Gov. Mark Sanford's vision of Medicaid for South Carolina is centered on "self-directed care," what some critics call the riskiest element in his proposed changes to Medicaid.

If the federal government approves, most of the state's 850,000 to 1 million Medicaid recipients will move from state-administered fee-for-service health care to managed health care administered by private insurance companies.

Using personal health accounts, all funded by Medicaid dollars, almost all the S.C. recipients would choose either to become part of a managed care organization, a medical home network or an alternative coverage option bought outside of Medicaid.

Sanford and state Health and Human Services Director Robbie Kerr, whose agency oversees Medicaid, say the self-directed option - S.C. Medicaid Choice - is a linchpin of their reform proposal. They say it would empower low-income patients covered by Medicaid by giving them a choice in their health care.

The risk is this: If a Medicaid recipient miscalculates his or her needs - developing a chronic illness or suffering a catastrophic accident, "the provider treats them as any other private pay patient," Sanford's plan states.

In that case, the Medicaid recipient - people who typically earn $1,241 a month for a family of three - would have to pay medical expenses not covered by their insurance or personal health account.

However, in nearly two months of negotiations, a mostly supportive-citizens 12-member advisory committee - hand-picked by Kerr - urged the state to severely restrict Sanford's self-directed care option, the centerpiece of his Medicaid reform.

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