Model of Care

The Centers for Medicare & Medicaid Services (CMS) requires all Special Needs Plans (SNP) to have a Model of Care (MOC).

The MOC includes:

  • Care coordination and care management for all Horizon NJ TotalCare (HMO D-SNP) members
  • An Individualized Care Plan (ICP) based on member assessment and member feedback
  • An interdisciplinary care team (IDT) that reviews the member’s Plan of Care and provides input in a collaborative way
    • A member’s IDT consist of:
      • Member/caregiver
      • Medical Director
      • Primary Care Provider
      • FIDE-SNP Care Manager
      • Behavioral Health Care Manager
      • Pharmacist
      • MLTSS Representative
      • Quality Representative
      • Physical therapy/occupational therapy
      • Dental Representative

Individualized Care Plan (ICP)

ICPs are:

  • Created for each Horizon NJ TotalCare (HMO D-SNP) member using the Health Risk Assessment Tool and other data
  • Coordinated with the member/caregiver
  • Culturally appropriate
  • Easy to understand
  • Updated when a member’s status changes
  • Shared with PCP and member

The member’s Care Manager will:

  • Develop goals with the member/caregiver
  • Coordinate care for members including doctor appointments, transportation, home care, prescription refills and durable medical equipment

For more information, contact Care Management at 1-888-621-5894 option 2.