As part of a cooperative agreement with the Centers for Medicare and Medicaid Services (CMS) and the state Medicaid agency, South Carolina established a federal-state partnership to blend payments and provide integrated benefits to Medicare-Medicaid beneficiaries age 65 and above. The beneficiaries cannot reside in a long-term care facility at the time of enrollment. The services are provided through managed care plans in all SC forty-six (46) counties. South Carolina's dual eligible Demonstration project is Healthy Connections Prime. As part of the cooperative agreement, and in an effort to support and protect the rights of the dual eligible beneficiaries, SC developed an independent Ombudsman program to advocate for and investigate on behalf of dual eligible enrollees.
The South Carolina Department on Aging Office of the State Long Term Care Ombudsman (OSLTCOP) is the lead entity to administer the Demonstration Ombudsman Program, which is known as the Prime Ombudsman Program (POP). The goals of the program are to advocate, provide resolution of identified issues, safeguard due process and serve as the early and consistent means of detecting systemic concerns. Prime Ombudsmen will leverage their existing partnerships to provide consistent program awareness and work to educate and empower the dual eligible enrollees. All services provided to the beneficiaries will be confidential and free of charge. The POP has multiple communication avenues to include a website, toll free telephone line, video chat, mail, email, fax, and, if required, a face-to-face visit. The Prime Ombudsmen will work to empower beneficiaries, conduct program awareness, investigate complaints, provide access to legal assistance/mediation, and collect and report data trends to CMS and the Medicaid agency.
The Prime Ombudsman Program is a dedicated unit in the OSLTCOP with the sole focus of providing advocacy and complaint resolution services to the dual eligible enrollees. Building on the current configuration of the Aging Network in SC and the infrastructure of the Long Term Care Ombudsman
Program, the POP has a presence in all of the Demonstration counties. The project is a natural transition to continuing the initial efforts implemented and the proposed expansion of the financial alignment demonstration.
