Model of Care

In accordance with Centers for Medicare and Medicaid Services (CMS), a Special Needs Plan (SNP) Model of Care (MOC) must provide the structure for care management processes and systems that will enable the Medicare Advantage Organization (MAO) to provide coordinated care for special needs individuals. An MAO must design separate MOCs to meet the special needs of the target population for each SNP it offers.

How the Model of Care Works

The MOC works as follows:

1. Shortly after a member enrolls with Highmark Health Options Duals (HMO SNP), the member is given an initial Health Risk Assessment (HRA).
2. Instructions on how to complete the assessment are mailed to the member with their Welcome Kit.
   • The member can return the assessment by mail, or can complete it online, through the member portal, or by telephone.
   • If the form is not completed within a specified period of time, outreach calls will be made to the member to complete the assessment.
3. The completed HRA is reviewed by a member of Case Management and the member as appropriate, and an Individualized Care Plan (ICP) is developed.
4. The member’s ICP is based on the HRA responses, claims data and input from the primary care physician (PCP) whenever applicable.
5. The ICP is made available to the member online or via mail and available to the member’s PCP, specialists and other Interdisciplinary Care Team (ICT) members as requested.
6. The member receives a level of care management services as indicated on his/her ICP.

At least annually, the member receives another HRA to determine if their needs have changed.

Referrals for care management services can be made at any time through Highmark Health Options Duals established internal processes, or by the PCP or other provider, member, and/or member’s caregiver.

Model of Care Elements

Description of SNP Population

The Special Needs Plan includes the identification and comprehensive description of the SNP-specific population that addresses the full continuum of care of current and potential SNP beneficiaries, including end-of-life needs and considerations (if relevant). SNPs must include a complete description of specially tailored services for beneficiaries considered especially vulnerable using specific terms and details.

This MOC section contains two elements:

• Description of Overall SNP Population
• Subpopulation-Most Vulnerable Beneficiaries

Care Coordination

Care coordination helps ensure that SNP beneficiaries’ health care needs, preferences for health services, and information-sharing across health care staff and facilities are met over time. Care coordination maximizes the use of efficient, safe, and high-quality patient services (including services furnished outside the SNP’s provider network) that ultimately lead to improved health care outcomes.

This MOC section contains six elements:

• SNP staff structure includes administrative and clinical staff who facilitate oversight and care coordination for members/caregivers and how staff are trained.
• Health Risk Assessment (HRA) tool is used to gather the physical, mental, and socioeconomic health needs of members to develop the ICP annually.
• The ICP may consist of health and Social Determinant of Health (SDoH) goals that are gathered from the member/caregiver, HRA responses, claims data, encounter data, and clinical notes.
• The ICT is made up of a core group: the member/caregiver, a clinical care manager, and the physician they see most often (PCP or Specialist) to coordinate care and work towards goals established in the ICP.
• Care transition protocols consist of established processes for managing care transitions between health care settings with members/caregivers, practitioners, and treating providers.
• Face-to-face encounters can occur in person or through a virtual visit with a member of the ICT annually to deliver care to all members.

Provider Network

The SNP provider network is a network of health care providers who are contracted to provide health care services to SNP beneficiaries. SNPs must ensure that their MOC identifies, fully describes, and implements the following elements for their SNP provider networks.

This MOC section contains four elements:

• Specialized Expertise
• Model of Care Training*
• Use of Clinical Practice Guidelines
• Care Transition Protocols

*Network providers are expected to review and attest to MOC training annually.

Quality Measurement

The goal of performance improvement and quality measurement is to improve the SNP’s ability to deliver high-quality health care services and benefits to its SNP beneficiaries. Achievement of this goal may be the result of increased organizational effectiveness and efficiency through incorporation of quality measurement and performance improvement concepts that drive organizational change. The leadership, managers and governing body of a SNP organization must have a comprehensive quality improvement program in place to measure its current level of performance and determine if organizational systems and processes must be modified, based on performance results.

This MOC section contains five elements:

• MOC Quality Performance Improvement Plan
• Measurable Goals and Health Outcomes for the MOC
• Measuring Patient Experience of Care (SNP Member Satisfaction)
• Ongoing Performance Improvement and Evaluation of the MOC
• Dissemination of SNP Quality Performance Related to MOC