SPECIAL NEEDS PLAN - MODEL OF CARE

Medicare Advantage Special Needs Plans (SNPs) are designed for specific groups of customers with special health care needs.

Eligibility

The three specific groups are:

  • "Dual eligible" beneficiaries (individuals who are eligible for both Medicaid and Medicare)
  • Individuals with chronic conditions
  • Individuals who are residents of a long-term care facility

In 2008, CMS issued the final regulation "Medicare Improvements for Patients and Providers Act of 2008," known as "MIPPA." This regulation mandated that all Special Needs Plans have a filed and approved Model of Care by January 1, 2010. The Patient Protection and Affordable Care Act reinforced the importance of the SNP Model of Care as a fundamental component by requiring NCQA review and approval.

The Model of Care is an evidenced-based process by which we integrate benefits and coordinate care for customers enrolled in Cigna-HealthSpring’s Special Needs Plans. The Model of Care facilitates the early assessment and identification of health risks and major changes in the health status of SNP customers with complex care needs, as well as the coordination of care to improve their overall health.

Goals

Cigna-HealthSpring’s Special Needs Plan Model of Care has the following goals:

  • Improve access to medical, mental health, and social services
  • Improve access to affordable care.
  • Improve coordination of care through an identified point of contact
  • Improve transitions of care across health care settings and providers
  • Improve access to preventive health services
  • Ensure appropriate utilization of services
  • Improve beneficiary health outcomes

Recently, the Centers for Medicare and Medicaid Services announced restructuring of the Quality Improvement Organization (QIO) program allowing two Beneficiary and Family-Centered Care (BFCC) QIO contractors to support program activities. The BFCC-QIO contactors will focus on conducting quality of care reviews, discharge and termination of service appeals, and other areas of required review.

Importantly, the Model of Care focuses on the individual SNP customer. SNP customers receive a Health Risk Assessment (HRA) within 90 days of enrollment and then, annually, within one year of completion of the last HRA. Based on the results of their assessment, an individualized care plan is developed using evidence-based clinical protocols. All SNP customers must have an individualized care plan. Interdisciplinary care teams are responsible for care management and support the assessment and care planning process.

Cigna-HealthSpring Primary Care Providers (PCPs) who treat SNP customers are core participants of their Interdisciplinary Care Team (ICT) and oversee clinical care plan development and maintenance. ICT participants include PCPs as well as practitioners of various disciplines and specialties, based on the needs of the customer. The customer may participate in the care team meetings, as may all health care providers. The plan-developed individualized care plan may be shared with all participants of the interdisciplinary care team, as indicated.

All providers are encouraged to participate in interdisciplinary care teams of SNP customers.

Cigna-HealthSpring uses a data-driven process for identifying the frail/disabled, customers with multiple chronic illnesses and those at the end of life. Risk stratification and protocols for interventions around care coordination, care transitions, barriers to care, education, early detection, and symptom management are also components of the SNP Model of Care. Based on the needs of plan customers, a specialized provider network is available to assure appropriate access to care, complementing each customer’s PCP.

Cigna-HealthSpring uses care transitions protocols and specific programs to support customers through transitions, connect customers to the appropriate providers, facilitate the communication process between care transition settings, promote customer self-management and reduce the risk for readmissions. Care transitions, whether planned or unplanned, are monitored, and PCPs are informed accordingly. PCP communication to promote continuity of care and ICT involvement is a critical aspect of Cigna-HealthSpring’s care transitions protocols.

Implementation of the SNP Model of Care is supported by systems and processes to share information between the health plan, health care providers and the customer. The SNP Model of Care includes periodic analysis of effectiveness, and all activities are supported by the Stars & Quality department.

For Dual SNP Customers

Providers may contact our Health Risk Assessment department to request patients’ HRA results at 1-800-331-6769.

To discuss and/or request a copy of an SNP customer’s care plan, refer an SNP customer for an Interdisciplinary Care Team meeting or participate in an Interdisciplinary Care Team meeting, please contact our Case Management department. Case Management Department phone number will vary by market:

State:   Contact:
Alabama, Georgia (All Counties excluding Catossa, Dade, and Walker),
Southern Mississippi, North Carolina, South Carolina and Northwest Florida
 1-866-382-0518
Illinois and Indiana  1-877-376-5193
Tennessee, Northern Georgia, and Eastern Arkansas  1-888-615-2709
Texas and Southwestern Arkansas  1-888-501-1116

For Chronic SNP Customers (Delaware, Maryland, Pennsylvania, and Washington DC only):

Providers may contact our Health Risk Assessment department to request a customer’s HRA results at 1-800-331-6769. To discuss and/or request a copy of a customer’s care plan, refer a customer for an Interdisciplinary Care Team meeting or participate in an Interdisciplinary Care Team meeting, please contact our Case Management department at

State:   Contact:
Maryland, Delaware, Washington DC, and Pennsylvania Providers should call: 1-877-562-4395

For Institutional SNP Customers (Delaware, Maryland, Pennsylvania, and Washington, DC only):

To discuss and/or request a copy of a customer’s comprehensive assessment results or care plan, refer a customer for an Interdisciplinary Care Teammeeting or participate in an Interdisciplinary Care Team meeting, please contact our Care Coordination department at 1-866-487-3004.