Medicare Advantage (MA)- Chapter 13, 2021 UnitedHealthcare Administrative Guide

Note: MA may include Dual Special Needs Plans (DSNP).

Clinical programs: Condition management and care management

Our MA plans provide a full spectrum of care management programs as part of our standard plan offerings. Clinical programs include inpatient care management, care and condition management, specialty care management (e.g., transplant and end stage renal disease (ESRD) management), behavioral health care management, Advanced Illness, HouseCalls (not all members are eligible for this program), and Solutions for Caregivers (available on select MA plans). Participation by the member is encouraged, but voluntary.

Condition management programs

These programs help members with chronic conditions, such as diabetes, heart failure, and ESRD, to be their healthiest. We offer education and resources to support optimal health of members actively treated for chronic conditions. Members receive case management and can attend workshops to help manage their condition.

Care management programs

  • Inpatient Care Management: Nurses review the clinical information that outlines the clinical treatment plan for the member. They evaluate appropriateness for admission based on evidence-based medicine and discharge planning needs, including identifying members for post-discharge follow-up and referral to outpatient programs.
  • Behavioral Health: Led by experienced psychiatrists and licensed behavioral health clinicians, our program integrates with our medical team to identify, engage and manage a member’s behavioral health concerns.
  • Community Transitions Program: Designed to reduce complications by smoothing the transition from hospital to home, program staff coordinate transitions in care or changes in member health status to avoid potential adverse outcomes and unnecessary readmissions.
  • High Risk Care Management: Nurses support members who have complex care needs by helping them access care, coordinate services and learn to better manage their chronic conditions.
  • Advanced Illness: Provides comprehensive care for members facing life-limiting illness generally defined as the last 12 months of life.
  • Transplant Resources: Our transplant management program drives positive clinical outcomes by addressing the complex needs of members who are facing transplants.
  • Post-Acute Transition Program: Uses an individualized, whole-person approach to remove barriers to discharge from post- acute care, such as SNF so the member can safely return to the least restrictive setting possible.

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

The MOC is the framework for care management processes and systems that enable coordinated care for SNP members. The MOC includes descriptions of:

  • SNP population (including health conditions)
  • Care coordination
  • Provider network
  • Quality measurement
  • Performance improvement.

The MOC helps ensure the unique needs of the population are identified and addressed through care management practices. We evaluate MOC goals on an annual basis to determine effectiveness.

To learn more, contact us at: snp_moc_providertraining@ uhc.com.

The Centers for Medicare & Medicaid Services (CMS) requires annual SNP MOC training for all care providers who treat SNP members. The training is reviewed and updated annually to reflect current practices related to care coordination. This includes communication of the Interdisciplinary Care Plan (ICP) for each member. The Annual SNP MOC Provider Training is available at UHCprovider.com/training. Updates about the annual training can be found at UHCprovider.com/networknews > Network Bulletin. To receive news updates by email, sign up at UHCprovider.com/subscribe.