If you have a special needs plan (SNP), you’ve likely heard about care coordinators. Care coordinators are individuals who help organize health care for SNP members. Care coordinators help by communicating between providers, patients, and social services. This improves health outcomes and lowers costs by ensuring all members of a care team are on the same page.
What are Model of Care requirements for special needs plans?
The Centers for Medicare and Medicaid Services (CMS) requires that all SNP providers submit Models of Care. A Model of Care is a document that outlines how an SNP provider will coordinate care and address the unique needs of its members.
What types of plans must have approved Models of Care and care coordinators?
All SNPs must have approved Models of Care and provide care coordinators for members. This includes the three primary types of SNPs:
Dual-Eligible Special Needs plans (D-SNPs). Those who qualify for both Medicare and Medicaid are considered dually eligible. D-SNPs are Medicare Advantage plans that work with Medicaid to provide the benefits of both programs.
Chronic Condition Special Needs plans (C-SNPs). C-SNPs are Medicare Advantage plans for those with specific chronic conditions. These conditions are diabetes, chronic heart failure, or a cardiovascular disorder.
Institutional Special Needs plans (I-SNPs). I-SNPs are Medicare Advantage plans for those living in a long-term care setting. Institutional Equivalent Special Needs plans (IE-SNPs) are for those who receive care at home or in assisted living.
How are Models of Care approved?
Models of Care are submitted by SNP providers to the National Committee for Quality Assurance (NCQA). The NCQA scores the Models of Care based on these criteria:
- Care coordination: SNP providers must coordinate care between members and their care teams.
- Description of the population: SNP providers must submit a detailed breakdown of member demographics.
- Provider networks: SNP providers must offer a network of health care providers that can meet the needs of members.
- Quality measurement and performance improvement: SNP providers must document and track model performance. Metrics include preventive care use, medication adherence, and member satisfaction.
Based on these criteria, plan providers are given a score up to 100%. These scores correlate with plan approval durations. Top-scoring plans earn three years of approval.
Why are care coordinators important?
Care coordinators advocate on behalf of SNP members. They ensure primary care providers and specialists understand a member’s unique needs. They also schedule follow-up care and can organize stays in skilled nursing facilities.
What is the difference between a care coordinator and case manager?
Both care coordinators and case managers advocate on behalf of patients. But while care coordinators support members with day-to-day health care needs, case managers plan and monitor care.
What is the Health Risk Assessment (HRA) and what can I expect
CMS requires that all SNP members complete a Health Risk Assessment (HRA). The HRA is a standardized form that helps SNP providers collect critical member information.
The HRA is used to assess a member’s overall health and document various health conditions. The HRA also helps identify gaps in care and unique needs.
What is an individualized care plan and can I add authorized representatives?
An individualized or personalized care plan is a document that outlines a member’s unique medical, emotional, and social needs. These care plans provide a roadmap for condition management and treatment. They’re used by health care providers and families to outline treatment goals and monitor conditions.
To add an authorized representative to a care plan, schedule a meeting with your care coordinator. During this meeting, you’ll outline the representative’s role and formally document their addition to the care team.
How do I reach my care coordination team?
To reach your care coordination team, call the number on the back of your insurance card. If you’re a UHC SNP member, call the number on the back of your UCard or start a live chat on uhc.com.
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