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Dual special needs plans managed by Optum - Chapter 5, 2021 UnitedHealthcare Administrative Guide

UnitedHealthcare Dual Special Needs Plans (DSNPs) are one type of Medicare Advantage Special Needs Plan. This protocol is applicable to:

  • PCPs in UnitedHealthcare’s network for DSNPs
  • Members of UnitedHealthcare DSNPs managed by our affiliate Optum

It does not apply to members who are assigned to an Accountable Care Organization based upon the member’s PCP or whose PCP participates in a global capitation or risk-sharing arrangement with UnitedHealthcare.

This protocol establishes the guidelines and process for clinical integration, cooperation, and collaboration of and with respect to the care of members of UnitedHealthcare DSNPs managed by Optum. UnitedHealthcare or Optum will advise PCPs and members in those plans.

UnitedHealthcare DSNPs managed by Optum include the Optum At Home Program, which is an integrated care delivery program that coordinates the delivery and provision of clinical care of members in their place of residence. When members participate in this program, their care providers must follow a communications structure that helps ensure better coordination of their medical care.

To promote the best possible outcomes, the program supports:

  • Sharing information between care team members, including performance reviews
  • Tracking clinical outcomes
  • Communicating evidence-based guidelines

The Optum At Home Program’s Interdisciplinary Care Team includes an Optum-trained advanced practice clinician (ARNP/PA), the member’s PCP and other care providers as appropriate, in addition to the member and the member’s family. Together, they provide care customized to the member’s needs and goals of care.

Optum clinicians:

  • Conduct annual evaluations
  • Provide longitudinal care management for high-risk members to address medical, behavioral and socioeconomic concerns
  • Help ensure care coordination for members experiencing a care transition

We do member evaluations, care management and care coordination along with the member’s PCP as well as other members of the Interdisciplinary Care Team.

The Optum At Home Program supplements care provided by our members’ PCPs. It is not intended to replace the care provided by our members’ PCPs.

Protocols for UnitedHealthcare DSNPs managed by Optum

If these protocols differ from or conflict with other protocols in connection with any matter pertaining to members of UnitedHealthcare DSNP plans managed by Optum, these protocols govern unless statutes and regulations dictate otherwise.

As the PCP of UnitedHealthcare DSNP members managed by Optum, you must:

  1. Collaborate and cooperate with the Optum At Home Program, including Optum advanced practice clinicians and other staff assigned to UnitedHealthcare DSNP members managed by Optum.
  2. Attend PCP meetings when requested by Optum.
  3. Take part in the review of information provided by Optum, including care provider performance reviews, tracking of clinical outcomes and the communication of evidence-based guidelines to team members.
  4. Work with other members of the Interdisciplinary Care Team designated by UnitedHealthcare and other treating professionals to provide and arrange for the provision of covered services to our UnitedHealthcare DSNP members managed by Optum.