The Plan ensures all Providers delivering care to our SNP members are properly educated regarding the unique needs of this population. The Plan makes every effort to offer and provide SNP Education training for all Providers. PCPs are required to attest that they have received initial education regarding the Special Needs Plan at the time of orientation and will then attest to an annual re-education regarding these services.
Chronic Disease Plans
After the member has completed the enrollment form to become a member of a Special Needs Plan (SNP), Optimum must verify with a physician that the member does in fact have the diagnosis to qualify them to join this Plan. This is done through our communication with you by using the “Enrollment Qualification/Verification” form and return envelope. It is very important that this form be returned within the first 30 days of the requested enrollment or the member may not be able to stay enrolled in the SNP.
After their enrollment, the member will receive health assessments that need to be completed and returned to us. These are very important in letting us know the member’s current health status and where they may need assistance. These assessments are:
Initial Health Assessment
- This assessment gives us a general idea of the member’s health.
Disease Specific Assessment
- This assessment gives us a very definite idea of how the member is managing the disease that is qualifying them for this program.
Determining Level Of Care Needed
From all this information the member has provided, they are then risk-stratified into three levels or tiers of care.
- Tier 1: The answers show that the member is managing their health very well
- Tier 2: The answers show that the member is managing their health well, but does show some areas where there may need to be more concerted effort.
- Tier 3: The answers show that the member is having trouble in managing their health and/or psychosocial needs and will require more focused assistance from a Nurse Case Manager and/or Social Worker who will be coordinating care and services with you.
Each “tier” or level of care generates a Care Plan that is shared with the provider to help in the management of the member’s healthcare. These care plans are based on Evidence-Based Medicine and Clinical Practice Guidelines developed by professional organizations. The guidelines are available for you on the ”Clinical Practice Guidelines” section. There is also a sample of the Tier 1 and Tier 2 Care Plans that can be reviewed in the “Care Plans” section.
After verification, the member will receive all the information that is stated above for the Chronic Disease Plans in order to give us information to help better manager their healthcare.
Dual Eligible Plans
After the member has enrolled and stated that they 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, the member will be enrolled.
Dual eligible members receive all their health care through the benefits supplied by their Special Needs Plan. There is no coordination or billing to Medicaid for any services.
More information is available on the “Providers Tools and Resources” page under SNP Provider Training. If you are a primary care physician and have not received any training on the Special Needs Plans then please contact your Provider Relations Representative to schedule an education session.