Introduction

AMH Health, LLC is offering Special Needs Plans (SNPs) to people eligible for both Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. Some SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid, which include supplemental benefits such as hearing, dental, vision, and transportation to medical appointments. Some SNP plans include a card or catalog for purchasing over-the-counter items, but SNPs do not charge premiums.

 

SNP members benefit from a model of care (MOC) that is used by ME AMH Health to assess needs and coordinate care. Each member receives a comprehensive health risk assessment (HRA) within 90 days of enrollment and annually thereafter, which covers physical, behavioral, and functional needs, along with a comprehensive medication review. The HRA is then used to create a member care plan. Members with multiple or complex conditions are assigned a health plan case manager.

 

SNP HRAs, care plans, and case managers support members and their providers by helping identify and escalate potential problems for early intervention, ensuring appropriate and timely follow-up appointments plus providing navigation and coordination of services across the Medicare and Medicaid programs.

 

Provider training required

Providers contracted for SNP plans are required to complete an annual training to keep up-to-date with plan benefits and requirements, including details on coordination of care and MOC elements. Every provider contracted for SNP is required to complete an attestation stating they have completed their annual training. These attestations are located at the end of the self-paced training document.

 

To take the self-paced training, please go to the MOC Provider Training link at https://www.availity.com.

 

How to access the Custom Learning Center on the Availity Portal:*

  1. Log in to the Availity Portal at https://www.availity.com.
    1. At the top of the Availity Portal, select Payer Spaces and select the appropriate payer.
  2. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
  3. In the Custom Learning Center, select Required Training.
  4. Select Special Needs Plan and Model of Care Overview.
  5. Select Enroll.
  6. Select Start.
  7. Once the course is completed, select Attestation and complete.

 

Not registered for the Availity Portal?

Have your organization’s designated administrator register your organization for the Availity Portal.

  1. Visit https://www.availity.com to register.
  2. Select Register.
  3. Select your organization type.
  4. In the Registration wizard, follow the prompts to complete the registration for your organization.

 

Questions & Answers

 

What does it mean to be dual-eligible? What is a D-SNP?

The term dual-eligible refers to people with Medicare coverage who also qualify for some type of state Medicaid benefit — meaning that these members are eligible for both Medicaid and Medicare. These individuals may have higher incidence of chronic conditions, cognitive impairments, and functional limitations. D-SNPs are special Medicare Advantage plans that enroll only dual-eligible people, providing them with more intensive coordination of care and services than those offered by traditional Medicare and Medicare Advantage plans.

 

What is a SNP Model of Care?

The Centers for Medicare & Medicaid Services (CMS) requires Special Needs Plans (SNPs) to have a model of care (MOC) that describes how the SNP will administer key components of care management programs, including assessments and training. The MOC describes the unique needs of the population being served and how AMH Health will meet those needs. Each SNP MOC is evaluated and scored by the NCQA and approved by CMS.

 

How does the MOC help physicians?

The three major components of the MOC — 1) the health risk assessment (HRA), 2) Care Plan, and 3) case manager — support providers in serving D-SNP members. Each member receives a comprehensive HRA that covers physical, behavioral, and functional needs, along with a comprehensive medication review. AMH Health staff use the HRA information to create a Care Plan. Members with multiple or complex conditions may be assigned to a case manager.

 

These key MOC components identify and escalate potential problems for early intervention, ensure appropriate and timely follow-up, and help coordinate services across Medicare and Medicaid programs. Through the provider website, providers have access to review the Care Plan, the results of the HRA, and other information to help manage care.

 

How are transitions of care managed?

AMH Health case managers are involved in transitions of care (for example, discharge from hospital to home for those at high-risk of readmission). Such transitions may trigger a reassessment and updates to the member’s Care Plan as needed. Following a discharge, case managers help ensure that D-SNP members see their PCP within a week and work through barriers that members experience in adhering to post discharge medication regimens.

 

Who makes up the Interdisciplinary Care Team (ICT)?

Members of the ICT include any of the following: nurses, physicians, social workers, pharmacists, the member and/or the member’s caregiver, behavioral health specialists, or other participants as determined by the member, the member’s caregiver, or a relative of the member.

 

Providers who care for AMH Health members are considered participants in the ICT and may be contacted by a case manager to discuss the member’s needs. The case manager may present recommendations concerning care coordination or other needs. The goal of the ICT is to assist providers in managing and coordinating patient care.

 

Do I have to become a Medicaid provider?

You are not required to become a Medicaid provider, but we recommend that you do. Even if you are only providing services covered by Medicare Part A or Part B to SNP members, we recommend that you attain a Medicaid ID because the state Medicaid agency may require this for the Medicare cost share.

 

How do I file claims for SNP members?

Claims for services to SNP members are filed the same way claims are filed for AMH Health members enrolled in Medicare Advantage who are not part of SNP. Providers should ensure that the claim has the correct member ID (including the prefix).

 

How is the SNP member’s cost-sharing handled?

SNP benefits are administered similarly to Medicare fee-for-service benefits. Upon receiving the Explanation of Payment (EOP) from AMH Health, you should bill the state Medicaid agency or the applicable Medicaid managed care organization (MCO) contracted with the state for processing of any Medicare cost-sharing applied.

 

Medicare cost-sharing is paid according to each state’s Medicaid reimbursement logic. Some states do not reimburse for Medicare cost sharing if the payment has already met or exceeded Medicaid reimbursement methodology.

 

Do I have to file claims twice for SNP members?

Yes, when you treat AMH Health members enrolled in a SNP, you will file the initial claim with AMH Health and then bill the state Medicaid agency or the applicable Medicaid MCO contracted with the state for Medicare cost sharing processing. Please use the same electronic claim submission or address you currently use for AMH Health claims filing.

 

Do SNP members have access to the same prescription drug formulary as other AMH Health members enrolled in Medicare Advantage?

Yes, SNP members have coverage for the same prescription drugs listed on the AMH Health prescription drug formulary for Medicare Advantage.

 

Please note that in California, the tier placement may vary. Be sure to review the plan’s specific formulary for details on California SNPs, as the formulary depends on the market.

 

What are SNP benefits for AMH Health members?

The SNP for AMH Health members covers all Medicare Part A and Part B services and includes full Part D prescription coverage. AMH Health also covers a range of preventive services with no-cost sharing for the member. In addition, the SNP includes coverage for supplemental benefits that may include routine dental, vision, and nonemergency medical transportation. A summary of the SNP benefits is posted on the provider website for AMH Health members.

 

Any Medicaid benefits available to the member will be processed under their Medicaid coverage directly with the state or the Medicaid organization in which the member is enrolled.

 

Does the SNP use the same procedure codes and electronic data interchange (EDI) payer codes?

Yes, the SNP uses the same procedure and payer codes and electronic filing procedures as other Medicare Advantage plans through AMH Health.

 

Is the EDI payer ID for this product the same as others?

Yes, all the claim submission information will be the same (this applies to EDI and paper). Providers must submit this information with the correct ID. Please check the EDI section of the provider website for the correct payer codes to use for your market.

 

* Availity, LLC is an independent company providing administrative support services on behalf of AMH Health, LLC.

 

AMHCRNU-0092-21

 



Featured In:
October 2021 Anthem Maine Provider News