Medicare Advantage SNP CMS Requirements

Provider Type

Physicians
Participating Physician Groups (PPG)

The Medicare Improvements for Patients and Providers Act (MIPPA) mandates that all health plans have in place an evidence-based model of care program with the appropriate networks of providers and specialists. Requirements include:

Case management program for all members.
An initial health risk assessment within 90 days of member enrollment and annual reassessment of the individual's physical, psychosocial and functional needs.
Development of an individualized care plan in consultation with the individual, if needed, that identifies goals and objectives, including measuring outcomes, as well as specific services and benefits to be provided.
The member’s risks are stratified to develop the care plan.
An interdisciplinary care team in the management of care.
Management of transitions - the organization monitors information on all members and identifies those who are at risk of experiencing a problem that could lead to a change in health status and a transition. Transition examples include transition from usual setting, such as home to hospital, skilled nursing facility, acute rehabilitation and inpatient hospice. Management of transitions includes communication of the care plan across care settings.
Measurement of health outcomes and indices of quality to evaluate the effectiveness of the care management plan.

SNP Model of Care Goals

The Centers for Medicare & Medicaid Services' (CMS') model of care plan is a member-centric model designed to identify, acknowledge and incorporate the member's unique needs and goals into a cost-effective, individualized care plan. The program is designed to:

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

The health plan owns the responsibility for all state specific and CMS required reporting based on regulations established by the Department of Health Care Services (DHCS) and CMS with regard to members enrolled in the SNP.

Care Coordination Road Map

Wellcare By Health Net providers can refer to the table below for an outline of responsibilities by the Health Plan, the provider group and for those that are shared between both.

The Health Plan	Shared Responsibilities	Provider Group
Outreach of members identified for Care Management as post discharge and/or high priority based on provider notifications and/or internally derived algorithms Conduct assessments with members Create member-centric and member approved individualized care plans (ICP) ICP creation/revisions (and related outreach) Provider collaboration as a member of the interdisciplinary care team (ICT) Coordinate/collaborate with the ICT team based on member risk/acuity/needs ·Facilitate ICT/IDCT meetings (and related outreach) as needed Coordination of care Assist with referrals to community-based resources for SDoH needs Assist with access to benefits to address member identified needs Address gaps in care	Coordination or referral for services, as needed Support managing chronic conditions to reduce hospitalizations	Timely notification of admissions, transfers, or discharges to/from facilities to the Plan if the PPG is responsible for prior authorizations/claims Authorize all needed services where the provider group is/remains delegated for utilization management, if applicable Communicate with Health Plan Case Management, as needed, to exchange information and ensure smooth transitions Participation on ICT/IDCT, if invited Facility timely post-discharge appointments to PCP and or specialist, document efforts Conduct care coordination on patient population based on need. Refer high risk/catastrophic members to Wellcare By Health Net for case management, if applicable Coordinate activities with Wellcare By Health Net’s case managers and ancillary providers as indicated

The Health Plan

Shared Responsibilities

Provider Group

Outreach of members identified for Care Management as post discharge and/or high priority based on provider notifications and/or internally derived algorithms
Conduct assessments with members
Create member-centric and member approved individualized care plans (ICP)
ICP creation/revisions (and related outreach)
Provider collaboration as a member of the interdisciplinary care team (ICT)
Coordinate/collaborate with the ICT team based on member risk/acuity/needs
·Facilitate ICT/IDCT meetings (and related outreach) as needed
Coordination of care
Assist with referrals to community-based resources for SDoH needs
Assist with access to benefits to address member identified needs
Address gaps in care

Coordination or referral for services, as needed
Support managing chronic conditions to reduce hospitalizations

Timely notification of admissions, transfers, or discharges to/from facilities to the Plan if the PPG is responsible for prior authorizations/claims
Authorize all needed services where the provider group is/remains delegated for utilization management, if applicable
Communicate with Health Plan Case Management, as needed, to exchange information and ensure smooth transitions
Participation on ICT/IDCT, if invited
Facility timely post-discharge appointments to PCP and or specialist, document efforts
Conduct care coordination on patient population based on need.
Refer high risk/catastrophic members to Wellcare By Health Net for case management, if applicable
Coordinate activities with Wellcare By Health Net’s case managers and ancillary providers as indicated