Special Needs Program Model of Care Training 2013

Transcription

1 Special Needs Program Model of Care Training 2013 Medical Management Department Presented by: Emblem Health February 1, 2013

2 TABLE OF CONTENTS Special Needs Plans: Overview.. Slide 4 Special Needs Plans: Definition...Slide 5 EmblemHealth Special Needs Plan Model of Care.. Slide 6 Goals for Our Members.Slide 7 Operation...Slide 8 Health Risk Survey (HRS)...Slide 9 Individualized Care Plan...Slide 10 Individualized Care Plan: Generation. Slide 11 Communication With SNP Team...Slide 12 Achieving Our SNP Goals Slide 13 How EmblemHealth Ensures Meeting SNP Goals..Slide 14 2

3 TABLE OF CONTENTS CONTINUED SNP Members Managed by Delegates...Slide 15 Special Needs Plans: Members Eligible for Medicaid Slide 16 Special Needs Plans Medicaid Advantage Plans..Slide 17 Special Needs Plans: Other Contracts.Slide 18 Dual Eligible SNP Program Descriptions.Slide 19 Dual-eligible SNP 2013 Eligibility Requirements...Slide 20 Dual-eligible Members and Cost Sharing.Slide 21 Dual Eligible HMO SNP...Slide 22 Dual Eligible HMO SNP: Plan Information Slide 23 Dual Eligible PPO SNP Slide 24 Dual Eligible PPO SNP: Plan Information.Slide 25 3

4 SPECIAL NEEDS PLANS - OVERVIEW A Special Needs Plan is a Medicare Advantage product that has been designated by CMS (Centers for Medicare and Medicaid Services), through a plan-submitted application, to have the ability to limit enrollment to a specific criteria. There are three types of Special Needs Plan options: Institutionalized Dual Eligible Chronic Conditions (e.g., diabetes, chronic heart failure (CHF)) Plans are expected to tailor their benefit packages to meet the needs of the population they are servicing. Members who lose their Special Needs Status are entitled to a grace period to give them an opportunity to regain their status, but must be disenrolled at the end of the grace period if status is not regained. 4

5 SPECIAL NEEDS PLANS: DEFINITION Medicare SNPs (Special Needs Plans) are specially designed for Medicare recipients. SNP Plans have the following features: Enrollment is limited to Medicare beneficiaries within the target SNP population. Benefit plan is custom-designed to meet the needs of the designated population. SNP members normally have additional election periods to change their Medicare coverage. 5

6 THE EMBLEMHEALTH SPECIAL NEEDS PLAN MODEL OF CARE The EmblemHealth SNP Model of Care is a service delivery mechanism that contains the following elements: Measurable goals Staff structure and care management roles Interdisciplinary care team Provider network having special expertise and use of clinical practice guidelines Model of care training Health risk assessment (HRA) Communication network Performance and health outcome measurements 6

7 GOALS FOR OUR MEMBERS Emblem Health s SNP Model of Care goals fall into six categories. Improve and assure the members receipt of: 1. Access to affordable care and medical, mental health, social and preventive health services 2. Coordinated care through an identified point of contact 3. Transition of care across health care settings and practitioners 4. Appropriate services 5. Cost-effective services 6. Beneficiary health outcomes 7

8 OPERATION Our SNPs have an appropriate medical team with clearly defined roles. The team possesses the infrastructure necessary to coordinate the plan of care and provide appropriate staff and program oversight. The Care Management staff assumes an important role in developing and implementing the individualized care plan, coordinating care and sharing information with the interdisciplinary care team and the member. The provider network provides broad practitioner representation from the medical, diagnostic and treatment arenas, thereby offering the specialized expertise to care for members within the dual-eligible SNP population. 8

9 HEALTH RISK SURVEY The health risk survey (HRS) is a customized survey tool that is sent to Medicare SNP members upon initial enrollment and annually thereafter. The HRS asks members questions about their current health status. This information is an important evaluation mechanism. If a completed survey is not received, a follow up with the member is initiated. The survey results are collected, analyzed and used to help develop the individualized care plan. 9

10 INDIVIDUALIZED CARE PLAN The individualized care plan (ICP) is the initial and ongoing mechanism for evaluating the member s current health care condition and medical history, and for formulating an action plan to address areas of concern. Since members can have varying levels of health (ranging from very healthy to very unhealthy), the ICP provides a structure to organize the outreach for the interdisciplinary care team and to document results. The ICP is re-evaluated on a regular basis or if the member s health status undergoes a substantial change. 10

11 INDIVIDUALIZED CARE PLAN: GENERATION ICPs are generated in the Care Management data system, based on the responses from the newly enrolled HRS and annual HRS surveys. The care plans are routed to Case Management and are reviewed to identify clinical issues. Cases are assigned to the appropriate resources (e.g., Case Management, Behavioral Health or Disease Management) for Medical Management. 11

12 COMMUNICATING WITH THE SNP TEAM The SNP has regular care coordination and case roundtable meetings to discuss the needs, challenges and successes of SNP members. The member cases that are discussed at these meetings will be selected based on various criteria, including poor health status, not meeting SNP goals or the sharing of best practices. If you are needed at one of these team meetings, we will make every effort to accommodate your schedule. However, it is important that you make yourself available to discuss your SNP patients as needed so that we can work together to move these members towards their optimal health status. 12

13 ACHIEVING OUR SNP GOALS We will know if we have achieved our goals for the SNP population by reviewing the available outcome measures. These reviews are part of the Quality Management (QM) and Utilization Management (UM) processes. 13

14 HOW EMBLEM HEALTH ENSURES MEETING SNP GOALS Emblem Health will closely monitor the following items to determine if we have met the SNP goals and if we need to make modifications to the SNP program: Member satisfaction with health services and health status Reduction of: - Hospitalizations - Skilled nursing facility placements Improvement of: - Self-management and independence - Mobility and functional status - Pain management - Quality of life 14

15 SNP MEMBERS MANAGED BY DELEGATES Delegates are responsible for performing all of the required SNP Model of Care functions to ensure compliance with the structure and process measures as well as with NCQA (National Committee for Quality Assurance) and CMS (Centers for Medicare and Medicaid Services) requirements. Delegates must: Develop an individualized plan of care for SNP members Monitor SNP transition-of-care requirements for their enrolled UM (Utilization Management) members Report on all of the SNP 1 and SNP 4 required measures to the plan Report SNP results by CMS Plan Benefit Package 15

16 SPECIAL NEEDS PLANS MEMBERS ELIGIBLE FOR MEDICAID Emblem Medicare has two Special Needs Plans in which enrollment is limited to beneficiaries who are eligible for Medicaid: Dual Eligible (HMO SNP) Dual Eligible (PPO SNP) 16

17 SPECIAL NEEDS PLANS - MEDICAID ADVANTAGE PLANS Both SNPs currently have Medicaid Advantage Plans attached to them for some members: Medicaid Advantage: State program for HMO or PPO members who are Full Benefit Dual Eligible members (receive full Medicaid). State provides additional capitation. Any Dual plans: No state capitation. Members may be full or partial dual (MSP). The PPO Medicaid Advantage plans are slated to terminate 1/1/13. 17

18 SPECIAL NEEDS PLANS OTHER CONTRACTS Emblem Medicare administers two types of Special Needs Plans for other contracts. GuildNet: HMO POS Special Needs Plan with a Medicaid Advantage Plus State contract Archcare: HMO Specials Needs Plan for Institutionalized beneficiaries 18

19 DUAL-ELIGIBLE SNP PROGRAM DESCRIPTIONS Any Dual Program (HMO and PPO) Medicare Advantage program that provides Medicare benefits through the plan. Members normally obtain additional Medicaid services through the Medicaid program, if coverage is available. Medicaid Advantage Program (HMO and PPO) Integrated program that provides Medicare and some Medicaid benefits through the plan. Member must have full Medicaid and sign an additional form to enroll. Managed Long Term Care Program (MLTC) (HMO only) Integrated program that provides Medicare and full Medicaid benefits through the plan. Member must have full Medicaid and must meet additional clinical requirements to enroll. 19

20 DUAL-ELIGIBLE SNP 2013 ELIGIBILITY REQUIREMENTS To join one of our Medicare Advantage dual-eligible SNPs in 2013, the individual must: Have Medicare Part A and Part B coverage. (Beneficiaries are eligible for Medicare through age [65 or older] or disability.) Live in the county where the plan they wish to join is offered Not have end stage renal disease (unless already enrolled in an EmblemHealth plan) Be eligible for some level of Medicaid coverage (Medicaid coverage level is normally determined by income and can range from payment of the Medicare Part B premium for higher income individuals to full medical coverage for lower income individuals.) 20

21 DUAL-ELIGIBLE MEMBERS AND COST SHARING SNP members have nominal cost sharing amounts for their covered services. SNP members can not be charged a copay (cost sharing amount) greater than the copay amount associated with their Medicare SNP benefit plan. Providers may bill the Medicaid program for payment of Medicaid-covered services if the benefit is not covered by the plan. 21

22 DUAL ELIGIBLE HMO SNP The Dual Eligible HMO SNP contains 3 subsets: Any Dual Plan Medicaid Advantage Plan Managed Long Term Care Plan (HMO only) 22

23 DUAL ELIGIBLE HMO SNP: PLAN INFORMATION Service Areas: New York City and Nassau, Suffolk and Westchester counties General SNP Information Link: med-special-needs-plans.html See Summary of Benefits for Dual Eligible HMO SNP benefit and cost information: Dual_Elig_SNP.pdf 23

24 DUAL ELIGIBLE PPO SNP The Dual Eligible PPO SNP contains 2 subsets: Any Dual Plan Medicaid Advantage Plan 24

25 DUAL ELIGIBLE PPO SNP: PLAN INFORMATION Service Areas: New York City and Nassau, Suffolk and Westchester counties General SNP Information Link: med-special-needs-plans.html See Summary of Benefits for Dual Eligible PPO SNP benefit and cost information: Dual_Elig_SNP.pdf 25

26 THANK YOU