Model of Care


In accordance with Centers for Medicare and Medicaid Services (CMS), a Special Needs Plan (SNP) Model of Care (MOC) must provide the structure for care management processes and systems that will enable Medicare Advantage Organization (MAO) to provide coordinated care for special needs individuals. An MAO must design separate MOCs to meet the special needs of the target population for each Special Needs Plan it offers.

How it Works

From a Highmark Wholecare Health Member's perspective, the MOC will work as follows:

  • Shortly after a member enrolls with any of the Medicare Assured® plans, the member is given a Health Risk Assessment (HRA). The assessment is mailed to the member and the member is asked to complete all questions on the form. The member can return the assessment by mail, or if they prefer, to complete the assessment through the member portal or by telephone. If the form is not returned within a specified period of time, outreach calls will be made to the member to complete the assessment.
  • The completed HRA is reviewed by the Interdisciplinary Care Team (ICT) and an Individualized Care Plan (ICP) is developed.
  • The member’s Individualized Care Plan is based on the HRA responses, claims data and input from the primary care physician (PCP) whenever applicable.
  • The ICP is mailed to the member and available to the member’s PCP, specialists and other ICT members as requested.
  • The member receives a level of care management services as indicated on his/her ICP. At least annually, the member receives another health assessment to determine if the needs of the member have changed.
  • Referrals for care management services can be made at any time through Highmark Wholecare’s internal processes or by the PCP, member or member’s caregiver.

Model of Care Elements

Provider Attestation

Download the PDF

For more information, or for a hard copy of the Model of Care, download the PDF.


This information is issued on behalf of Highmark Wholecare, coverage by Gateway Health Plan, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 14 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 14 counties in northeastern Pennsylvania, 12 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.

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