Steve Boucher, Director of Managed Care Services for the South Carolina Alliance of Health Plans (SCAHP)  has  accepted an invitation from Eunice Medina, Director of the South Carolina Department of Health & Human Services (SCDHHS,) to serve as a member of the South Carolina Medicaid Advisory Council (MAC) through 2026.In her invitation, Eunice commented that "my leadership and expertise would be invaluable in strengthening our collective efforts to ensure equitable access to high-quality health care for all Healthy Connections Medicaid members. We are committed to building an action-oriented council with a broad scope of backgrounds and expertise and I am confident your contributions will help shape the future of Medicaid in South Carolina."

The MAC has been established to advise SCDHHS on health and medical care services, with a focus on creating a consumer-driven approach that optimizes the efficiency and effectiveness of the South Carolina Healthy Connections Medicaid program. The council will help the agency address the health care needs of our state’s Medicaid population, which includes the state’s most vulnerable populations. The MAC will advise the Director of SCDHHS on matters of concern related to policy development and matters related to the effective administration of the Medicaid Program. The MAC replaces the former Medical Care Advisory Committee (MCAC). The MAC is required for all Medicaid programs effective July 9, 2025.

This appointment recognizes the quality of the expertise and leadership present in the SCAHP and recognizes the impact that we have in developing and furthering policies and practices that are creative and innovative to meet the needs of South Carolina's Medicaid population. 

Statement from Gov. Henry McMaster on the Confirmation of Eunice Medina as SCDHHS Director

COLUMBIA, S.C. – Governor Henry McMaster today released the following statement on the confirmation of Eunice Medina as the next director of the South Carolina Department of Health and Human Services: 

"Eunice Medina's expertise in Medicaid policy and her leadership within the Department of Health and Human Services make her exceptionally qualified to lead the agency," said Governor Henry McMaster. "Her experience at the executive level has prepared her to build on the agency's success, ensuring efficiency and accountability in South Carolina's healthcare system. I have full confidence in her leadership and look forward to working with her in this new role." 

COLUMBIA, S.C. – Governor Henry McMaster today formally requested the U.S. Department of Health and Human Services (HHS) work with the South Carolina Department of Health and Human Services (SCDHHS) to reinstate the state’s Healthy Connections Community Engagement Initiative, also known as Medicaid Work Requirements. The initiative promotes healthier outcomes and incentivizes financial independence by adding community engagement requirements for qualifying Medicaid members that would include 80 hours of monthly work, job training, education, or community service.

"Granting South Carolina the authorities necessary to reinstitute this initiative will strengthen the Medicaid program's dual missions of financing health services and improving opportunities for independence, self-reliance, and prosperity for the state's citizens," Governor McMaster wrote in the letter to Acting HHS Secretary Dorothy Fink.

The governor's letter added: "South Carolina pursued the Section 1115 waivers that made up its Healthy Connections Community Engagement Initiative to close the health care coverage gap created by the Patient Protection and Affordable Care Act (ACA) and incentivize employment among its citizens. Under the ACA, adults are eligible for subsidized health care coverage on the federal exchange when their earnings reach the federal poverty level. However, Medicaid coverage ends for many working parents at a threshold that is below the federal poverty level. This flawed structure created a health care coverage gap that disincentivizes many low-income families from earning additional income. This presents working families with an undesirable choice: earn additional income to support their family or lose their healthcare coverage."

In January 2018, Governor McMaster directed SCDHHS to seek federal waivers to establish work requirements for qualifying Medicaid recipients. South Carolina’s application was approved by the Trump Administration in December 2019 but it was paused during the COVID-19 pandemic to comply with federal requirements under the Families First Coronavirus Response Act. The Biden Administration then withdrew approval of the initiative in August 2021.

The governor's request for reinstatement is centered around restoring the New Coverage for Parents and Community Engagement components of the Palmetto Pathways to Independence section 1115 waiver that was approved by the Centers for Medicare and Medicaid Services in December 2019.

Last week, Governor Henry McMaster recognized Robby Kerr, the departing Director of SC DHHS, for his outstanding service to South Carolina. The ceremony at the State House drew over 300 attendees, reflecting the deep appreciation for his contributions to our state. Director Kerr received the Order of the Palmetto from the Governor, and a beautiful piece of art from the MCO plan presidents.  SCAHP extends its heartfelt thanks to Robby for his years of dedicated leadership and commitment to South Carolina.

Governor Names Next SCDHHS Director

November 11, 2024. Governor Henry McMaster announced  the retirement of South Carolina Department of Health and Human Services (SCDHHS) Director Robert Kerr, effective November 1, 2024.  The SCDHHS administers Healthy Connections, the state’s Medicaid program. Director Kerr served in this leadership role for more than three years, following the governor’s 2021 nomination. Previously, Kerr served as SCDHHS Director from 2003 to 2007, and worked for the Department for 22 years.

The governor named Eunice Medina as Kerr’s successor as SCDHHS Director. Medina has been serving as the Chief of Staff and Deputy Director of Programs at the agency since June 2021. She has 20 years of experience in Medicaid  policy and operations, and previously served as Bureau Chief with the Florida Agency for Health Care Administration, where she managed oversight of the state’s Medicaid MCOs.  Medina’s appointment is now subject to confirmation by the state senate, and the Senate Medical Affairs Committee Chair stated that the confirmation process will be the committee’s first order of business.

Check out the announcement from the governor here.

The SCAHP Q3 Meeting was held at Wild Dunes Resort on October 9.  Our featured speaker was Kobra Eghtedary, PhD.  Dr. Eghtedary is the Director of the State Health Improvement Office at the S.C. Department of Public Health. 

Prior authorizations are considered obstacles by many physicians and patients alike, with 9 in 10 physicians saying in an American Medical Association survey prior authorization has a negative effect on patient outcomes.

To combat that burden, UnitedHealthcare is rolling out a gold-card program that will reward contracted provider groups that "consistently adhere to evidence-based care guidelines" by allowing certain physicians to bypass the prior authorization process.

While some physicians and groups have expressed concern over the program, other physicians are optimistic it could help combat lengthy wait times and existing prior authorization requirements.

Joshua Rosenow, MD. Director of functional neurosurgery at Northwestern Medicine (Chicago): UHC has been the perpetrator of some of the most onerous prior authorization requirements. While the gold-card program does not solve all of the myriad issues with UHC prior authorization, it will hopefully reward practices for successfully navigating UHC's thicket of prior authorization requirements with a year of exemptions. However, this is renewable annually and it is unclear exactly how UHC will recertify practices' gold-card status if they are not submitting prior authorization requests. It is possible that submitting annual data and medical records to maintain gold-card status could be just as time consuming and frustrating as the prior authorization process itself. Moreover, the list of procedures that would be eligible for inclusion in the gold-card program won't be released until Sept. 1, so we don't yet know how applicable this will be to spine and pain practices.

Zeeshan Tayeb, MD. Owner and medical director of Pain Specialists of Cincinnati: The proposal behind the gold-card program from UHC is one that will work to help alleviate pre-certification requirements if the program works as designed. The qualifying criteria for provider enrollment is something that will help raise the standards of care for all patients receiving treatment. It would be an additional incentive if providers qualifying for the UHC gold card enrollment were provided an elevated fee schedule for services.

Manufacturing of novel cell and gene therapy (CGT) products is extremely complex and patient-specific, so it can be a heavy lift to distribute these agents. However, several leading specialty pharmacies have developed dedicated programs focused on the unique financial, delivery, temperature control and patient support challenges associated with providing these therapies.

Orsini an Early Adopter

With three decades of experience in rare disease pharmacy, Illinois-based Orsini Specialty Pharmacy was well positioned to move into the CGT space in 2017, when it began supporting the cell therapy autologous cultured chondrocytes on a porcine collagen membrane (MACI, Vericel), used for the repair of full-thickness knee cartilage defects in adults. A year later, in 2018, Orsini entered the gene therapy channel with a program to support patients who are prescribed onasemnogene abeparvovec-xioi (Zolgensma, Novartis), an adeno-associated viral vector–based gene therapy for pediatric spinal muscular atrophy (SMA). Orsini currently supports six CGTs, including:

• valoctocogene roxaparvovec-rvox (Roctavian, BioMarin), the first gene therapy for hemophilia A;
• etranacogene dezaparvovec-drlb (Hemgenix, CSL Behring), the first gene therapy for hemophilia B; and
• delandistrogene moxeparvovec-rokl (Elevidys, Sarepta), the first gene therapy for Duchenne muscular dystrophy.

“Taken together, we are managing or have managed around 6,500 patients receiving these cell and gene therapies,” said Allison Droba, Orsini’s gene therapy operations manager. Ms. Droba heads a small, tightly focused team that works directly with patients receiving CGT and with Orsini’s larger payor team and pharmacists and program managers who communicate with the manufacturers. “When a new referral comes in, everyone knows about it and it’s all hands on deck,” she said. On average, they can process any new cell and gene patient in five to seven business days and schedule shipment to the appropriate facility.

Rare disease specialty pharmacy programs often take a sequential approach to patient care, with different parts of the process moving from one functional team to another. Orsini’s care team, in contrast, “wraps around the case and the patient and monitors every step, sometimes hour by hour, to ensure the therapy gets to the patient on the time line we have established,” said Eyad Farah, the company’s chief operating officer.

With many CGTs, time is of the essence. Onasemnogene abeparvovec-xioi, for example, has completely transformed the prognosis for SMA, a rare genetic disease that causes progressive loss of muscle control and function. But time to treatment makes an enormous difference: Outcomes are better in infants who are treated before they begin to show symptoms. One real-world study found that the children with the best motor outcomes were those who had received gene therapy at a significantly younger age—a median of 1.7 versus 7.85 months in the overall group (Pediatr Neurol 2023;144:60-68).

“As soon as we get the referral for Zolgensma from the manufacturer hub, we stop everything we’re doing and work on that one first,” Ms. Droba said. “My team gets on the phone with the insurance company to verify benefits, determine whether it is covered under pharmacy or medical benefit and if prior authorization is needed, and immediately informs the physician’s office of what we need to submit. We follow up on that authorization at least two or three times a day; sometimes every hour on the hour.”

Accredo Focuses on Access

Accredo by Evernorth, part of Evernorth Health Services, is another leading specialty pharmacy with deep expertise in gene therapies, including several of the CGTs supported by Orsini as well as others such as lovotibeglogene autotemcel (Lyfgenia, Bluebird Bio) for the treatment of sickle cell disease and voretigene neparvovec-rzyl (Luxturna, Spark Therapeutics) for the treatment of inherited retinal disease.

Its GeneAXS team is solely dedicated to ensuring access to GCTs, which encompasses payor contracting, benefits investigation, fulfillment, patient services and clinical consultation. “This team regularly engages with patients, clinicians and their caregivers, as well as manufacturers, to ensure everyone is coordinated and in sync for each gene therapy order,” said Mark Jacob, the senior director of product management at Accredo. “Our team has expertise in navigating payor contracting, benefits investigation, fulfillment and patient services such as coordinating access to pharmacists, nurses, social workers, nutritionists and others as appropriate.”

Overcoming Payor Hurdles

Both specialty pharmacies stressed that complex insurance authorizations for costly rare disease therapies can be exponentially more challenging for CGTs costing more than $2 million or $3 million. “The approval pathway often has several extra steps for that high dollar amount, and every payor might have a different process,” Mr. Farah said. “Some may take each approval to the president of the business unit.”

The first approval of a new gene therapy with a specific payor is always the most challenging. “We have to learn how they want the drug billed, or if they have a specific letter of agreement designed,” Ms. Droba said. However, the process gets easier with time; the first approval may take a week, and the second several days, “because we know exactly what they’re looking for.

“Sometimes you get a rep on the phone who will rattle off a script and it could be wrong information,” she continued. “I have two benefit verifications done right off the bat for every patient, and if I don’t like what I’m hearing, if something doesn’t sound right, I’ll do a third and keep digging.”

Evernorth Health Services has a financial “benefit protection” platform called Embarc that covers certain gene therapy drugs. Participating health plans and clients pay a per-member, per-month fee to participate; the patient has no copay. “Many gene therapies can cost in the millions of dollars per patient, running the risk of bankrupting a small business with a single claim,” said Leslie Achter, the senior vice president of pharmacy benefit manager account management at Express Scripts by Evernorth. “For a small monthly fee per patient per month, Embarc offers significant protection, while ensuring access to these potentially lifesaving therapies.”

Pay-over-time contracts have been proposed as one model for helping payors manage the enormous up-front cost of gene therapy along with the attendant risk. (How long will the therapy’s benefits persist? What happens if a patient receives a gene therapy while covered by one health plan and then moves to another plan within a short time after Plan 1 has paid for therapy?)

But at this point, Orsini has no gene therapy contracts structured that way. “We have had several conversations on both the payor and manufacturer side, where everyone is thinking that it would make sense to think about pay-over-time or value-based contracts,” Mr. Farah said. “There are also several smaller companies trying to carve gene therapy out from the primary benefit and pooling it as a specific cell and gene benefit sold back to the employers. We haven’t yet had someone come to the table with a viable approach. As an industry we need all stakeholders to come together and agree about how we share the risk associated with these therapies in a way that will be transformative.”

‘Everything Is Personal for Us’

As soon as an approval is completed at Orsini, Ms. Droba’s team determines the delivery time and day and coordinates thawing time with this information, and monitors the therapy’s journey from the manufacturer to their pharmacy, using real-time tracking technology. Gene therapy manufacturers all have their own advanced high-tech systems for temperature control and monitoring of these gene therapies. For example, Novartis uses a system called evo to protect and track the journey of its SMA gene therapy, developed by New Mexico–based Savsu Technologies. “When we log into the portal, we can see not only exactly where the shipment is in real time, but whether the package was tilted and to what degree, and exactly what temperatures have been maintained throughout the shipment,” Ms. Droba said.

Gene therapy is not a nine-to-five job for the specialty pharmacy, she said. “We work on these day and night. Because we have such a dedicated team, all day long we are working on these specific patients, getting to know them and what they need, and building relationships with their families, doctors and care teams,” Ms. Droba said. “Everything is personal for us, and that’s why I feel like we can be as efficient as possible in getting the treatment they need in shortest time possible. [The patients] have enough problems and stress, and we do everything we can to make one part of their situation less stressful.”

Critics continue to say the Georgia Pathways to Coverage program falls short of expectations, but proponents say Georgia’s cumulative approach puts more people on private health insurance plans.

State officials initially indicated roughly 345,000 Georgians could qualify for the program. However, officials later said the estimated adoption rate would reach around 90,000 to 100,000 by 2025.

Less than 4,500 Georgians enrolled in Georgia Pathways to Coverage as of mid-June.

“Every Georgian deserves access to affordable health care,” Laura Colbert, executive director of Georgians for a Healthy Future, said in a recent announcement. “Unfortunately, the Pathways to Coverage program is falling far short of that vision for our state.

“Unfair paperwork requirements and other bureaucratic hurdles are keeping hard-working Georgians from getting covered,” Colbert added. “It’s time to remove these barriers to health coverage for uninsured Georgians, and to look at broader solutions to closing the coverage gap.”

In remarks this week, Republican Gov. Brian Kemp said Georgia Pathways and Georgia Access, a state-based exchange where Georgians can shop for health insurance, provide health coverage to more than 714,000 Georgians who earn less than 138% of the federal poverty level.

Georgia’s Office of the Insurance and Safety Fire Commissioner launched Georgia Access on Nov. 1, 2023, as a state-based exchange on the federal platform ahead of Open Enrollment 2024. Last week, state officials said the Centers for Medicare and Medicaid Services confirmed approval for Georgia to transition to a state-based exchange.

Citing September 2023 U.S. Census Bureau data, Georgia Access’ website indicates that 1.2 million Georgians do not have health insurance. According to remarks provided by his office, Kemp said that “through Georgia Access, 400,000 Georgians who were previously on Medicaid now have private sector insurance that provides better coverage, with more options, while saving taxpayer dollars.”

“To be clear, the rosiest projections for traditional Medicaid expansion estimate 500,000 people under 138 percent of the federal poverty limit would be eligible. Not actually enrolled – just eligible,” the governor added.

What’s more, analysts note that care and coverage are not the same.

“When we discuss Medicaid, it is important to remember that coverage does not mean care,” Chris Denson, Georgia Public Policy Foundation’s director of policy and research, recently told The Center Square via email. “Medicaid is a fundamentally flawed program. In Georgia, providers are paid, on average, 80 cents on the dollar for every Medicaid patient they see. As such, only 60% of Georgia physicians accept new Medicaid patients.

“The promise of Georgia Pathways comes from providing an opportunity for these enrollees to transition one day to commercial health insurance while receiving Medicaid coverage in the interim — by engaging in 80 hours each month of work, educational opportunities, or community service,” Denson added. “Even expanding Medicaid under the Affordable Care Act would only cover Georgians up to 138% of the federal poverty level.

“In Georgia, we provide fully subsidized coverage on the health insurance exchange for individuals up to 200% of the federal poverty level. Which provides a better deal for patients and providers alike.”

With tens of millions of enrollees now dropped from the Medicaid rolls, a group of 189 health care organizations have taken another step they hope will add permanency to the program. The coalition, organized by the Association for Community Affiliated Plans (ACAP) and Families USA, sent a letter on Aug. 13 to congressional leaders calling for 12-month continuous enrollment for adults enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).

They asked for support of the Stabilize Medicaid and CHIP Coverage Act, which was introduced in the House by Rep. Debbie Dingell (D-Mich.) in September 2023 and in the Senate by Sen. Sherrod Brown (D-Ohio) the next month.