Dual-Eligible Special Needs Plan - Medicaid and Medicare

Because of the complex health care needs of this population, The Health Plan has developed a specific model of care (MOC) to provide comprehensive care management to members enrolled in the D-SNP. The Health Plan’s MOC is a written document that describes the measurable goals of the program, along with The Health Plan staff structure and care management roles, and the use of clinical practice guidelines and protocols. The program includes both training for personnel and our providers, a health risk assessment tool to collect information on the health needs of the members as they enroll and the development of an individualize care plan for each member. Our communication efforts and care management strategies for the most vulnerable sub-populations represented in this product will be essential to ensure a performance which ensures optimal health outcomes.

Included in the MEASURABLE GOALS are:

  • Improving access to essential services including medical, behavioral health, and social services by providing a comprehensive network. D-SNP members will select a primary care physician and in many cases a secondary care physician appropriate to his or her clinical needs.
  • Streamlining the process of transition of care across health care settings by working with our physicians and other providers.
  • Improving access to preventive care as well as ongoing chronic needs.
  • Improving member health outcomes as reflected through annual HEDIS® data collection as well as member survey measures.
  • Providing each D-SNP member with an assigned case manager who can assess ongoing needs and access needed social services that are appropriate.

The above measurable goals are just a brief description of some of our areas of focus for this population.

Provider Reimbursement and Billing for D-SNP

The provider will bill The Health Plan for medically-appropriate covered services provided to the D-SNP member just as they currently do for our Medicare Advantage populations. The Health Plan will reimburse the provider for services rendered according to the member’s benefit plan, less any copays, coinsurance, or deductible amounts. The provider will then submit any balance associated with the copays, coinsurance, and deductibles directly to West Virginia or Ohio Medicaid programs.