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 |
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