60-day Track Change MOC Matrix Req

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Model of Care Requirements for Medicare Advantage Special Needs Plans
Introduction
Under section 1859(f)(1) of the Social Security Act (the Act), Medicare Advantage (MA) special
needs plans (SNPs) are able to restrict enrollment to MA beneficiaries who are: (1)
institutionalized individuals, who are currently defined in 42 CFR § 422.2 as those residing or
expecting to reside for 90 days or longer in a long-term care facility, and institutionalized
equivalent individuals who reside in the community but need an institutional level of care when
certain conditions are met; (2) individuals entitled to medical assistance under a State plan
under Title XIX; or (3) other individuals with certain severe or disabling chronic conditions who
would benefit from enrollment in a SNP.
As outlined at 42 CFR § 422.2, SNPs are a specific type of MA coordinated care plan that
provides targeted care to individuals with unique special needs, and are defined as:
1) Institutionalized or institutionalized-equivalent beneficiaries (I-SNPs)
2) Beneficiaries who are dually eligible for both Medicare and Medicaid (D-SNPs), and
3) Beneficiaries who have a severe or disabling chronic condition(s) (C-SNPs).
Section 1859(f)(7) of the Act requires that all MA SNPs be approved by the National Committee
for Quality Assurance (NCQA). As a component of the MA application and renewal process,
SNPs are required to submit Models of Care (MOCs) through the Health Plan Management
System (HPMS). A MOC is a narrative submitted to the Centers for Medicare & Medicaid
Services (CMS) by the SNP that describes the basic quality framework used to meet the
individual needs of its enrollees and the infrastructure to promote care management and
coordination. SNP MOCs are also considered a vital tool for quality improvement.
MOC approval is based on NCQA’s evaluation using scoring guidelines developed by NCQA and
CMS for the Secretary of the Department of Health and Human Services. The MOC elements
cover the following areas: MOC 1: Description of the SNP Population; MOC 2: Care
Coordination; MOC 3: Provider Network; and MOC 4: Quality Measurement & Performance
Improvement. Based on the SNP type and MOC scores, with the exception of C-SNPs, all other
SNPs receive an approval for a period of one, two, or three years. C-SNPs may only receive a
one-year approval.
Care Management Plan Outlining the Model of Care
Attachment A includes MOC Elements 1-4 and represents the minimal requirements for MOC
development. SNPs must address each of the elements and sub-elements. A SNP’s policies and
procedures approved by NCQA should align with the relevant CMS regulations specified at §
422.101(f) and all MOC requirements outlined in Attachment A. CMS also notes that the MOC
requirements are distinct from the CMS SNP Audit Protocol 1, and SNPs are audited based on
0 F

1

: https://www.cms.gov/files/zip/medicare-part-c-and-part-d-program-audit-protocols-cms-10717.zip-2

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these standards, accordingly.
For all SNP types, using the tables in Attachment A, list the page number and section of the
corresponding description for each element in your MOC. Once you have completed
Attachment A, upload it into HPMS along with your MOC.
For D-SNPs, within HPMS, complete the questionnaire contained in Attachment B and upload it
along with your MOC. It is intended to capture information unique to D-SNPs.

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Attachment A
Model of Care Matrix Upload Document For Initial Application and Renewal
Table 1: Contract Information
Contract Information

SNP Contract Name (as provided in HPMS)
SNP CMS Contract Number

Applicant’s Information Field

Enter Contract Name here
Enter Contract Number here (Also list other
contracts where this MOC is applicable)

MOC Element 1 A: Description of the Overall SNP Population
The identification and A comprehensive description of the SNP-specific population is an
integral component of the MOC because all of the other elements depend on the firm
foundation of a comprehensive population description and provides the foundation for care
coordination, the provider network and quality performance and improvement. The
organization must provide information about its local target population in the service areas
covered under the contract,. Information about national population statistics is insufficient. It
must provide an overview that fully and addresses the full continuum of care, of current and
potential SNP beneficiaries, including end- of -life needs and considerations, for current and
potential SNP enrollees. if relevant to the target population served by the SNP. The
description of the SNP population must include, but not be limited to, the following:
MOC Element 1A: Description of the Overall SNP Population and Most Vulnerable Enrollees
Clear documentation of how the health plan staff determines or will determine,
verify, and track eligibility of SNP beneficiaries.
 Identify the specific SNP type and whether the MOC submission is an initial, renewal,
or off-cycle.
 For C-SNPs: Identify the chronic condition(s)
 For I-SNPs: Identify the setting(s) in which your enrollee population resides
(i.e., skilled nursing facility, community, other residential or institutional
settings, etc.).
o For D-SNPs: Indicate if the D-SNP(s) are seeking to be fully integrated dual
eligible (FIDE) SNP, highly integrated dual eligible (HIDE) SNP, coordination only
D-SNP, or includes multiple SNP types. Describe the eligibility categories and
criteria for the D-SNP (Qualified Medicare Beneficiary (QMB Only); QMB Plus;
Specified Low-Income Medicare Beneficiary (SLMB Only); SLMB Plus; Qualifying
Individual (QI); Qualified Disabled and Working Individual (QDWI); Full Benefit
Dual Eligible (FBDE). Describe the overall benefit structure and how care is
coordinated.
 Provide the following information for each SNP type, differentiating between the
general SNP enrollees and the most vulnerable enrollees:
 Demographic information including a detailed profile of the population
demographics (e.g., average age, gender, ethnicity, language, education


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level, socioeconomic status, etc.).
A detailed profile of the medical status, including health conditions, social,
cognitive, environmental aspects, living conditions, and co-morbidities
associated with the SNP population in the plan’s geographic service area.
Identification and dA description ption of of the health conditions and/or
other factors impacting the health of SNP beneficiariesenrollees, including the
most vulnerable, providing specific information about actual and/or potential
health disparities, other characteristics that affect health such as, population
demographics (e.g., average age, gender, ethnicity, and potential health
disparities associated with specific groups such as: language barriers, deficits
in health literacy, poor socioeconomic status, housing, food, transportation
insecurities, cultural beliefs/barriers, caregiver considerations, otheretc.) and
the associated challenges these characteristics pose.
A description of how the SNP addresses enrollee needs related to social
determinants of health.

Define unique characteristics for the SNP population served:
 C-SNP: What are the unique chronic care needs for beneficiaries enrolled in a
C-SNP? Include limitations and barriers that pose potential challenges for
these C-SNP beneficiaries.
 D-SNP: What are the unique health needs for beneficiaries enrolled in a DSNP? Include limitations and barriers that pose potential challenges for these
D-SNP beneficiaries.
 I-SNP: What are the unique health needs for beneficiaries enrolled in an ISNP? Include limitations and barriers that pose potential challenges for these
I-SNP beneficiaries as well as information about the facilities and/or home and
community-based services in which your beneficiaries reside.

Note: SNPs must differentiate between the general SNP population from the most vulnerable
enrollees.

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MOC Element 1B: Sub-Population: Services for the Most Vulnerable BeneficiariesEnrollees

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As a SNP, you must include a complete description of the specially-tailored services for
beneficiaries considered especially vulnerable using specific terms and details (e.g.,
members with multiple hospital admissions within three months, “medication spending
above $4,000”). The description must differentiate between the general SNP population
and that of the most vulnerable members, as well as detail additional benefits above and
beyond those available to general SNP members. Other information specific to the
description of the most vulnerable beneficiaries must include, but not be limited to, the
following:
 A description of Describe the internal health plan procedures (i.e., methodology
and specific criteria) for used to identifying the most vulnerable beneficiaries

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within the SNP and differentiate between the most vulnerable enrollees
compared to those that are less resource intensive or have lower risk
stratification scores.
 A description of the relationship between the demographic characteristics of the
most vulnerable beneficiaries with their unique clinical requirements. Explain in
detail how the average age, gender, ethnicity, language barriers, deficits in health
literacy, poor socioeconomic status and other factor(s) affect the health outcomes of
the most vulnerable beneficiaries.
 Describe in detail the specially tailored services for beneficiaries considered especially
vulnerable and the additional benefits above and beyond those available to general
SNP members.
• Address how the SNP will meet enrollee needs throughout the full continuum
of care, including end of life considerations.
• The identification and dDescribe ption of the established partnerships with
community organizations that assisteither provide, facilitate, or assist in
identifying resources in identifying resources for the most vulnerable
beneficiariesenrollees and/or their caregivers, including the processes that is
used to support and/or maintain continuity of community these partnerships
and facilitate access to community services by the most vulnerable
beneficiaries and/or their caregiver(s).
• Include a list of the partnerships and available services specific to the
service area.
Note: SNPs renewing their contract(s) after year two of operations must provide their own
historical data instead of other local, national, or proxy data.

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1.

MOC Element 2.: Care Coordination:

Care coordination involves deliberate organization and communication of health care
activities with stakeholders, including providers both inside and outside of the SNP’s
network, to helps ensure that SNP beneficiaries’enrollees health care needs, preferences
for health services and information sharing across health care settings staff and facilities
are met over time. Effective Ccare coordination maximizes the use of effective, efficient,
safe, and high-quality patient services that ultimately leads to improved enrollee
healthcare outcomes. , including services furnished outside the SNP’s provider network as
well as the care coordination roles and responsibilities overseen by the beneficiaries’
caregiver(s). The following MOC sub-elements are essential components to consider in
the development of a comprehensive care coordination program; no sub-element must
be interpreted as being of greater importance than any other. All five sub-elements
below, taken together, must comprehensively address the SNPs’ care coordination
activities. The description of care coordination must include but not be limited to the
following:
MOC Element 2A: SNP Staff Structure
 Fully define the SNP staff roles and responsibilities for both employed and contracted
staff, across all health plan functions that directly or indirectly affect the care
coordination of beneficiaries enrolled in the SNP. This includes, but is not limited to, the
identification and detailed explanation of:
Specific employed and/or contracted staff responsible for performing administrative
functions, such as: enrollment and eligibility verification, claims verification and
processing, other.
o Employed and/or contracted sStaff that perform clinical functions, such as: direct
beneficiaryenrollee care and education on self-management techniques, care
coordination, pharmacy consultation, behavioral health counseling, etcother.
o Employed and/or contracted sStaff that performs administrative and clinical
oversight functions. , such as: license and competency verification, data analyses
to ensure appropriate and timely healthcare services, utilization review, ensuring
that providers use appropriate clinical practice guidelines and integrate care
transitions protocols.
 Provide a copy of the SNP’s organizational chart that shows howincluding staff
responsibilities identified in the MOC are coordinated with and job titles related to
care coordination. If applicable, include a description of any instances when a
change to staff title/position or level of accountability was required to accommodate
operational changes in the SNP.
 IdentifyDescribe the SNP’s contingency plan(s) and disaster/emergency preparedness
plans used to ensure ongoing continuity of critical staff functions.
 Describe how the SNP conducts initial and annual MOC training for its employed
and contracted staff, which may include, but not be limited to, printed instructional
materials, face-to-face training, web-based instruction, and audio/videoconferencing.

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Renewal MOCs must provide detailed examples of training materials (e.g., slide deck,
printed materials, etc.). Initial MOCs must provide a detailed description of training
topics, and/or training materials, if available. Note that a general high-level overview of
content is not sufficient.
 Describe how the SNP documents and maintains training records as evidence to ensure
the MOC training provided to its employed and contracted staff was completed.
 Explain any challenges associated with the completion of MOC training for SNP
employed and contracted staff and describe what steps the SNP will take to ensure that
MOC training(s) have been completed.


MOC Element 2B: Health Risk Assessment Tool (HRAT)
The quality and content of the HRAT should identify the medical, functional, cognitive,
psychosocial and mental health needs of each SNP beneficiary. The content of, and methods
used to conduct the HRAT have a direct effect on the development of the Individualized Care
Plan and ongoing coordination of Interdisciplinary Care Team activities; therefore, it is
imperative that the MOC include the following:
 Provide Aa clear and detailed description of the policies and procedures for
completing the HRAT including:
 Detailed explanation for hHow the initial HRAT and annual reassessment are
conducted for each beneficiaryenrollee.
 Which personnel conduct the initial HRA and annual reassessment and their
level of licensure, as applicable.
How the HRA identifies the medical, functional, cognitive, psychosocial,
mental health, and social determinants of health needs for each SNP
enrollee.
 Description ofDescribe how the HRAT is used to develop and update, in a
timely manner, the Individualized Care Plan (ICP) (MOC Element 2C) for each
beneficiaryenrollee, and how the HRAT information is disseminated to and
used by the Interdisciplinary Care Team (ICT) for care management (MOC
Element 2D).
 Detailed explanation for how the initial HRAT and annual reassessment are
conducted for each beneficiary.
 A description of Describe how the SNP ensures that the results from the
initial HRAT and the annual reassessment HRAT conducted for each enrollee
individual are addressed in the ICPindividual’s care plan.
 Describe how the SNP addresses challenges associated with enrollees who
decline to participate in HRA completion or are unable to be reached.
 Detailed plan and rationale for reviewing, analyzing, and stratifying (if
applicable) the results of the HRAT, including the mechanisms to ensure
communication of that information to the ICTnterdisciplinary Care Team,
provider network, beneficiariesenrollees and/or their caregiver(s) or
designated representative, as well as other SNP personnel that may be
involved with overseeing the SNP beneficiary’s enrollee’s ICPplan of care. If

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Commented [MMCO1]: I added this question in to get a
better understanding of the staff level and licensure plans
use to conduct the HRAs. Such a question is also consistent
with 2D where we ask about staff involved in developing the
ICPs.

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stratified results are used, include a detailed description of how the SNP
uses the stratified results to improve the care coordination process.
Describe how the SNP uses stratified results to improve the care
coordination process.

MOC Element 2C: Face-to-Face Encounter
A face-to face encounter must be conducted between the SNP and each consenting enrollee
no less than on an annual basis. Face-to-face encounters can be conducted in-person or
through remote technology, such as telehealth, and must occur within the first 12 months of
enrollment. The face-to face encounter is part of the overall care management strategy, and
as a result, the MOC must include the following:
 A clear and detailed description ofDescribe the policies, procedures, purpose,
timing (within 12 months of enrollment and annually thereafter) and intended
outcomes of the face-to-face encounter., including:
 A description ofDescribe who will conduct the face-to-face encounter, (e.g.,
employed and/or contracted staff)., and how the encounter will be conducted.
 Describe the process used to obtain consent from enrollees to complete a face-toface encounter and how the SNP verifies that the enrollee has granted consent
prior to the face-to-face encounter.
 Describe how the SNP verifies that enrollees have participated in a face-to-face
encounter between each enrollee and a member of the enrollee's interdisciplinary
team or the plan's case management and coordination staff, or contracted plan
healthcare providers:
o Detail the process for reviewing enrollee claims data and how it is used.
o Identify responsible staff; and
o Describe any follow-up communications with enrollee/caregiver, if
applicable.
 A description of Describe the types of clinical functions, assessments and/or
services that may be provided during the face-to-face encounter and how health
concerns and/or active or potential health issues are will be addressed during the
face-to-face encounter, and,. This includes a description of how the SNP will
conduct care coordination activities through and ensure that appropriate follow-up,
referrals and scheduling are completed as necessary.
MOC Element 2D: Individualized Care Plan (ICP)
 The ICP components must include, but are not limited to: beneficiary selfmanagement goals and objectives; the beneficiary’s personal healthcare preferences;
description of services specifically tailored to the beneficiary’s needs; roles of the
beneficiaries’ caregiver(s); and identification of goals met or not met.
 When the beneficiary’s goals are not met, provide a detailed description of
the process employed to reassess the current ICP and determine appropriate
alternative actions.
 Explain Describe the process for developing the ICP, and which SNP personnel are
responsible for the development of the ICP, and how the beneficiary enrollee and/or
his/hertheir caregiver(s) or representative(s) isare involved in itsthe development.

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and how often the ICP is reviewed and modified as the beneficiary’s healthcare needs
change. If a stratification model is used for determining SNP beneficiaries’ health care
needs, then each SNP must provide a detailed explanation of how the stratification
results are incorporated into each beneficiary’s ICP.
 Describe how the ICP is documented and updated, including updates based on more
recent HRAT information, as well as, where the documentation is maintained to ensure
accessibility to the ICT, provider network, beneficiary and/or caregiver(s).
 Describe how the SNP will incorporate the following requirements into the ICP: enrollee
self-management goals and objectives to meet their medical, functional, cognitive,
psychosocial, mental health, and social determinants of health needs identified in the
HRA (based on enrollee preferences for delivery of services and benefits); how often
goals will be evaluated; the enrollee’s personal health care preferences; description of
services specifically tailored to the enrollee’s needs; and role of the caregiver(s).
 Describe how often SNP personnel review and update and/or modify the ICP based
on the evaluation of enrollee goals, changes in health care needs/status and/or
recent HRA information, etc.
 ExplainDescribe how updates and/or modifications to the ICP are communicated to the
beneficiaryenrollee and/or their caregiver(s), the ICT, applicable network providers,
other SNP personnel and other stakeholders as necessary.
 Describe how the ICP is maintained (documented, updated etc.), and the methods for
ensuring access by the appropriate stakeholders, ICT, provider network, enrollees
and/or caregiver(s), etc.
 Describe how the SNP provides enrollees and/or their caregivers with copies of or
electronic access to their ICP.
 D-SNPs: Describe how the ICP coordinates Medicare and Medicaid services and, if
applicable, the D-SNP or affiliated Medicaid plan provides these services, including longterm services and supports and behavioral health services.

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MOC Element 2E: Interdisciplinary Care Team (ICT)
 Provide a detailed and comprehensive description of the composition of the ICT, ;
includinge how the SNP determines ICT membership and a description of the roles
and responsibilities of each member. Specify how the expertise, training, and
capabilities of the ICT members align with the identified clinical and social needs of
the SNP beneficiariesenrollees, and how the ICT members contribute to improving the
health status of enrolleesSNP beneficiaries. If a stratification model is used for
determining SNP beneficiaries’ health care needs, then each SNP must provide a
detailed explanation of how the stratification results are used to determine the
composition of the ICT.
 Explain Describe how the SNP facilitates the participation ofinforms and
invites beneficiariesenrollees and their caregivers to participate as active
members of the ICT.
 Describe how the beneficiary’senrollee’s HRAT (MOC Element 2B) and ICP
(MOC Element 2C) are used to determine the composition of the ICT;,

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including those cases where additional team members are needed to meet
the unique needs of the individual beneficiaryenrollee.
 ExplainDescribe how the ICT SNP usesanalyzes enrollee health care needs
and healthcare outcomes data to implement changes and/or adjustments to
the ICT compositionevaluate established processes to manage changes
and/or adjustments to the beneficiary’s health care needs on a continuous
basis.
 Identify and explain the use ofDescribe how clinical managers, case managers or
others who play critical roles in plan staff ensure ing an effectivethat the SNP’s
interdisciplinary care processes is being conducted are effective in meeting enrollee
needs.
 Provide a clear and comprehensive description of the SNP’s communication plan that
ensures the exchanges of beneficiaryenrollee information is occurroccursing regularly
withinamongst the ICT, and includes ing but is not be limited to, the following:
 Clear evidence of an established communication plan that is overseen by SNP
personnel who are knowledgeable and connected to multiple facets of the
SNP MOC. Explain Describe how the SNP maintains effective and ongoing
communication between SNP personnel, the ICT, beneficiariesenrollees,
caregiver(s), community organizations and other stakeholders.
 Describe Tthe types of evidence used to verify that communications have
taken place, (e.g., written ICT meeting minutes, documentation in the ICP, etc
other.)
o Describe Hhow communication is conducted with beneficiariesenrollees who
have hearing, visual or other impairments, language barriers and/or cognitive
deficiencies and those that need information provided in alternate formats or
other languages (verbal or written).
o D-SNPs: Explain how the ICT coordinates with Medicaid providers when there
are needed Medicaid-covered medical or social services that the plan does not
cover, if applicable.
Element F: Care Transitions Protocols
 Explain Describe how care transitions protocols are used to maintain continuity of
care forSNP beneficiaries, including . Provide details and specify the the process and
rationale for connecting the beneficiaryenrollee to the appropriate provider(s),
services, community resources, etc., regardless of network affiliation.
 Describe which personnel (e.g., case manager) are responsible for coordinating care
transition process and ensuring that follow-up services and appointments are
scheduled and performed, and how the enrollee and/or their caregiver(s) is informed
on their SNP point of contact throughout the transition process as defined in MOC
Element 2A.
 ExplainDescribe how the SNP ensures elements of the beneficiary’s ICP and/or other
relevant information are transferred between healthcare settings (e.g., community,
hospital or institutional settings) when the beneficiaryenrollees experiencesexperience

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an applicable transition in care, either planned or unplanned. This must include the
steps that need to take place before, during and after a transition in care has occurred.
 Describe, in detail, the process for ensuring the SNP beneficiaryenrollee and/or
caregiver(s) have access to and can adequately utilize the beneficiaries’their personal
health information to facilitate communication between the SNP beneficiary and/or
their caregiver(s) with healthcare providers in other healthcare settings and/or health
specialists outside their primary care network share with other providers, help
facilitate care, make informed decisions, etc.
 Describe how the beneficiaryenrollee and/or caregiver(s) will be educated about
indicators that his/her their condition, signs/symptoms has of improvementd or
worsening, self-management techniques, when to contact their provider(s), ed and
how they will demonstrate their understanding of this informationthose indicators and
appropriate self-management activities.
 D-SNPs: Explain how the plan coordinates with providers of any Medicaid covered
services during a care transition, where applicable.

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Describe how the beneficiary and/or caregiver(s) are informed about who theirpoint of
contact is throughout the transition process.

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MOC Element 3.3. SNP Provider Network:
The SNP Provider Network is a network of health care providers who are contracted to provide
health care services to SNP beneficiariesenrollees. The SNP is responsible for maintaining a
network description that must includes relevant facilities and practitioners necessary to address
the unique or specialized health care needs of the target population. as identified in MOC 1,
and provide oversight information for all of its network types. Each SNP is responsible for
ensuring their MOC identifies, fully describes, and implements the following for its SNP Provider
Network: The description of the SNP provider network must include but not be limited to the
following:
MOC Element 3A: Specialized Expertise
 Provide a complete and detailed description of the specialized expertise available to
SNP beneficiariesenrollees in the SNP’s provider network. that corresponds to the
SNP population identified in MOC Element 1.
 The description must include evidence that the SNP provides each enrollee with an
interdisciplinary team ICT that includes providers with demonstrated experience and
training in the applicable specialty, or area of expertise, or as applicable, training in a
defined role appropriate to their licensure in treating individuals that are similar to
the target population.
 ExplainDescribe how the SNP oversees its provider network facilities and ensures its
providers are actively licensed and competent (e.g., confirmation of applicable board
certification) to provide specialized healthcare services to SNP beneficiariesenrollees.
Specialized expertise may include, butinclude but is not limited to: internistsal
medicine, endocrinologists, cardiologists, oncologists, nephrologists, mental health
specialistsproviders, etcother.
 Describe how providers collaborate with the ICT and SNP enrollees, (MOC Element 2D)
and the beneficiary, contribute to the ICP (MOC Element 2C) and ensure the delivery of
necessary specialized services. For example, describe: how providers communicate SNP
beneficiaries’enrollee care needs to the ICT and other stakeholders;, how specialized
services are delivered to the SNP beneficiary in a timely and effective waymanner;, and
how reports relevant information/data regarding services rendered are is shared with
the ICT and how relevant information is incorporated into the ICP.
 Describe how the SNP maintains current information on providers, including the
process and frequency used to make updates to ensure an accurate provider network
directory.
MOC Element 3B: Use of Clinical Practice Guidelines & Care Transitions Protocols
 Explain Describe the processes for ensuring that network providers utilize
appropriate clinical practice guidelines and nationally-recognized protocols, and the
methods used to monitor, track and verify compliance. This may include, but is not
limited to: use of electronic databases, web technology, and manual medical record
review to ensure appropriate documentation.

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13
DefineDescribe how the SNP any challenges encountered with overseesing
enrollees patients withwhose complex health care needs require where clinical
practice guidelines and nationally-recognized protocols may need to be modified to
fit the unique needs of vulnerable SNP enrolleesbeneficiaries. Also describe Provide
details regarding how these decisions are made, incorporated into the ICP (MOC
Element 2C), and communicated with the ICT (MOC Element 2D) and acted upon.
 ExplainDescribe how the SNP providers ensures care transitions protocols are being
used both internally and by contracted providers to maintain continuity of care for the
SNP beneficiary as outlined in MOC Element 2E .


MOC Element 3C: MOC Training for the Provider Network Staff
 Describe Explain, in detail, how the SNP conducts initial and annual MOC training for
provider staff, including both in-network providers and out-of-network providers (note:
out-of-network providers include providers seen by beneficiariesenrollees on a routine
basis.). Provider staff may include care coordination staff, admin staff, other clinical or
support staff, etc.
 Acceptable approaches to training may include This could include, but not be limited to:
printed instructional materials, face- to-face training, web-based instruction,
audio/video-conferencing, and availability of instructional materials via the SNP plans’
website.
o Renewal plans must provide detailed examples of training materials (e.g., slide
deck, printed materials, etc.). Initial plans must provide a detailed description of
training topics (not a general high-level overview of content) and/or training
materials, if available.
 Describe how the SNP tracks, verifies documents and maintains training records as
evidence of MOC training for their network provider staffs. Documentation may
include, but is not limited to: copies of dated attendee lists, results of MOC
competency testing, web- based attendance confirmation, electronic training records,
and physician attestations, etc of MOC training.
 Describe Explain any challenges associated with the completion of MOC training for
both in-network and out-of network providers staff, and describe what specific actions
provide strategies the SNP Plan will takeimplement to facilitate compliance when the
required MOC training has not been completed (e.g., how the SNP will work with
providers to connect with the appropriate staff and facilitate completion of the
trainings) or is found to be deficient in some way.
MOC Element 4.4: MOC Quality Measurement & Performance Improvement:
The goals of performance improvement and quality measurement are to improve the SNP’s
ability to deliver high quality health care services and benefits to its SNP beneficiariesenrollees
in a high-qualitytimely manner. Achievement of those goals may result from increased
organizational effectiveness and efficiency by incorporating quality measurement and
performance improvement concepts used to drive organizational change. The SNPs’ leadership

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14
team, managers and and governing body of a SNP organization must have a comprehensive
quality improvement program in place to measure its current level of performance, a
methodology for assessing improvement and distributing and determine if organizational
systems and processes must be modified based on performance results.
SNPs are required to establish measurable goals related to the 1) overall MOC performance,
and 2) enrollee health outcomes for the SNP population. MOC Element 4A establishes the SNPs’
overall quality performance improvement plan. MOC Element 4B establishes the goals for the
overall MOC performance, such as improving access and affordability, care coordination, etc.,
and goals for enrollee health outcomes, such as improving rates for preventive services and
screenings, medication adherence, etc. The description of the MOC quality measurement and
performance improvement plan must include but not be limited to the following:
MOC Element 4A: MOC Quality Performance Improvement Plan
 Describe Explain, in detail, the overall quality performance improvement plan and how
it ensures that appropriate services are being delivered to SNP beneficiariesenrollees.
The quality performance improvement plan must be designed to detectdetermine
whether the overall MOC structure effectively accommodates enrollees beneficiaries’
unique health care needs, while delivering high quality care and services. The plan must
address but not be limited to improving access to and coordination of care,
member/provider satisfaction, and program effectiveness. The description must include,
but is not limited to, the following:
 Describe how the SNP leadership team and other SNP personnel and stakeholders are
involved with the internal quality performance process.
 Describe Tthe complete process, by which the SNP continuously collects, analyzes,
evaluates and reports evaluates, reports on quality performance and supports ongoing
improvement of the MOC. based on the MOC by using specified data sources,
performance and outcome measures. The MOC must also describe the frequency of
these activities.Also describe the processes used by the SNP to determine if
goals/outcomes are met/not met, the use of benchmarks, timeframes for measurement
and re-measurement when goals are not achieved.
 Describe how the goals established for the overall MOC performance and enrollee
health outcomes (as outlined in MOC 4B) are integrated into the overall performance
improvement plan.
 Describes what the SNP does to systematically identify which enrollees receive no
covered Medicare services during a defined period of time and action taken by the SNP
to identify and connect with these enrollees.

how the SNP leadership, management groups and other SNP personnel and
stakeholders are involved with the internal quality performance process.
 Details regarding how the SNP-specific measurable goals and health
outcomes objectives are integrated in the overall performance
improvement plan (MOC Element 4B).
 Process it uses or intends to use to determine if goals/outcomes are met,
there must be specific benchmarks and timeframes, and must specify the

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15
re-measurement plan for goals not achieved.
MOC Element 4B: Measurable Goals & Health Outcomes for the MOC
 Identify and clearly defineDescribe the SNP’s measurable goals for the 1). Overall
MOC performance and 2). Enrollee health outcomes for the SNP population as a
whole. and describe how identified measurable goals and health outcomes are
communicated throughout the SNP organization. Responses must include but not be
limited to, the following: All goals must be measurable and specific, contain relevant
information, data source(s), frequency for measurement, etc. and describe how the
goals are communicated throughout the SNP and to stakeholders.
 Provide relevant information on how the SNP will achieve the MOC’s goals, including
the frequency of evaluation and the process the SNP uses or intends to use to
determine if goals/outcomes are met (including specific benchmarks, timeframes,
etc.).
 Indicate whether the SNP achieved the previous MOC’s goals:
 MOC renewals must specify if the goals of the previously approved MOC were
met or not met and include results and a plan of action of action if not met.
 If the MOC did not fulfill the previous MOC goals, indicate how the SNP will
achieve or revise the goals for the next MOC.
 For SNPs submitting an initial MOC, provide relevant information pertaining to
the MOC’s goals, e.g., include the specific goals, data sources, frequency for
measurement, etc.
Specific goals for improving access and affordability of the healthcare
needs outlined for the SNP population described in MOC Element 1.
 Improvements made in coordination of care and appropriate delivery of
services through the direct alignment of the HRAT, ICP, and ICT.
 Enhancing care transitions across all healthcare settings and providers for SNP
beneficiaries.
 Ensuring appropriate utilization of services for preventive health and
chronic conditions.
Identify the specific beneficiary health outcomes measures that will be used to
measure overall SNP population health outcomes, including the specific data
source(s) that will be used.
Describe, in detail, how the SNP establishes methods to assess and track the
MOC’s impact on the SNP beneficiaries’ health outcomes.
Describe, in detail, the processes and procedures the SNP will use to determine if the
health outcomes goals are met or not met.
For MOC renewals: Include appropriate data pertaining to the fulfillment or
achievement of the previous MOC’s goals.
If the MOC did not fulfill the previous MOC goals, the plan must describe how it will
achieve or revise the goals for the plan’s next MOC implementation.





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Overall MOC Performance Goals
 Provide a description of the overall MOC performance goal(s) using the
criteria outlined above. Examples may include, but not be limited to:
 Improving access and affordability of care for the SNP population.
 Improvements made in care coordination and appropriate delivery of services
through the direct alignment with the HRA, ICP, and ICT.
 Enhancing care transitions across all providers and healthcare settings.
Enrollee Health Outcomes Goals
 Provide a description of the enrollee health outcome goal(s) for the overall SNP
population using the criteria outlined above. Examples may include but not be limited
to:
 Appropriate utilization of services for chronic conditions
o Improving hemoglobin A1c rate levels in enrollees with diabetes
o Improving medication adherence
o Lowering all cause readmissions
 Preventive Health Services
o Improving rates of breast cancer or colorectal screenings
o Improving rates of depression screenings
o Improving influenza, pneumonia, RSV or shingles vaccination rates
MOC Element 4C: Measuring Patient Experience of Care (SNP Member Satisfaction)
 Describe the specific SNP survey(s) used and the rationale for selection of a particular
tool(s) to measure SNP beneficiaryenrollee satisfaction.
 Detail the methodology used to collect survey data and specify the sample size for each
survey used.
 Explain Describe how the results of SNP memberenrollee satisfaction surveys are
analyzed and integrated into the overall MOC performance improvement plan and used
to implement new programs that target areas for improvement. , including specific
steps to be taken by the SNP to
 Describe the process used to address issues identified in response to the survey results.
Element D: Ongoing Performance Improvement Evaluation of the MOC
 Explain, in detail, how the SNP will use the results of the quality performance indicators
and measures to support ongoing improvement of the MOC, including how quality will
be continuously assessed and evaluated.
 Describe the SNP’s ability to improve, on a timely basis, mechanisms for interpreting
and responding to lessons learned through the MOC performance evaluation process
 Describe how the performance improvement evaluation of the MOC will be
documented and shared with key stakeholders.
MOC Element E4D: Dissemination of SNPMOC Quality Performance Results related to the
MOC

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ExplainDescribe, in detail, how the SNP communicates its quality improvement
performance results and other pertinent information on a routine basis to its multiple
stakeholders, which may include, but not be limited to: SNP leadership teams, SNP
management groups, SNP boards of directors, SNP personnel & staff, SNP provider
networks, SNP beneficiariesenrollees and caregivers, the general public, and regulatory
agencies on a routine basis.
o This description must include, but is not limited to, the scheduled frequency of
communications and the methods for ad hoc communication with the various
stakeholders, such as : a webpages for announcements; printed newsletters;,
bulletins;, and other forms of media announcement mechanisms.
 Identify the individual(s) responsible for communicating performance updates/results in
a timely manner as described in MOC Element 2A.
 Describe how the performance improvement updates/results will be documented and
shared with key stakeholders.


According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0938- 1296 (CMS-10565). The current
expiration date is February 28, 2025. The time required to complete this information collection is estimated to average 6 hours per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.

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18
Attachment B
Dual Eligible Special Needs Plan Model of Care Questionnaire
Medicare Advantage (MA) organizations with at least one dual eligible special needs plan (DSNP) must complete this questionnaire along with the Model of Care (MOC) submission. MA
organizations should assume responses are at the contract level.
1.

Please tell us about your D-SNP’s care coordination process:
• Does every enrollee have an assigned, consistent care coordinator?
(Yes or No)
• Does the D-SNP delegate care coordination functions to the provider
level? (Yes or No)
• Does the D-SNP contract with first tier, downstream, or related
entities (FDRs) that conduct care coordination activities such as
administering health risk assessments (HRAs) or outreach? (Yes or No)

2.

Who conducts HRAs? (Please select all that apply)
• In-house staff
• Contracted staff
• External vendor staff
• Primary care providers (PCP) or other contracted providers
• Enrollee’s assigned care coordinator
• Staff who only conduct HRAs

3.

Which mechanisms does the D-SNP use to administer HRAs? (Please
select all that apply)
• Hard copy mail
• Telephone
• Video conference
• In-person
• Other

4.

How does the D-SNP outreach to enrollees to maximize HRA
completion? (Please select all that apply)
• Mails letter to enrollee in advance of HRA
• Sends text or email message to enrollee in advance of HRA
• Calls enrollee from phone number that shows the plan’s name in
caller ID
• Care coordinator conducts the HRA during a care coordination
call
• Other

5.

When is the individualized care plan (ICP) updated? (Please select all that
apply):

19
• After all hospitalizations
• After all skilled nursing facility (SNF) / nursing facility (NF)
admissions
• After all emergency department visits
• After any known change in condition
• After any new major diagnosis social change (e.g., caregiver passing
away)
• After every annual HRA reassessment
• After identification of long term services and supports (LTSS) needs
• After request from enrollee or caregiver
• Other
6.

How are updates and/or modifications to the ICP communicated to
the interdisciplinary care team (ICT), applicable network providers, other
D-SNP personnel, and other stakeholders as necessary. (Please select
all that apply)
• Email
• Hard copy mail
• Electronic portal
• Fax
Other

7.

When the HRA identifies housing stability, food security, and/or access
to transportation needs for enrollees, how does it generate a referral to
community resources? (Please choose from the below responses):
• Automatic referral generated
• Referral made on case-by-case basis
• The D-SNP does not refer to community resources

8.

Describe how the D-SNP communicates with enrollees and caregivers
about the ICT. (Please select all that apply):
• Hard copy mail
• Text message
• Email message
• Electronic portal
• Fax
• Other

9.

Will D-SNP enrollees receive Medicaid services through Medicaid
managed care? (Yes/No)
• If Yes, will D-SNP enrollees receive Medicaid services from
organizations other than the D-SNP or affiliates under the DSNP’s parent organization? (Yes/No)

20
• If Yes, for the purposes of coordinating Medicaid services per
42 CFR 422.107(c)(1), how will the D-SNP determine the
Medicaid managed care plans in which the D-SNP enrollees
are enrolled? (Please check all that apply)
• D-SNP has an electronic data exchange with the state
• D-SNP asks new enrollees as part of the annual HRA
• Other
10.

With which types of community organizations has the D-SNP established
partnerships that assist in identifying resources for enrollees? (Please
select all that apply):
• Centers for independent living
• Area agencies on aging
• Protection & advocacy systems, such as those listed at the following link:
https://acl.gov/programs/aging-and-disability-networks/stateprotection-advocacy-systems
• State councils on developmental disabilities
• Mental health services networks
• Other N/A

11.

Does the D-SNP ever use one HRA to meet all CMS and state
requirements? (Yes or No)
• If No, does the D-SNP coordinate its HRA with any state-required
assessments (e.g., for HCBS)? (Yes/No)
• If Yes, how does the D-SNP coordinate with the state on
conducting the one HRA? (Please select all that apply):
• The D-SNP obtains state-required assessment results from
state Medicaid agency or independent entity that conducts
the state-required assessment
• The D-SNP conducts the HRA and shares the results with
state Medicaid agency or independent entity responsible for
assessing compliance with Medicaid requirements
• Other

12.

CMS will accept a Medicaid HRA that is performed within 90 days before
or after the effective date of Medicare enrollment as meeting the Part C
obligation to perform an HRA. Does the D-SNP use recently completed
Medicaid HRAs in lieu of a separate HRA conducted by the D-SNP, if the
Medicaid HRA meets the minimum Medicare HRA requirements? (Yes or
No)

13.

If the D-SNP or affiliated plan covers Medicaid services, can the
enrollee’s care coordinator directly authorize Medicaid services (Yes or
No)?

14.

Does the D-SNP identify whether enrollees are receiving services included in

21
their ICP, either through comparison of claims data against the ICP or
through some other mechanism? (Yes/No)
15.

Does the D-SNP systematically identify potential Medicaid covered services
needs among its enrollees? (Yes/No)
• If yes, the D-SNP tracks this information in its: (select all that apply)
• Care management system
• Customer service system
• Appeals and grievances system
• Other
• If yes, the D-SNP offers assistance to those enrollees with:
• Obtaining Medicaid covered services through helping the
enrollee contact the Medicaid managed care plan or state
Medicaid agency? (Yes/No)
• Requesting authorization of Medicaid services? (Yes/No)
• Navigating Medicaid appeals and grievances in connection with
the enrollee’s own Medicaid coverage regardless of whether such
coverage is in Medicaid fee-for-service or a Medicaid managed
care plan? (Yes/No)
• Other

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 1296 (CMS-10565).
The current expiration date is TBD. The time required to complete this information collection is estimated to average 6 hours
per response, including the time to review instructions, search existing data resources, gather the data needed, and complete
and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

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