Please review the MOC training and fill out the provider information at the bottom of the page. Click agree to acknowledge you have reviewed and understand Highmark Wholecare’s Model of Care Information and submit your attestation.
As a Special Needs Plan (SNP), Highmark Wholecare is required by the Centers for Medicare and Medicaid Services (CMS) to administer a Model of Care (MOC) Plan. In accordance with CMS guidelines, Highmark Wholecare’s SNP MOC Plan is the basis of design for our care management policies, procedures, and operational systems that will enable our Medicare Advantage Organization (MAO) to provide coordinated care for special needs individuals.
Our MOC has goals and objectives for targeted populations, a specialized provider network, utilizes nationally-recognized clinical practice guidelines, conducts health risk assessments to identify the special needs of beneficiaries, and adds services for the most vulnerable beneficiaries including, but not limited to, those beneficiaries who are frail, disabled, or near the end-of-life.
The SNP MOC includes 4 main sections: Description of the SNP population, Care Coordination, SNP Provider Network, and MOC Quality Measurement & Performance. This training will focus on the SNP Provider Network section, and explains what Highmark Wholecare expects from their providers.
Provider Network- The SNP provider network is a network of health care providers who are contracted to provide health care services to SNP beneficiaries. SNPs must ensure that their MOC identifies, fully describes, and implements the following elements for their SNP provider networks.
- Specialized Expertise
- Use of Clinical Practice Guidelines and Care Transition Protocols
- Model of Care Training
Within the above elements, Highmark Wholecare’s expectations of providers are explained in detail. The below is a summary of our provider network composition and responsibilities.
- Highmark Wholecare expects all network practicing providers to utilize established clinical practice guidelines when providing care to members to ensure the right care is being provided at the right time, as well as to reduce interpractitioner variation in diagnosis and treatment.
- We encourage practitioners to follow the adopted clinical practice guidelines, but allow practitioners to execute treatment plans based on a member’s medical needs and wishes. When appropriate, behavioral health guidelines are followed utilizing government clinical criteria.
- During a care transition, it is expected that the transferring facility will provide, within one business day, a discharge summary and care plan information to the receiving facility or if returning home, to the PCP and member.
- We expect all network practicing providers to receive MOC training annually. If there is a trend of continued non-attestation, those providers found to be non-compliant with the Model of Care may be targeted for potential clinical interventions. For those non-compliant providers, individual results such as, but not limited to, utilization patterns, hospital admissions, readmissions and HEDIS performance outcomes may be reviewed.
- We conduct medical record reviews at least annually. Reviews are conducted on PCPs, Specialty Care Practitioners, Behavioral Health Practitioners, and ancillary providers. Results from the review are communicated to providers and include opportunities for improvement and education.
- We provide multiple ways for providers to receive information about updates. Provider manuals and newsletters are located on the provider portal and website. Newsletters are updated quarterly and provide information regarding any new clinical programs or updates that would affect the provider’s communication with their direct pod or ICT. Provider manuals are updated annually and reviewed during annual trainings. Current manuals are always available on the provider section of our website.
- Our provider directories are continuously updated regarding taking new members, how long waiting lists are to see specialists, and other barriers that may affect the member.
Common MOC Terms and Definitions:
Members may ask you about the following information that is routinely discussed with their case manager.
- Health Risk Assessment (HRA) Survey: We utilize the HRA to provide each Medicare member a means to assess their health status and interest in making changes to improve their health promoting behaviors. The HRA is also used by the case managers to provide an initial assessment of risk that can generate automatic referrals for complex case management and then at least annually with continuous enrollment. Newly enrolled members identified from the Centers for Medicare and Medicaid Services (CMS) monthly enrollment file are requested to complete an initial HRA within 90 days of their effective date of enrollment as required by CMS Model of Care standards. Each member with a year of continuous enrollment is requested to complete a reassessment HRA within 12 months of the last documented HRA or the member’s enrollment date, if there is no completed HRA.
- Individualized Care Plan (ICP): Highmark Wholecare’s goal is to have Care Plans be as individualized as possible to include:
- Services specifically tailored to the member’s needs, including but not limited to specific interventions designed to meet needs as identified by the member or caregiver in the HRA
- Member personal healthcare preferences
- Member self-management goals and objectives, determined via participation with the member and/or caregiver
- Identification of:
- Goals and measurable outcomes
- Whether they have been “met” or “not met”
- Appropriate alternative actions if “not met”
- Interdisciplinary Care Team (ICT):Member care routinely demands a combination of efforts from physicians of various disciplines, registered nurses, and licensed social workers, as well as other pertinent skilled health care professionals and paraprofessionals. Comprehensive patient care planning involves coordination, collaboration, and communication between this ICT and the member.
As a provider, you are an important part of the member’s ICT. The ICT members come together to conduct a clinical analysis of the member’s identified level of risk, needs, and barriers to care. Once an Individualized Care Plan (ICP) is developed it is then reviewed with the member. The member’s agreement to work in partnership with his/her care manager, towards achievement of established goals, is obtained. The ICT analyzes, modifies, updates, and discusses new ICP information with the member and providers, as appropriate.
Highmark Wholecare’s Provider Portal should be utilized frequently for any communication regarding members, their individual ICP, or ICT. Additionally, please watch for the Provider Dashboard, which is sent to providers on a quarterly basis. This dashboard identifies members’ current care gaps and chronic disease conditions.
Other Important Information about Our MOC
We recognize that a member’s care needs are varied and subject to change. Policies and procedures have been put in place to allow members to receive the level of care management needed for their particular circumstance.
Members may be referred for Care Management in a variety of ways, including referral by Provider, a Highmark Wholecare employee, or self-referral by member.
Highmark Wholecare employees may refer members via the established internal process.
Oversight of the Model of Care Plan is managed by the Quality Improvement, Regulatory and Accreditation department. Specific questions with regard to the Model of Care Plan should be addressed with your Highmark Wholecare Provider Representative.