Special Needs Plan

Model of Care
(MOC)
Training

SPECIAL NEEDS PLAN MODEL OF CARE TRAINING

Objectives

At the end of this training, you'll be able to:

• Define the following terms
  • Model of Care (MOC)
  • Special Needs Plan (SNP)
    • Dual Special Needs Plan (D-SNP)
    • Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP)
• Understand the Centers for Medicare & Medicaid Services (CMS) requirements for SNP Models of Care
• Identify how you support the SNP Models of Care

SPECIAL NEEDS PLAN MODEL OF CARE

What is an SNP?

An SNP is a type of Medicare Advantage plan (like a health maintenance organization [HMO] or a preferred provider organization [PPO]):

• There are two types of SNPs:
  • Dual Eligible SNP (D-SNP)
  • Institutional SNP (I-SNP)
• BlueCare Plus Tennessee is a D-SNP

SPECIAL NEEDS PLAN MODEL OF CARE

Benefits for BlueCare Plus, Plus Choice and Select

BlueCare Plus is a Dual Eligible Special Needs Plan (D-SNP) for Medicare beneficiaries who are also eligible for Medicaid.

BlueCare Plus Choice and Select are Fully Integrated Dual Eligible Special Needs Plans (FIDE SNP) for Medicare beneficiaries who are also eligible for Medicaid and:

• Certain long-term services and supports (LTSS) benefits under the TennCare program as part of CHOICES Groups 1, 2 or 3.

All 3 plans cover benefits under the Medicare Advantage plan and coordinates Medicaid benefits through the TennCare managed care organization (MCO).*

Plan members generally have one or more comorbidities and medically complex chronic conditions.

*Some benefits may vary.

SPECIAL NEEDS PLAN MODEL OF CARE

What's the SNP Model of Care?

CMS requires all SNPs to have a Model of Care. It's a document reviewed and approved by CMS that describes:

• Basic framework to support the SNP in meeting the needs of each of its enrolled beneficiaries
• Infrastructure to promote and evaluate quality, care management and care coordination processes for the SNP

SPECIAL NEEDS PLAN MODEL OF CARE

The Four Core MOC Elements:

SPECIAL NEEDS PLAN MODEL OF CARE

MOC Elements 1 & 2

As providers you are a MAJOR component of successful Care Coordination!

SPECIAL NEEDS PLAN MODEL OF CARE

MOC Elements 3 & 4

Our high-quality provider network is essential to providing the best care to our members!

SPECIAL NEEDS PLAN MODEL OF CARE TRAINING

What is your role as a provider?

You are a key member of the ICT

• Your active participation as a member of ICT is crucial to members' health
• The ICT is composed of:
• Member and/or appropriate family/caregiver
• Care Coordination Team (Case Manager, Health Navigator and Pharmacy Technician)
• Treating providers (based on member’s expressed need and preferences, the team may expand to include other specialists and community support)

SPECIAL NEEDS PLAN MODEL OF CARE TRAINING

Roles of the Provider

Participate as an active member of the ICT to:

• Develop and execute the ICP with tailored goals specific to the member’s conditions and preferences
• The plan’s staff, as part of the ICT, will communicate updates to the ICP through secure notification methods such as mail, email, digital communication, and/or fax
• Conduct annual wellness exam, preventive screenings, and prioritized condition specific goals
• Review patient’s goals and provide feedback via the PACF
• Identify vulnerable, fragile, or at-risk members
• Perform face-to-face or virtual visits annually, or more frequently (based on needs)

SPECIAL NEEDS PLAN MODEL OF CARE TRAINING

Determining the Right Care Setting

As a Provider, we need your input.

• Through the Nursing Facility Diversion Program, the care coordination team works to allow members to continue living safely in the home and community-based settings.
• Members in home settings, inpatient settings and nursing facilities are all screened to determine the most appropriate setting for their care.
• Providers may receive requests for medical records or input regarding the most appropriate setting for the member.
• As the member’s provider you have the chance to assess components of the member’s living situation that are key to making the best decision (Caregiver situation, home environment, ADL’s, etc.).

SPECIAL NEEDS PLAN MODEL OF CARE

MOC Clinical Processes

SPECIAL NEEDS PLAN MODEL OF CARE

Your Role on the ICT

How does the team work together?

• You’re an essential part of the care team
• We ask providers to review the ICP and provide any comments or updates based on the member’s needs and communicate back to the plan.
• We rely on you to partner with us to provide the best care, by sharing changes in the member’s health status and clinical data.
  • This may include providing updates to the member’s ICP
  • Working with us and members to provide seamless and safe care transitions
  • Completing and submitting PACF

SPECIAL NEEDS PLAN MODEL OF CARE

ICT Activities

As a provider serving BlueCare Plus Tennessee D-SNP members, you're considered part of the ICT. Compensation is provided for provider participation in ICT activities.

• Our MOC requires that a PACF is performed annually with the member's primary care provider.
• Providers are encouraged to complete the PACF with an annual wellness visit.
• Submitting PACFs timely will reduce the number of unnecessary follow up faxes and/or phone calls.

*Claim must be filed with appropriate codes for reimbursement. Submitting PACF alone is not sufficient for reimbursement.

SPECIAL NEEDS PLAN MODEL OF CARE

ICT Activities: How to Participate

Complete the BlueCare Plus PACF:

https://bluecareplus.bcbst.com/docs/providers/BlueCare_Plus_Patient_Assessment_and_Care_Planning_Form.pdf

You can submit the PACF:

• In Availity® under the Quality Care Rewards Tool
• By fax to (423) 591-9504
• If the medical record contains all required elements of the PACF, we can accept it in place of the PACF

If you need training or help with the PACF or ICT processes, call our Care Coordination Team at 1-877-715-9503.

SPECIAL NEEDS PLAN MODEL OF CARE TRAINING

Quality Improvement

BlueCare Plus, BlueCare Plus Choice and BlueCare Plus Select annually select pertinent quality improvement measures to track and trend throughout the year to improve and monitor member health outcomes.

• Data is collected, analyzed and evaluated to measure the overall program performance.
• As a provider, and part of the ICT, you are expected to participate in quality improvement efforts to improve measures, such as:
• Annual Wellness Exams
• Care for Older Adults (COA) measures; medication review, pain assessment, and functional status screening
• Completion of care transition support i.e., timely follow-up visits with members post Emergency Department visit and/or inpatient hospital discharge
• Compensation is offered for participation in ICT activities (mentioned in previous slides)