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

Description of SNP Population

Identification and comprehensive description of the SNP-specific population that addresses the full continuum of care of current and potential SNP beneficiaries, including end-of-life needs and considerations (if relevant). SNPs must include a complete description of specially tailored services for beneficiaries considered especially vulnerable using specific terms and details. This MOC section contains 2 Elements:

  • Description of Overall SNP Population
  • Subpopulation-Most Vulnerable Beneficiaries

Care Coordination
Care coordination helps ensure that SNP beneficiaries’ health care needs, preferences for health services and information sharing across health care staff and facilities are met over time. Care coordination maximizes the use of effective, efficient, safe, high-quality patient services (including services furnished outside the SNP’s provider network) that ultimately lead to improved health care outcomes. This MOC section contains 5 Elements: 

  • SNP Staff Structure 
  • Health Risk Assessment Tool (HRAT) 
  • Individualized Care Plan (ICP) 
  • Interdisciplinary Care Team (ICT) 
  • Care Transition Protocols

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. This MOC section contains 3 Elements:

  • Specialized Expertise
  • Use of Clinical Practice Guidelines and Care Transition Protocols
  • Model of Care Training

Quality Measurement
The goal of performance improvement and quality measurement is to improve the SNP’s ability to deliver high-quality health care services and benefits to its SNP beneficiaries. Achievement of this goal may be the result of increased organizational effectiveness and efficiency through incorporation of quality measurement and performance improvement concepts that drive organizational change. The leadership, managers and governing body of a SNP organization must have a comprehensive quality improvement program in place to measure its current level of performance and determine if organizational systems and processes must be modified, based on performance results. This MOC section contains 5 Elements:

  • MOC Quality Performance Improvement Plan
  • Measureable Goals and Health Outcomes for the MOC
  • Measuring Patient Experience of Care (SNP Member Satisfaction)
  • Ongoing Performance Improvement Evaluation of the MOC
  • Dissemination of SNP Quality Performance Related to MOC

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




To Top