Model of Care

• Overview
• SNP Model of Care Elements
• How the Model of Care Works for a Member
• Other Important Information About Gateway's Model of Care

Overview

Gateway Health Plan^® (Gateway) offers a Special Needs Plan (SNP), Medicare Assured^® HMO, for individuals who have Medicare Parts A and B, and Full or Qualified Medicare Beneficiary (QMB) Medicaid eligibility. These individuals are referred to as “dual-eligibles”.

As a SNP, Gateway is required by the Centers for Medicare and Medicaid Services (CMS) to administer a Model of Care Plan. The SNP Model of Care Plan is the architecture for care management policy, procedures, and operational systems.

SNP Model of Care Elements

1. Staff Structure and Care Management Roles

   There are three essential care management roles within Gateway’s Model of Care:

   • Administrative Roles – These roles involve the day-to-day operations of the plan such as processing enrollments, paying claims, and handling appeals and grievances.
   • Service Delivery Roles – These roles involve providing care to the beneficiary, including such things as Advocating, Informing and Educating Beneficiaries, Identifying and Facilitating Access to Community Resources, and ensuring that the member receives the care he/she needs.
   • Oversight Roles – These include oversight of both Administrative and Clinical functions. Some examples include Monitoring Model of Care Compliance, Assuring Statutory and Regulatory Compliance, and Evaluating the Model of Care Effectiveness; And, Monitoring the Interdisciplinary Care Team (see below), Assuring Timely and Appropriate Delivery of Services and Assuring Seamless Transitions and Timely Follow-up to care, and Conducting Chart Reviews
   
   
2. Provider Network Having Specialized Expertise and Use of Clinical Guidelines

   Gateway contracts with a network of providers with the clinical expertise pertinent to the Medicare Assured^® HMO population. The providers go through appropriate credentialing processes and are expected to use appropriate clinical guidelines in the care of Gateway’s members.

3. Health Risk Assessment (HRA)

   Health Risk Assessments are a set of questions designed to provide Gateway with an overview of a member’s health status and risks. Shortly after enrolling, each member is asked to complete a Health Risk Assessment, either by paper or over the phone. Reassessments are performed at least annually thereafter.

4. Interdisciplinary Care Team (ICT)

   EACH member of Medicare Assured^® HMO is assigned to an Interdisciplinary Care Team base upon his/her level of need as indicated by the assessment of the HRA. The composition of the team varies based on the needs of the member. Under most circumstances, the member’s Primary Care Physician (PCP) is included on the ICT. Whenever possible, the member or member’s caregiver is included as part of the team.

5. Individualized Care Plan (ICP)

   An individualized care plan contains goals, objectives and plan of care for the member. The ICP is developed by the ICT based on needs identified by the Health Risk Assessment.

6. Communication Network

   Gateway has a communication network to facilitate communication between the Plan, the member, providers, and when necessary the ICT. Communication is primarily handled via printed materials / reports, faxes, and telephone calls.

7. Performance and Health Outcomes

   Performance and health outcomes are measured in a variety of ways within Gateway. Some of these include the Medicare Health Outcomes Survey (HOS), the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, the Healthcare Effectiveness Data and Information Set (HEDIS) measures, various member surveys, and analysis of encounter data.

8. Measurable Goals.

   Using CMS guidelines, Gateway has established Model of Care goals that measure, and attempt to improve outcomes for things such as Access to Medical, Mental Health, and Social Services; Access to Preventable Health Services; and Cost-effective Service Delivery.

9. Model of Care Training

   Model of Care Training is provided to Gateway Medicare Assured^® HMO employees, sub-contractors, and providers at time of hire / contract, and annually thereafter.

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How the Model of Care Works for a Member

• Shortly after a member enrolls with Medicare Assured^® HMO, the member is given a Health Risk Assessment. The assessment is mailed to the member as part of the member’s new member packet. The member is asked to complete and return the form. If the form is not returned within a specified period of time, Care Management outreaches to that member by telephone.
• The completed Health Risk Assessment is reviewed, and based on that review, the member is assigned to an Interdisciplinary Care Team (ICT).
• The ICT develops the member’s Individualized Care Plan (ICP). Input is gathered from the primary care physician (PCP) whenever applicable.
• The ICP is communicated to the member, the member’s primary care physician (PCP), and other ICT members as appropriate; normally by mail.
• The member receives care 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.

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Other Important Information about Gateway’s Model of Care

• Gateway recognizes that member’s care needs are varied and are 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:
  • Providers may call 1-800-685-5212, option 1
  • Members may self-refer by calling 1-800-685-5212, option 1.
  • Gateway employee via an internal process.
• Oversight of the Model of Care Plan is handled by the Medicare Administration Department. Specific questions with regard to the Model of Care Plan should be addressed with your Gateway Provider Representative.

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