OVERVIEW

Gateway Health Plan® (Gateway) currently offers two Special Needs Plans (SNPs):

• Gateway Health Medicare Assured Diamond^SM –Is a Dual Eligible Special Needs Plan (DSNP) and covers those who have both Medicare Parts A & B and full Medical Assistance (Medicaid) or Qualified Medicare Beneficiary (QMB/QMB Plus) or Specified Low-Income Medicare Beneficiary (SLMB). Note: The Centers for Medicare & Medicaid Services (CMS) reminds all Medicare providers and suppliers, including pharmacies, that they may not bill beneficiaries enrolled in the QMB program for Medicare cost-sharing.

• Gateway Health Medicare Assured Ruby^SM– Is a Dual Eligible Special Needs Plan (DSNP) and covers those who have both Medicare Parts A & B and receive assistance from the state (benefit categories: Specified Low-Income Medicare Beneficiary (SLMB), Qualified Disabled and Working Individual (QDWI) or Qualified Individual (QI)).

As a Special Needs Plan (SNP), Gateway is required by the Centers for Medicare and Medicaid Services (CMS) to administer a Model of Care (MOC) Plan. In accordance with CMS guidelines, Gateway’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. An MAO must design separate MOCs to meet the special needs of the target population for each Special Needs Plan (SNP) it offers, meaning that Gateway has multiple MOCs.

Gateway has a MOC that has goals and objectives for the targeted populations, a specialized provider network, uses 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.

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 Gateway 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. There are three (3) elements in this MOC section:

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

Within the above elements, Gateway’s expectations of providers are explained in detail. The below is a summary of Gateway’s provider network composition and responsibilities.

• 1. Gateway 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 inter-practitioner variation in diagnosis and treatment.
• 2. Gateway encourages practitioners to follow the adopted clinical practice guidelines, but allows the practitioner to execute treatment plans based on member’s medical needs and wishes. When appropriate, behavioral health guidelines are followed utilizing government clinical criteria.
• 3. During a care transition, it is expected that the transferring facility will provide, within one business day, discharge summary and care plan information to the receiving facility or if returning home, to the PCP and member.
• 4. Gateway expects 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 noncompliant providers, individual results such as, but not limited to, utilization patterns, hospital admissions, readmissions and HEDIS performance outcomes may be reviewed.
• 5. Gateway conducts 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.
• 6. Gateway provides multiple ways for providers to receive information about Gateway updates. Provider manuals and newsletters are located on the Gateway provider portal and webpage. 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 given out during annual trainings. The manuals are also available on Gateway’s provider website.
• 7. Gateway expects provider directories to be 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: Gateway uses 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 ninety (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 twelve (12) months of the last documented HRA or the member’s enrollment date, if there is no completed HRA.

• Individualized Care Plan (ICP):Gateway’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, when possible
  • Member personal healthcare preferences, when possible
  • Member self-management goals and objectives, determined via participation with the member and/or caregiver, when possible

  • Identification of:

    • Gals and measureable 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 team members come together to conduct a clinical analysis of the member’s identified level of risk, needs and barriers to care, and an Individualized Care Plan (ICP) is developed and 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.

  Gateway’s Provider Portal should be utilized frequently for any communication regarding members, or their individual ICP or ICT. Additionally, please watch for the Provider Dashboard, which is sent to providers on a quarterly basis. This dashboard identify members’ current care gaps and chronic disease conditions.

Other Important Information about Gateway’s Model of Care

*Action Required – Please go to https://gatewayltd.insightincloud.com/model-of-care Fill out the provider information on the left hand side and review the MOC training. Click agree to acknowledge you have reviewed and understand Gateway’s Model of Care Information and submit your attestation.