- Select “Prescribers” and click on “Prior Authorization”
- Enter your NPI number and State to access the prescriber portal
- Phone number: 1-833-478-6370
- TTY phone number: 711
For Pharmacies:
- Access payer sheets and other information at https://elixirsolutions.promptpa.com
- Select “Pharmacies” and click “Pharmacies Login”
- Enter your NPI number and NCPDP number to access the pharmacy portal
- Phone number: 1-833-478-6370
- TTY phone number: 711
Institutional Special Needs Plan Model of Care and Training
At Iowa Health Advantage, we specialize in improving health care and advancing a truly unique philosophy of care to meet the complex needs of the institutional Medicare beneficiary population, while simultaneously streamlining administrative functions for our Providers. The Iowa Health Advantage Model of Care focuses on providing a unique level of customized clinical care and services for residents in nursing facilities or individuals living in the community or a contracted assisted living facility (ALF) but require an institutional level of care (LOC) As we help extend your care, our care model concentrates on addressing each Member’s full range of medical, functional, and behavioral health care needs in a coordinated and Member-centric manner. This means putting the Member’s preferences at the center of the care planning process and leveraging Provider resources to ensure every Member receives the services necessary to achieve their short-term and long-term care goals. Our model organizes best practices and industry innovations including:
- The Advanced Nurse Practitioner (ANP) and primary care physician (PCP)/NFist (a PCP specializing in the care of nursing home patients) care team providing onsite, facility-based PCP support;
- A risk-assessment tool designed for a senior, nursing facility patient population;
- A comprehensive history and physical assessment that generates an Individualized Care Plan (ICP);
- A care management platform that helps identify needed preventive health/HEDIS services, ensures the use of evidence-based clinical guidelines, and facilitates care team communications for care coordination; and
- Frequent face-to-face Member and caregiver/family member interactions that identify Member care preferences and allow time for important care decision discussions and counseling.
It is important that all of our Providers are properly trained and informed about the Iowa Health Advantage Model of Care. Our top priority is making sure all of the providers in the Iowa Health Advantage network meet the training and education needs of our institutional Medicare beneficiary population. The purpose of the Model of Care Training is to comply with the statutory requirement of the Centers for Medicare and Medicaid Services (CMS), that all Special Needs Plans provide a general understanding of the requirements of the Model of Care. In addition, this will also help you to seamlessly serve Iowa Health Advantage Members, your patients.
Model of Care Training
- Click on each ‘+’ below to review material.
- Complete Attestation
Overview
- Centers for Medicare and Medicaid Services (CMS) requires all Medicare Advantage Special Needs Plans (SNPs) to have a Model of Care (MOC)
- CMS requires all SNPs to conduct initial and annual training that reviews the major elements of the MOC for providers and staff
- Purpose of this training is to comply with the statutory requirements of CMS that all SNPs provide a general understanding of the requirements of the MOC
What is an Institutional Special Needs Plans (I-SNP)
I-SNPs are Medicare Advantage Prescription Drug Plans that restrict enrollment to Medicare eligible individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a:
- Skilled nursing facility (SNF)
- LTC nursing facility (NF)
- Intermediate care facility for the intellectually disabled (ICF/ID)
- Inpatient psychiatric facility
OR - Individuals living in the community or a contracted assisted living facility (ALF) but require an institutional level of care (LOC)*.
*As determined by a state assessment tool and evaluation. The tool is the same as that used for individuals residing in an institution.
Who is Eligible for an I-SNP?
- Entitled to Medicare Part A (Hospital Insurance)
- Enrolled in Medicare Part B (Medical Insurance)
- Live in Plan service area
- Must reside, or be expected to reside, in a participating I-SNP nursing facility for greater than 90 days at the time of enrollment, individuals living in the community or a contracted assisted living facility (ALF) but require an institutional level of care (LOC)
Learning Objectives – Four Elements of MOC
Model of Care – Element 1
Special Needs Plan (SNP) Population- General Population
- Vulnerable Subpopulations
Model of Care – Element 2
Care Coordination- I-SNP Staff Structure
- Health Risk Assessment (HRA)
- Individualized Care Plan (ICP)
- Interdisciplinary Care Team (ICT)
- Care Transition Protocols
Model of Care – Element 3
Provider Network- Specialized Expertise
- Use of Clinical Practice Guidelines
- Model of Care Training
Model of Care – Element 4
Quality Measurement and Performance Improvement- Model of Care Performance Improvement
- Measurable Goals and Health Outcomes for the Model of Care
- SNP Member Satisfaction
- Evaluation of the Model of Care
- Dissemination of SNP Quality Performance Related to the Model of Care
Model of Care Element 1: Target Population / Subpopulation
- Institutionalized in a Long-Term Care (LTC) Facility or in the community and need institutional type of care usually provided in a long-term care facility
- Frail/vulnerable
- More likely to be Female
- Average age is 75 years old
- Clinical Risk Factors
- Diabetes
- Heart failure
- Pressure injury
- Respiratory conditions
- Psychosis
- Falls
- Pressure ulcers
- Urinary tract infections
- Incontinence
Model of Care Element 2: Care Coordination
SNP Staff Structure
- The I-SNP has a care coordination team in place that includes an Advanced Practice Provider, Case Manager, Member Advocate, Clinical Pharmacist, and other providers
Health Risk Assessment (HRA):
- HRA is conducted to identify medical, psychosocial, cognitive, functional and mental health needs and risks
- Initial HRA is completed within 90 days of enrollment and annually thereafter; findings are integrated into the member’s care plan
- Stratification level dictates Advanced Practice Provider and Case Manager’s intervention schedule
Individualized Care Plan (ICP):
- Includes goals that are member specific driven from clinical information obtained from HRAs and other Plan data
Interdisciplinary Care Team (ICT):
- The Interdisciplinary Care Team reviews and approves the ICP
- Composition varies and is dependent on each member’s unique goals and member preferences
- Includes the member and any designated representative(s)
Care Transitions:
- Advanced Practice Provider conducts a care transition assessment, including comprehensive medication review post discharge. The Case Manager updates the ICP and communicates with ICT, as relevant
Model of Care Element 3: Provider Network
Specialized Expertise
- Comprehensive network of providers that collaborate with the I-SNP’s ICP and ICT
- Comprehensive network of providers that meet CMS adequacy standards
- All contracted providers are credentialed
Clinical Practice Guidelines:
- Nationally developed and approved; reviewed minimally every two years, or significant change
- Available for provider reference
MOC Training is required for:
- Health Plan Staff
- Contracted Providers and Vendors
- Long Term Care Facility Staff
Model of Care Element 4: Quality Measurement
Quality Measurement & Performance Improvement:
- Continuous improvement and monitoring of medical care, patient safety, and delivery of services
- Data analysis and standard reporting is used in the Annual Quality Improvement Work Plan
Measurable Goals and Health Outcomes for the Model of Care
- Processes and procedures to determine health outcomes are met
Member Satisfaction:
- Assessed annually
Model of Care Evaluation:
- Data is collected, analyzed and evaluated on a monthly, quarterly, and annual basis from each Model of Care domain to monitor performance, identify areas for improvement, and to ensure program goals have been meet
Dissemination of SNP Quality Performance Results
- Results shared within the organization and provider network
Model of Care Training Attestation
Become a Network Provider
Iowa Health Advantage contracts with physicians, facilities and other allied providers to ensure we have an adequate Provider network which is essential for the delivery of health care services to our members. All Providers must be credentialed before they can be added to our network as a participating Provider. Why Partner with Iowa Health Advantage:
- From the beginning, physicians discover that Iowa Health Advantage isn’t just another Medicare Advantage health plan.
- We have a different philosophy, attitude and approach to caring for our Members.
- Our emphasis is on encouraging proactive health care and offering programs and services that can make a difference in our Members/your patients’ quality of life.
- We strive to provide our Members exceptional benefits and an abundance of attention.
- And we believe Iowa Health Advantage Providers deserve the same.
For more information on becoming a Iowa Health Advantage contracted Provider, please contact Network Operations at 1-866-327-0523; TTY 1-833-312-0046 or via email at networkservices@amhealthplans.com.
Compliance
Iowa Health Advantage’s business is governed by complex, demanding, and ever-changing laws, rules, and regulations.
We are committed to acting with integrity and making decisions based on the highest standards of ethical behavior, including complying with applicable laws and regulations.
To provide quality health care services in compliance with these laws, Iowa Health Advantage has developed a compliance program that provides guidelines and assigns responsibilities for controls and procedures that promote consistent and proper organizational behavior.
The Compliance Program has been developed to assist in establishing a culture within Iowa Health Advantage that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal and state law and federal and state health care program requirements.
The Compliance Program describes our commitment to ethical business practices and behavior. Additionally, the Compliance Program provides the framework to assure that our employees, including officers, managers, volunteers, interns, Board of Directors, vendors (contractors, subcontractors), and first-tier, downstream, and related entities (FDRs) comply with the applicable legal and ethical standards of conduct, including our standards of conduct and requirements to prevent, detect, and mitigate fraud, waste, and abuse (FWA).
Medicare FWA and General Compliance Training
Iowa Health Advantage contracts with the Centers for Medicare & Medicaid Services (CMS) to provide health care and prescription drug benefits under Medicare Advantage and Medicare Part D programs to our Medicare beneficiaries. As a part of these contracts, CMS requires Iowa Health Advantage to oversee our first tier, downstream, and related entities (FDRs) who provide health care or administrative services.
As an FDR for Iowa Health Advantage, you are an important partner in the continued success of our Compliance program.
Medicare requires FDRs to participate in the Iowa Health Advantage Compliance program, and we are committed to providing you with the tools needed to ensure you meet the obligations of this program. Our Standards of Conduct and other resources for reporting concerns or issues are available to you.
CMS requires our FDRs to complete Medicare FWA and general compliance training on an annual basis.
In accordance with CMS guidance, providers who have enrolled in Medicare Parts A or B or are accredited as Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers are deemed to have met the requirement for the FWA training and education. However, this does not exempt your organization from having to complete the general compliance training on an annual basis.
In order to ensure consistency and reduce the burden on providers, suppliers, contractors, and organizations, CMS has developed a web-based training module that can be used to satisfy the FWA and the general compliance training and education requirements.
FDRs must satisfy CMS’ general compliance and FWA training requirements. FDRs can complete the general compliance and/or FWA training modules available through the CMS Medicare Learning Network (MLN). Or, FDRs may download, view or print the content of the CMS standardized training modules from the CMS website to incorporate into their organization’s existing compliance training materials/systems. The CMS training content cannot be modified to ensure the integrity and completeness of the training.
Regardless of the training program used, Iowa Health Advantage requires FDR agents to complete the FWA training within 90 days of contracting with Iowa Health Advantage and annually thereafter.
Thank you for your cooperation. If you have any questions about whether your organization is required to complete FWA and general compliance training, or whether your organization’s internal training or third-party training is sufficient, please contact the Iowa Health Advantage Compliance Officer at (866) 205-2866. If you need assistance or have comments, please email Compliance@AmHealthPlans.com.
Compliance Hotline
American Health Plan of Iowa, Inc., doing business as Iowa Health Advantage has implemented a Compliance Hotline for our Members; employees; first-tier, downstream, and related entities; and other contractors and agents.
The Compliance Hotline provides a mechanism for callers to report activity related to known or suspected non-compliance with Iowa Health Advantage’s mission; policies and procedures; Compliance program; Standards of Conduct; or any Federal, State, or local laws and regulations.
All calls to the Compliance Hotline will be treated as confidential and private to the fullest extent possible.
Compliance Hotline: 1-866-205-2866 (toll free)
If you are not comfortable or able to make a report via the Compliance Hotline, you may send a written report by mail to:
Iowa Health Advantage
Attn: Compliance
201 Jordan Road, Suite 200
Franklin, TN 37067
Or Email: Compliance@AmHealthPlans.comWhether reporting by telephone or in writing, please provide as much detail as possible, including, but not limited to, names, dates, times, locations, and the specific conduct you feel may violate the law or Iowa Health Advantage Policy.
No individual making a good faith report of a suspected violation shall be retaliated against. However, any individual who knowingly makes a false allegation shall be subject to disciplinary action in accordance with Iowa Health Advantage Policy.
