Special Needs Plan Information - Providers

Special Needs Plans (SNP) offer services and benefits specially tailored for people who have certain chronic diseases or are dual eligible (receive both Medicare and Medicaid benefits).

Introduction

Optimum Health Care offers Special Needs Plans (SNPs) for members who have either certain chronic diseases or are Dual-eligible (receive both Medicare and Medicaid benefits). The following SNPs are available:

  • Chronic Combined SNP- for members with Diabetes, Cardiovascular Disease or Chronic/Congestive Heart Failure
  • Chronic Pulmonary SNP- for members with Chronic Lung Disorders
  • Dual Eligible SNP- for members who receive both Medicare and Medicaid benefits 

Chronic Combined SNP

The chronic diseases that are included under the Chronic Combined SNP are:

  • Diabetes
  • Cardiovascular Disease for the following only:
    • Cardiac Arrhythmias
    • Coronary Artery Disease
    • Peripheral Vascular Disease
    • Chronic Venous Thromboembolic Disorder
    • Chronic/Congestive Heart Failure

Chronic Pulmonary SNP

The chronic diseases that are included under the Pulmonary SNP are:

  • Chronic Lung Disorders
    • Chronic Obstructive Pulmonary Disease which includes Chronic Bronchitis, Asthma and Pulmonary Fibrosis

Dual Eligible SNP

The Dual Eligible SNP includes all members who qualify for Medicare and Medicaid benefits and is not based on any chronic disease.

Special Needs Plan: How Do Members Qualify and Enroll?

To qualify for the Special Needs Plans (SNPs) the member lets the Plan know that they have one of the chronic diseases that were discussed on the “Introductory” page or that they qualify for Medicare and Medicaid benefits.

Chronic Combined or Pulmonary SNP

A member may qualify and enroll in one of these Plans at any time during the year. If the member did not have one of these chronic diseases at the time of their initial enrollment, but do now, they may qualify to change to one of these SNPs.

Once the member has requested enrollment into a Special Needs Plan, Optimum HealthCare will have to receive confirmation from a physician that they do indeed have one of these diseases before their enrollment is completed. You or the member will receive an “Enrollment Qualification/Verification Form” with a return envelope that must be completed by a physician and returned to Optimum HealthCare before enrollment can be completed.

Dual Eligible SNP

Dual eligible beneficiaries are classified as either full or partial dual eligible, depending on their current income level and other qualifying criteria. Optimum HealthCare will confirm their level of eligibility at the time of their request for enrollment and will later receive confirmation of their actual level from Centers for Medicaid and Medicare Services (CMS) soon after enrollment. The information from CMS will be the deciding factor of their eligibility for this program.

If you would like more information regarding these Plans or would like to recommend a member for enrollment, please contact Member Services.

Special Needs Plan: What Happens After Enrollment?

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.

Special Needs Plan: Case Management - Provider

The Special Needs Plan (SNP) provides Case Management assistance to all members, but primarily assists those that are determined to need the most help (Tier 3). Case Managers are nurses who work with you to improve your patient’s ability to manage their health. This program also includes Social Workers who can help with community resources assistance.

Getting enrolled in Case Management
There are several ways a member can be enrolled in Case Management:

1. Information on Health Assessments:
The information given on the health assessments determines if your patient needs the services of a Case Manager or Social Worker. Your patient will be called by the Nurse or Social Worker to talk about their healthcare and/or social needs.

2. Member Referral (Member, Family or Caregiver)
If the member feels that they may need the help of a Case Manager or Social Worker, they may call us at 1-888-211-9913 any time and ask to speak to a Case Manager or Social Worker to be evaluated.

3. Provider Referral
If you feel that your patient may need help from a Case Manager or Social Worker, you can complete a Case Management/Social Service Referral form which is provided to you in the Provider Manual and fax it to Case Management at 1-888-314-0794. Your patient will then be called to see if they would like to participate in this service.

Case Management is strictly voluntary. They will be asked at the beginning of the conversation if they wish to participate in Case Management and at that time they may say “yes” or “no”. If they first say, “yes” and later decide they do not want to remain in Case Management, they can elect to stop receiving services at any time.

Care Plans

All members enrolled in the SNP have a Care Plan developed that is provided to you as a reference tool in managing their health care. You can see an example of a Care Plan for Tier 1 and Tier 2 members in the Care Plans section.

Care Plans take the information your patient has provided about their health and then determines what steps should be taken to help them reach their highest level of health. These Care Plans are based on Evidence-Based Medicine and Clinical Practice Guidelines.

If your patient is enrolled in Case Management, the Care Plan will be more detailed and will be developed by you, the patient and the Case Manager. This Care Plan will be provided to you.

Special Needs Plan: Care Plans - Provider

Every member enrolled into a Special Needs Plan (SNP) has a Care Plan developed specifically from the responses given on the Disease Specific Assessment. Member responses on the Initial Health Assessment Tool will also provide the Plan with information regarding their health as well as functional and emotional needs. From those responses, members are placed into one of three “tiers.”

Tier 1:

These Care Plans are for members who are adequately and appropriately managing their disease. The Care Plan that will be available to you for these members are based on Clinical Practice Guidelines for the monitoring of these diseases. Below is a link of a Tier 1 Care Plan sample.

Tier 2:

These Care Plans are developed based on the individual responses the member provided on their Disease Specific Assessment. These Care Plans will be mailed to you for inclusion in the patient's medical record as a helpful tool in managing their health outcomes. Below is a link of a Tier 2 Care Plan sample.

Tier 3:

These Care Plans are developed in coordination with the member’s assigned Nurse Case Manager and/or Social Worker who will contact the member and do another in-depth assessment of the member’s needs. This Care Plan will be coordinated through information from you and the member and will include specific interventions and goals to help the member reach their maximum health and psychosocial potential. Tier 3 Case Management is strictly voluntary for members and they may elect to “opt out” or not receive these services.

Examples of Care Plans

Care Plan Manual with Tier 1 & Tier 2 Care Plan Samples

SNP - Provider Tools & Resources

Last updated 10/15/2019

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