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Special Needs Plans, Preferred Care Partners - 2019 UnitedHealthcare Administrative Guide

Special Needs Plans

Special Needs Plans (SNP) Model of Care (MOC)

The Model of Care is a framework for providing health care and health care plans designed by theory, evidence-based protocols, and accepted standards. The Model of Care contains specific elements that delineate implementation, analysis, and improvement of care.

These elements include description of SNP population (including health conditions), Care Coordination, ProviderNetwork and Quality Measurement and Performance Improvement.

The Model of Care is a quality improvement tool and helps ensure the unique needs of our SNP members are identified and addressed through care management practices. Model of Care goals are evaluated annually to determine effectiveness. To learn more, contact us via email at: snp_ moc_providertraining@uhc.com.

The Centers for Medicare and Medicaid (CMS) requires annual SNP Model of Care training for all care providers who treat SNP members. View the Annual SNP Model of Care Provider Training. Reminders about the training requirements are communicated annually through the Network Bulletin described in Chapter 17.

Risk Management

Risk management addresses liability, both proactively and reactively. Proactive is avoiding or preventing risk. Reactive is minimizing loss or damage after an adverse or bad event. Risk management in health care considers patient safety, quality assurance, and patients’ rights. The potential for risk is present in all aspects of health care, including medical mistakes, electronic record-keeping, care provider organizations, and facility management.

An adverse event is defined as an event over which health care personnel could exercise control rather than as a result of the member’s condition. Identifying something as an adverse event does not imply “error,” “negligence” or poor quality care. It indicates that an undesirable clinical outcome resulted from some aspect of diagnosis or therapy, not an underlying disease process. Adverse events interfere with a care provider’s delivery of medical care and may result in litigation.

Agency for Healthcare Administration

The Florida Agency for Healthcare Administration (AHCA), as directed under F.S. 641 Parts I, II, III and other applicablestate laws, provides oversight and monitoring of health plans operating in the State of Florida as an HMO and their compliance to applicable regulations.

This includes implementation of a Risk Management Program (RMP). The program helps identify, investigate, analyze and evaluate actual or potential risk exposures by a state licensed risk manager. The Risk Management Program also corrects, reduces and eliminates identifiable risks through instruction and training to staff and care providers.

For more information, go to the AHCA website at ahca.myflorida.com.