Special Needs Plan: What Happens After I Enroll? - Members

Combined / Pulmonary SNP Programs

After you return the completed enrollment form to become a member of a Special Needs Plan (SNP), Optimum HealthCare must verify your qualifying diagnosis with one of your doctors in order for you to join this Plan. This is done through our communication with your doctor, or you may receive an “Enrollment Qualification/Verification” form with a return envelope to take with you to your doctor to have completed and returned to us. This must happen within the first 30 days of your enrollment or you may not be able to stay enrolled in the SNP.

After your enrollment, you will receive health assessments for you to fill out and return to us. These assessments are very important in letting us know your current health status and where you may need assistance. These assessments are:

Initial Health Assessment

  • This assessment gives us a general idea of your health.

Disease Specific Assessment

  • This assessment gives us a very definite idea of how you are managing the disease that is qualifying you for this program.

Please complete the assessments and return them to us in the provided envelopes as soon as possible so we can begin assessing your needs.

Determining Level Of Care Needed

From the information you provide, you will be placed into one of three levels of care.

  • Tier 1»Your answers show that you are managing your health very well.
  • Tier 2»Your answers show that you are managing your health well, but also shows some areas where you may need some assistance.
  • Tier 3»Your answers show that you are having difficulty managing your health and/or psychosocial needs and may require more focused assistance from a Nurse Case Manager and/or Social Worker who will be contacting you for more information.

Each “tier” or level of care results in a Care Plan developed that is shared with your doctor to help in the management of your health care. These Care Plans are based on Evidence-Based Medicine and Clinical Practice Guidelines developed by professional organizations. The guidelines are available for you to read by selecting Special Needs Plan: Tools & Resources - Members. There is also a sample of the Tier 1 and Tier 2 Care Plans that can be reviewed by selecting “Care Plans” from the "Quick Links" section, "SNP Information".

Dual-Eligible Program

After you have enrolled and indicated that you qualify for Medicare and Medicaid benefits, the Plan will need to verify this information through communication with the Center for Medicaid and Medicare Services (CMS). Once verified, you will be enrolled. It is very important that you provide all necessary information to Medicaid to maintain your eligibility.
After verification, you will receive all the information that is stated above for the Chronic Disease Program in order to give us information to help you manage your health.

Last updated 10/01/2023