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Provider Information on the WellCare Special Needs Plan (SNP) For WellCare Access and Select Plan Members

December 16, 2009

The 2008 Medicare Improvements for Patients and Providers Act (MIPPA) included new accountability measures for Medicare Advantage Plans. CMS notified Plans with MA Products that they were responsible for ensuring their member's increased access to preventative care and Mental Health Services.

In response to requirements of this Act, WellCare filed two plans with CMS, the Access and Select Plans, as focused, special needs Model of Care Plans. Access and Select Members are considered enrolled in a Special Needs Plan by virtue of being a "dual-eligible" member, meaning Medicare and Medicaid eligible.

SNP Programs typically have other requirements such as requiring that the member be institutionalized, or those having a chronic illness as a requirement for entry into the SNP Program. But these two requirements do not apply to the Access and Select Plan members.

A SNP Program Model of Care is the architecture for care management policy, procedures and operational system. SNP Programs require the following:

• A focused Model of Care Program with Coordination of Care through Case Management.
• Proactive identification of members for Case Management services using available data systems.
• Coordination of services for members with complex conditions and assistance for the members to access needed services, including mental health and social services.
• Trained case managers to help members regain optimum health or improved functional capacity in the right setting and in a cost-effective manner.
• Case Management involvement in developing a mandated, comprehensive health risk assessment of a members' condition, including clinical history, ADL's, Mental Health stats, caregiver resources, determination of available insurance benefits and resources, individual care planning and performance goal development, self management activities and a monitoring and follow-up schedule.
• An interdisciplinary care team approach to managing a member's care including collaborative PCP involvement with the Care Team.
• A network of providers with special expertise in caring for Medicare Advantage members, model of care training, use of clinical guidelines, health outcome measures, goals, staff structure and roles, and a communication network.
• Management of the process of care transitions and identification of problems that could cause transitions, and, where possible, prevent unplanned transitions.
• Coordination of Medicare and Medicaid benefits and services for members.

Access and Select SNP Members may be referred into case management services through multiple avenues. These include hospital discharge planner referral, disease management referral, UM referral, if applicable, member self-referral, practitioner referral, Health Information Line referral.

Initial and annual training is required for Case Management staff and Providers involved in caring for Access and Select SNP members. This informational piece on the WellCare Access and Select SNP Program Model of Care serves as training for HFNI Physicians. Physicians may also view the brief PowerPoint SNP slide training on the HFNI website.

Physicians will receive member care plans throughout the year for existing and new members, including each time the Care Plan is updated. WellCare is requesting Physician participation to review the faxed Care Plan for each SNP member to whom they provide care; to update each care plan with any changes and send it back to the case manager; to communicate with the Interdisciplinary Care Team (ICT) as requested, to ensure optimal coordination of care and transition of care. SNP Model of Care Training ProgramPP.pptx

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