Health Care programs: Medical Assistance (MA) is for adults and children that meet state income limits. MinnesotaCare is for people of any age. There is a monthly premium for most families based on family size and income. MN Senior Care Plus (MSC+) is for people 65 or older who are eligible for Medical Assistance. 23 Service Area and Programs

24 24 SeniorCare Complete, a MN Senior Health Options (MSHO) program for people age 65 or older that combines Medicare and MA benefits into an integrated health care plan. Special Needs Basic Care (SNBC) is a MN program for people ages 18 to 64 with disabilities who are eligible for MA with or without Medicare parts A and B. South Country has three SNBC programs: AbilityCare (HMO SNP) combines Medicare and MA benefits into one integrated South Country health care plan. SingleCare (SNBC) provides South Country MA benefits for individuals not eligible for Medicare benefits. SharedCare (SNBC) provides South Country MA benefits for individuals who receive their Medicare benefits from other health plans. Service Area and Programs

25 The Joint Powers Board (JPB) is accountable for providing leadership to South Country in fulfilling its obligations to its members, the organization, and the Member Counties. Board Duties and Responsibilities 25 Governance and Oversight

26 Capitation Payments DHS and CMS pay South Country a fixed amount per member per month for a defined group of services. This is an alternative to Fee-for-Service where the state pays providers directly for services. South Country is at full financial risk for all services provided regardless if the capitation rates cover the costs. 26 Funding

27 The focus of CBP is Cost Benefit vs. Cost Containment or Cost Shifting. Cost Benefit puts savings earned through preventive care, coordination, and efficiency back into improvements in the health care delivery system for the public benefit. Cost Containment restricts certain benefits of a health plan, with savings and profits going directly back into the managed care business. Cost Shifting focuses on short-term savings by minimizing preventive care opportunities which causes higher health care costs later, either to the member or taxpayer. 27 Our History

28 County staff and South Country work together to achieve goals through committees tasked to review specific topics. Some of these committees are: Utilization Management Committee Quality Assurance Committee Compliance Committee Community Care Connectors Family Health Committee Care Coordination Meeting Member Advisory Committee (MAC) 28 A Health Plan Plus

29 The committees include representatives from: The Joint Powers Board Health and Social Services Directors and Staff Community Providers South Country Staff Our Members 29 A Health Plan Plus

30 Public Health and Social Service Director Advisory Committee works with South Country staff directly through various sub-committees: Service Enhancement Committee Health Outcomes Committee Public Relations Committee Non-Emergency Transportation Committee County Supervisor Committee Meets quarterly to oversee Community Care Connector and care coordination work 30 A Health Plan Plus

31 Describes a single care delivery system through integration of medical services with Public Health and Social Service programs The Model of Care was developed to build on county structures and relationships with members. Provides access to health care that is fair and consistent Maximizes benefits and minimizes risk Required by Centers for Medicare and Medicaid Services (CMS) 31 A Health Plan Plus

32 32 South Country contracts with each member county to perform certain duties on behalf of South Country. South Countrys Delegation Agreement with each member county includes: Care Coordination Community Care Connectors Use of Elderly Waiver contracted provider network Access transportation service (bus, taxi, volunteer driver) A Health Plan Plus

33 The County Connection Newsletter is a monthly communication to county staff about South Country updates, changes, and news. Distributed via emailed link Subscribe online at the South Country website, www.mnscha.org, or contact Member Services at 1-866-567-7242. www.mnscha.org 33 A Health Plan Plus

34 Member Services is the main point of contact for members, caregivers, county workers, and providers for a variety of issues and questions. To efficiently serve our members, Member Services teams are assigned to each county allowing them to be more familiar with local resources. Member Services Free Phone Numbers 1-866-567-7242 Minnesota Relay 711 (for hearing impaired) Hours of Operation: 8 a.m. to 8 p.m., Monday-Friday 34 A Health Plan Plus

35 Interpreter Services Available South Country offers free telephonic interpretation services for all our members. Interpreter services can be used by Connectors and other county workers to assist South Country members. Call Member Services for more information about interpreter services. 35 A Health Plan Plus

36 Welcome Calls are made to Medical Assistance and MinnesotaCare members within 30 days of enrollment to: Perform a Health Risk Assessment survey Encourage preventative care visits Inform of available services Refer members to appropriate resources 36 A Health Plan Plus

37 The MAC is a representative committee of volunteers made up of members, family of members, or advocates from each of our counties. The mission statement of the MAC is to help South Country Health Alliance respond to the needs of the member. Members experience and assistance help us make sure we are doing what is needed and doing it right. 37 A Health Plan Plus

38 The MAC is a representative committee of volunteers made up of members, family of members, or advocates from each of our counties. 38 Hilary Helgeson, Chair – Steele County Claudette Moran – Morrison County Brad Hartle – Steele County Stacey Schultz – Steele County Hope Kujath – Wabasha County Judith De La Fosse – Waseca County Jeremy Hoffman, Vice Chair – Wabasha County Michael Hawkins – Morrison County Committee members Updated: 3/26/2014 A Health Plan Plus

39 Program Includes: Be Buckled car seat education and distribution Community Education & Early Childhood Family Education class scholarships Embracing Life prenatal care guide Rewards for completing immunizations, lead tests, well-child visits, prenatal & postpartum care, mammograms, and other health care services BE FIT & BE Active exercise reward program (health club discount) 39 Take Charge!

40 Disease Management staff supports member knowledge and follows the plan of care members have with their providers. Provides disease-specific educational materials to member Offers telephonic support according to members needs and desires Reduces health care costs or minimizes the effects of a chronic disease by educating members on self-care and guiding members staying with their plan of care 40 Disease Management

41 Works with members with chronic conditions : Heart Failure Asthma Diabetes All members are eligible regardless of product Identified through: Claims data (medical and pharmacy) Referrals from caregivers, county, self, South Country staff, and providers Member health assessments 41 Disease Management

42 This program was created by the Minnesota Health Care Programs (MHCP) and is administered by the Department of Human Services (DHS). Only for MA, MinnesotaCare, MSC+, and SingleCare members Identifies members who have used services at a frequency or amount that is not medically necessary, through claims and pharmacy data and referrals from the state, staff, providers, and others Members are: Placed in program for a period of 24-36 months Assigned to a specific provider, pharmacy, and hospital Required to participate in case management 42 Restricted Recipient Program

43 43 Member Services: 1-866-567-7242 Fraud & Abuse: Internet: www.reportit.netwww.reportit.net Username: SCHA Password: Owatonna Telephone: Toll-free hotline 1-877-788-5463 Provide username and password (above) Write to: Compliance Officer at the address below Grievances & Appeals: Call Member Services Marketing: marketing@mnscha.org marketing@mnscha.org Website: www.mnscha.org – much information is here! www.mnscha.org South Country Health Alliance 2300 Park Dr., Suite 100 Owatonna, MN 55060 Mail to:

44 44 Glossary of Acronyms CBP – County-Based Purchasing CMS – Centers for Medicare and Medicaid CRG – Clinical Resource Group DHS – Minnesota Department of Human Services EW – Elderly Waiver FFS – Fee-for-Service HIPAA – Health Insurance Portability and Accountability Act ICT – Interdisciplinary Care Team MAC – Member Advisory Committee MDH – Minnesota Department of Health MHCP – Minnesota Health Care Programs MSC+ – Minnesota Senior Care Plus MSHO – Minnesota Senior Health Options NCQA – National Committee on Quality Assurance QAC – Quality Assurance Committee RIDE – Regulatory, Internal Monitoring, Delegation Entity SNBC – Special Needs Basic Care UM/DM – Utilization Management, Disease Management

45 45 Nina Huntington, Chair - Steele County Dan Rechtzigel, Vice Chair - Goodhue County Harold Pettis, Past Chair - Sibley County Kathi Ellis - Kanabec County Andrew Lochner - Brown County David Erickson - Dodge County Don Meyer - Morrison County Gary Kneisl -Todd County David Harms - Wabasha County Bill Stearns - Wadena County Jim Peterson - Waseca County Updated: 3/26/2014

46 Provide continuity for the organization by setting up a legal existence and development of by-laws Select a chief executive to whom responsibility for the administration of the organization is delegated Govern the organization by broad policies and objectives, developed and agreed upon by the CEO and employees Acquire sufficient resources for the operations to ensure the organizations capacity to carry out the services/programs Provide for fiscal accountability Accounting to stakeholders for the organizations performance 46 Board Duties and Responsibilities

47 The boards responsibilities are defined in these key areas: Planning Organization Fiscal Accountability Monitor and Evaluate 47 Board Duties and Responsibilities

48 Determine the organization's mission and purpose Participate in the development of the Strategic Plan Determine and monitor the organizations services and programs 48 Board Duties and Responsibilities

49 Be a champion and spokesperson for the organization and its issues Ensure that programs and services are designed to meet member needs Understand and follow governing documents Delegate Board work to committees as appropriate Be an active participant in board meetings and board actions Allow no conflict of interest Provide adequate resourcesstaff, dollars, facilitiesto achieve the strategic goals and objectives Provide direction, encouragement, and support for the executive leadership 49 Board Duties and Responsibilities

50 Participate in financial planning Approve the budget Safeguard and manage assets of the organization 50 Board Duties and Responsibilities

51 Review operations, performance, and results Monitor financial performance Verify compliance with all financial, legal, and ethical requirements 51 Board Duties and Responsibilities

52 52 Connectors are county employees in either the public health or social services department serving as the primary link between South Country and the county. Connectors help build fluid communication among members, providers, county staff, South Country staff, and other outside organizations. See the complete list of Connectors.


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