Peoples Health D-SNPs provide specialized care for plan members, called dual-eligibles, who have both Medicare and Medicaid. These members, who qualify for Medicaid based on income or disability, have more complex medical and social needs, often referred to as “special” needs. Dual-eligibles also tend to have fragmented care experiences, leading to higher use of health services. We have created a D-SNP model of care that addresses their special needs via access to and utilization of affordable care, health education, assistance with management of complex health care needs, and care coordination.
Additionally, our D-SNP model of care addresses the specially tailored services we provide to our most vulnerable subpopulation. The most vulnerable D-SNP members are those who are frail, are disabled, have multiple comorbidities, have chronic illnesses, or are near the end of life. The plan targets these subsets because they are most at risk among the dual-eligible population.
Our D-SNPs are structured according to the regulations of the CMS Managed Care Manual. Your participation in our D-SNP care planning and care coordination processes will help us meet regulatory and quality performance requirements, as well as ensure the best health outcomes for your Peoples Health D-SNP patients.
To facilitate the relationship between patients new to a Peoples Health D-SNP and their Peoples Health PCP and to ensure the patients have their medical and psychosocial needs addressed early on, we encourage an initial PCP visit within the first 90 days of enrollment into the plan.
Peoples Health D-SNPs provide enhanced access to medical and psychosocial services. We conduct health risk assessments (HRAs) to evaluate the patient’s needs and develop and update the patient’s individualized care plan (ICP). The HRA collects information about the patient’s medical, functional, cognitive, psychosocial and mental health needs. The Peoples Health D-SNP Interdisciplinary Care Team, which providers are a part of, evaluates the patient’s responses to the HRA, along with available medical records, to create the ICP. We may occasionally request information from your medical records or copies of your Peoples Health patient records to assist us in developing the ICP. The ICP consists of health goals and interventions (actions the patient may take to manage their care) for each condition identified in the HRA. ICPs are mailed to patients and are available in their member portal account. ICPs are mailed or faxed to providers and are available on the Provider Portal. These care plans are completed within the first three months of enrollment and updated at least annually, as well as whenever the patient experiences a change in health status. ICPs enable Peoples Health to better assist you and your Peoples Health patients in managing their health.
Information from the HRA helps us focus on areas in which the patient may benefit from assistance. Information gathered through the HRA and other Peoples Health assessments and records helps identify conditions that may affect D-SNP patients, including ability to access care and the presence of complex health care needs. The HRA also helps determine whether the patient needs information about life-planning resources, advance directives or hospice services. In addition, the HRA is vital to providing needed information on population demographics, such as socioeconomic status or cultural beliefs, that can be used in care planning.
In addition to an ICP, most D-SNP patients also benefit from lower out-of-pocket costs for most covered health care services and prescription drugs. They are eligible for benefits and waiver services through Louisiana Medicaid and have lower out-of-pocket costs for many plan benefits compared to other Peoples Health plan members, depending on their level of Medicaid coverage. Beneficiaries in D-SNPs are eligible for Extra Help to pay prescription drug costs if their resource and income limits are below a certain level, which is determined by the federal poverty level (FPL). For information on the annual FPL, visit www.medicaid.gov and input “federal poverty level” in the search field. A chart of federal poverty levels by percentage is available at https://aspe.hhs.gov/poverty-guidelines. This information is generally released in February of each calendar year. For Extra Help income and resource limits, visit www.medicare.gov/basics/costs/help/drug-costs.
All patients, including D-SNP patients, discharged from an inpatient facility must have a reconciliation of medications performed by their PCP within 30 days of discharge. Peoples Health will send notification of the admission via fax to the patient’s PCP. The provider has 30 days following discharge to reconcile the patient’s discharge medications and current prescriptions. The provider must date and initial all medication reconciliation documentation in the patient’s health records. By completing post-discharge medication reconciliation documentation for your Peoples Health patients, you can help ensure their safety by preventing potentially harmful drug interactions or overdoses and decrease the potential for unnecessary readmission due to medication errors.
For more information on documenting post-discharge medication reconciliations for your Peoples Health patients, contact the director of quality improvement, Stars and HEDIS at 1-800-631-8443. Dial ext. 1339.
If you have any questions about Peoples Health D-SNPs or would like more information, contact the special needs plan program administrator at 1-800-631-8443. Dial ext. 8277.
If you believe that any of the Peoples Health patients you are treating may be eligible for Medicaid, please refer them to our member services department, and a representative will help confirm Medicaid eligibility and provide information about our D-SNPs.
When a dual-eligible beneficiary joins a Peoples Health D-SNP, the beneficiary retains membership in Louisiana Medicaid. This means that both Louisiana Medicaid and Peoples Health may provide coverage for services the beneficiary receives. For your reference, a comparison chart of benefits covered by Peoples Health D-SNPs and Louisiana Medicaid is available on our website under the Providers tab and Plan Documents and Forms link. Look under Other Important Documents, Links and Forms.
Prior to treating Peoples Health D-SNP members, verify Medicaid eligibility. Doing so ensures appropriate billing and collection of patient cost-sharing as applicable. For some services, cost-sharing varies depending on Medicaid coverage level. Check the patient’s Medicaid ID card and Peoples Health ID card at every visit. To verify eligibility and cost-sharing levels, call the Medicaid Recipient Eligibility Verification System at 1-800-776-6323 and follow the prompts. Access eligibility information using the patient’s:
- 16-digit card control number and 8-digit birth date or Social Security number
- 13-digit Medicaid ID number (valid during the last 12 months)
The patient can never pay more for covered services than he or she would under Original Medicare. You can also contact Peoples Health member services to verify Medicaid eligibility.
Medicaid status can change frequently. You can easily check status in the Eligibility & Benefits tab on the Provider Portal. Simply enter the patient’s member ID number, also called the G number, and review the Member Responsibility field to determine if the patient is responsible for copays. Per CMS guidelines, Medicare providers may not collect coinsurance or copayments from some dual-eligible plan members and may not refuse to serve plan members who receive assistance from a state Medicaid program. For more information, see the Dual-Eligible Patient Cost-Sharing Quick Reference under the Provider Portal Resources tab.