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 Protocol1, and SNPs are audited based on 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 along with your MOC. It is intended to capture information unique to D-SNPs.
Attachment A
Model of Care Matrix Document
Table 1: Contract Information
Contract Information |
Applicant’s Information Field |
SNP Contract Name (as provided in HPMS) |
Enter Contract Name here |
SNP CMS Contract Number |
Enter Contract Number here (Also list other contracts where this MOC is applicable) |
MOC Element 1: Description of the Overall SNP Population
A comprehensive description of the SNP population is an integral component of the MOC 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, and address the full continuum of care, including end of life needs and considerations for current and potential SNP enrollees. 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
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.).
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, sex, ethnicity, language, education 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.
A description of the conditions and/or other factors impacting the health of SNP enrollees, including the most vulnerable, providing specific information about actual and/or potential health disparities (e.g., language barriers, deficits in health literacy, poor socioeconomic status, housing, food, transportation insecurities, cultural beliefs/barriers, caregiver considerations, etc.), and the associated challenges these characteristics pose.
A description of how the SNP addresses enrollee needs related to social determinants of health.
Note: SNPs must differentiate between the general SNP population and the most vulnerable enrollees.
MOC Element 1B: Services for the Most Vulnerable Enrollees
Describe the internal health plan procedures (i.e., methodology and specific criteria) used to identify the most vulnerable beneficiaries within the SNP and differentiate between the most vulnerable enrollees compared to those that are less resource intensive or have lower risk stratification scores.
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.
Describe the established partnerships with community organizations that either provide, facilitate, or assist in identifying resources for the most vulnerable enrollees and/or their caregivers, including the processes to support and/or maintain these partnerships and facilitate access to community services.
Include a list of the partnerships and available services specific to the service area.
Explain any challenges associated with the establishment of partnerships with community organizations that impact the ability to connect enrollees to specific community services.
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.
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 help ensure that enrollees health care needs, preferences for services, and information sharing across health care settings are met. Effective care coordination ultimately leads to improved enrollee outcomes. 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. This includes but is not limited to the identification and detailed explanation of:
Staff that perform clinical functions, such as direct enrollee care and education on self-management techniques, care coordination, pharmacy consultation, behavioral health counseling, etc.
Staff that perform clinical oversight functions.
Provide a copy of the SNP’s organizational chart including staff responsibilities and job titles related to care coordination.
Describe 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.
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 (HRA)
Provide a detailed description of the policies and procedures for completing the HRA including:
How the initial HRA and annual reassessment are conducted for each enrollee.
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.
Describe how the HRA is used to develop and update, in a timely manner, the Individualized Care Plan (ICP) for each enrollee, and how the HRA information is disseminated to and used by the Interdisciplinary Care Team (ICT) for care management.
Describe how the SNP ensures that the results from the initial HRA and the annual reassessment HRA conducted for each enrollee are addressed in the ICP.
Describe how the SNP addresses challenges associated with enrollees who decline to participate in HRA completion or are unable to be reached.
Detail the plan for reviewing, analyzing, and stratifying the results of the HRA, including the mechanisms to ensure communication of information to the ICT, provider network, enrollees and/or their caregiver(s) or designated representative, as well as other SNP personnel that may be involved with overseeing the SNP enrollee’s ICP.
Describe how the SNP uses stratified results to improve the care coordination process.
MOC Element 2C: Face-to-Face Encounter
Describe the policies, procedures, purpose, timing (within 12 months of enrollment and annually thereafter) and intended outcomes of the face-to-face encounter.
Describe who will conduct the face-to-face encounter including but not limited to employed and/or contracted staff role (e.g., care managers, specialists, PCP, social workers, behavioral health workers or community health workers, etc.), and how the encounter will be conducted.
For encounters initiated by the SNP, describe the process used to obtain consent from enrollees to complete a face-to-face 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:
Detail the process for reviewing enrollee claims data and how the data is used.
Identify responsible staff; and
Describe any follow-up communications with enrollee/caregiver, if applicable.
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 addressed. This includes a description of how the SNP will conduct care coordination activities and ensure that appropriate follow-up, referrals, and scheduling are completed as necessary.
MOC Element 2D: Individualized Care Plan (ICP)
Describe the process for the developing the ICP, which SNP personnel are responsible, and how the enrollee and/or their caregiver(s) or representative(s) are involved in the development.
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.
Describe how updates and/or modifications to the ICP are communicated to the enrollee and/or their caregiver(s), the ICT, network providers, other SNP personnel, and stakeholders as necessary.
Describe how the SNP addresses challenges associated with enrollees who decline to participate in ICP process or are unable to be reached.
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).
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 long-term services and supports and behavioral health services.
MOC Element 2E: Interdisciplinary Care Team (ICT)
Provide a comprehensive description of the composition of the ICT, including 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 SNP enrollees, and how the ICT members contribute to improving the health status of enrollees.
Describe how the SNP informs and invites enrollees and their caregivers to participate as active members of the ICT.
Describe how the enrollee’s HRA and ICP are used to determine the composition of the ICT, including those cases where additional team members are needed to meet the unique needs of the individual enrollee.
Describe how the SNP analyzes enrollee health care needs and outcomes data to implement changes and/or adjustments to the ICT composition.
Describe how clinical managers, case managers, or other plan staff ensure that the SNP’s interdisciplinary care processes are effective in meeting enrollee needs.
Provide a comprehensive description of the SNP’s communication plan that ensures the exchange of enrollee information occurs regularly amongst the ICT, and includes but is not limited to the following:
Describe how the SNP maintains effective and ongoing communication between SNP personnel, the ICT, enrollees, caregiver(s), community organizations, and other stakeholders.
Describe the types of evidence used to verify that communications have taken place (e.g., ICT meeting minutes, documentation in the ICP, etc.)
Describe how communication is conducted with enrollees 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).
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
Describe how care transitions protocols are used to maintain continuity of care for SNP beneficiaries, including the process for connecting the enrollee 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 and ensuring that follow-up services and appointments are scheduled and performed, and how the enrollee and/or their caregiver(s) is informed of their SNP point of contact throughout the transition process.
Describe how the SNP ensures elements of the ICP and/or other relevant information are transferred between healthcare settings (e.g., community, hospital or institutional settings) when the enrollee experiences a transition in care, either planned or unplanned.
Describe the process for ensuring the SNP enrollee and/or caregiver(s) have access to and can adequately utilize their personal health information to share with other providers, help facilitate care, make informed decisions, etc.
Describe how the enrollee and/or caregiver(s) will be educated about their condition, signs/symptoms of improvement or worsening, self-management techniques, when to contact their provider(s), and how they will demonstrate understanding of this information.
D-SNPs: Explain how the plan coordinates with providers of any Medicaid covered services during a care transition, where applicable.
MOC Element 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 enrollees. The SNP is responsible for maintaining a network that includes relevant facilities and practitioners necessary to address the unique or specialized health care needs of the target population. The description of the SNP provider network must include but not be limited to the following:
MOC Element 3A: Specialized Expertise
Provide a detailed description of the specialized expertise available to enrollees in the SNP’s provider network.
The description must include evidence that the SNP provides each enrollee with an 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.
Describe 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 enrollees. Specialized expertise may include but is not limited to internists, endocrinologists, cardiologists, oncologists, nephrologists, mental health providers, etc.
Describe how providers collaborate with the ICT and SNP enrollees, contribute to the ICP and ensure the delivery of necessary specialized services. For example, describe how providers communicate SNP enrollee care needs to the ICT and other stakeholders, how specialized services are delivered in a timely and effective manner, and how relevant information/data is shared with the ICT and 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
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.
Describe how the SNP oversees enrollees whose complex health care needs require clinical practice guidelines and nationally-recognized protocols to be modified to fit the unique needs of vulnerable SNP enrollees. Also describe how these decisions are made, incorporated into the ICP, and communicated with the ICT.
Describe how the SNP ensures care transitions protocols are used both internally and by contracted providers to maintain continuity of care.
MOC Element 3C: MOC Training for the Provider Network Staff
Describe how the SNP conducts initial and annual MOC training for provider staff, including both in-network and out-of-network providers (note: out-of-network providers include providers seen by enrollees 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 printed instructional materials, face-to-face training, web-based instruction, audio/videoconferencing, and availability of instructional materials via the SNP plan’s website.
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, and maintains training records as evidence of MOC training for their network provider staff. Documentation may include copies of dated attendee lists, results of MOC competency testing, web-based attendance confirmation, electronic training records, and attestations, etc.
Describe any challenges associated with the completion of MOC training for both in-network and out-of-network provider staff and provide strategies the SNP will implement to facilitate compliance (e.g., how the SNP will work with providers to connect with the appropriate staff and facilitate completion of the trainings) .
MOC Element 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 SNP enrollees in a timely manner. The SNPs’ leadership team and governing body must have a comprehensive quality improvement program in place to measure its current level of performance and a methodology for assessing improvement and distributing 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 SNP’s overall quality performance improvement plan. MOC Element 4B establishes goals for achieving the desired overall MOC performance outcomes (e.g., improving access, affordability, care coordination, etc.), as well as goals for enrollee health outcomes (e.g., 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 the overall quality performance improvement plan and how it ensures that appropriate services are being delivered to SNP enrollees. The plan must be designed to determine whether the overall MOC structure effectively accommodates enrollees’ unique health care needs, while delivering high quality care and services. At a minimum, the plan must address its process for improving access to and coordination of care, member/provider satisfaction, and program effectiveness.
Describe how the SNP leadership team and other SNP personnel and stakeholders are involved with the internal quality performance process.
Describe the process by which the SNP continuously collects, analyzes, evaluates, and reports on quality performance, as well as supports ongoing improvement of the MOC. Also describe the processes used by the SNP to determine if goals/outcomes are met/not met, the use of benchmarks, and 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.
MOC Element 4B: Measurable Goals
Describe the SNP’s measurable goals for 1) overall MOC performance and 2) enrollee health outcomes for the SNP population as a whole. 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 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.
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
Improving hemoglobin A1c rate levels in enrollees with diabetes
Improving medication adherence
Lowering all cause readmissions
Preventive health services
Improving rates of breast cancer or colorectal screenings
Improving rates of depression screenings
Improving influenza, pneumonia, RSV, or shingles vaccination rates
MOC Element 4C: Measuring Patient Experience of Care (SNP Enrollee Satisfaction)
Describe the specific SNP survey(s) used and the rationale for selection of a particular tool(s) to measure enrollee satisfaction.
Detail the methodology used to collect survey data and specify the sample size for each survey used.
Describe how the results of enrollee satisfaction surveys are analyzed and integrated into the overall MOC performance improvement plan and used to implement new programs that target areas for improvement.
Describe the process used to address issues identified in the survey results.
MOC Element 4D: Dissemination of MOC Quality Performance Results
Describe in detail how the SNP communicates its quality improvement performance results and other pertinent information on a routine basis to its stakeholders, which may include, but not be limited to: SNP leadership teams, board of directors, personnel and staff, provider networks, enrollees and caregivers, the general public, and regulatory agencies.
Describe the scheduled frequency of communications and the methods for communication with the various stakeholders (e.g., webpages, printed newsletters, bulletins, other forms of media).
Identify the individual(s) responsible for communicating performance updates/results in a timely manner.
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 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.
1 : https://www.cms.gov/files/zip/medicare-part-c-and-part-d-program-audit-protocols-cms-10717.zip-2
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Williamson, Donna (CMS/CM) |
| File Modified | 0000-00-00 |
| File Created | 2025-07-01 |