Crosswalk

CMS-10565, OMB 0938-1296 Crosswalk Document

Attachment A – Model of Care Matrix Document

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
ATTACHMENT B Revised Model of Care Matrix Upload Document	Deleted	Del	CMS eliminated MOC Matrix B as all MOC requirements for an initial, renewal and off-cycle submissions are now included in Attachment A, Model of Care Matrix Document.	Budget Neutral
ATTACHMENT B Dual Eligible Special Needs Plan Model of Care Questionnaire	Deleted	Del	In response to public comments, CMS eliminated the proposed Dual Eligible Special Needs Plan Model of Care Questionnaire	Budget Neutral
Element A: Description of the Overall SNP Population The identification and 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. 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 addresses the full continuum of care of current and potential SNP beneficiaries, including end- of-life needs and considerations, if relevant to the target population served by the SNP.	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.	Rev	These revisions were made to streamline the language of this element.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

Change

2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
	MOC Element 1A: Description of the Overall SNP Population and Most Vulnerable Enrollees	New	This is a new subheading of a MOC element.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
Element 1A: Description of the Overall SNP Population Clear documentation of how the health plan staff determines or will determine, verify, and track eligibility of SNP enrollees.	Deleted	Del	This element content was removed to streamline the requirements. We do note that this requirement is an existing operational requirement for SNPs, however, it will no longer be captured as part of the MOC submission.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
New language	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.).	New	This is new language and requirements that have been added to Element 1A to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
	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.
Element 1A: Description of the Overall SNP Population A detailed profile of the medical, social, cognitive, and environmental aspects, the living conditions, and the co-morbidities associated with the SNP population in the plan’s geographic service area. Identification and description of the health conditions impacting SNP enrollees, including specific information about other characteristics that affect health, such as population demographics (e.g., average age, gender, ethnicity) and potential health disparities associated with specific groups (e.g., language barriers, deficits in health literacy, poor socioeconomic status, cultural beliefs/barriers, caregiver considerations, other).	MOC Element 1A: Description of the Overall SNP Population and Most Vulnerable Enrollees 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	Rev	These are revisions for clarity and/or moved/reordered from a previous location; and to align with Executive Order 14168	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
Definition of unique characteristics for the SNP population served: C-SNP: What are the unique chronic care needs for C-SNP enrollees? Include limitations and barriers that pose potential challenges for these C-SNP enrollees. D-SNP: What are the unique health needs for D-SNP enrollees? Include limitations and barriers that pose potential challenges for these D-SNP enrollees. I-SNP: What are the unique health needs for I-SNP enrollees? Include limitations and barriers that pose potential challenges for these I-SNP enrollees as well as information about the facilities and/or home and community-based services settings in which your enrollees reside.	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.
New language	MOC Element 1A: Description of the Overall SNP Population and Most Vulnerable Enrollees Note: SNPs must differentiate between the general SNP population from the most vulnerable enrollees.	New	This is new language that has been added to Element 1A to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
Element B: Sub-Population: Most Vulnerable Enrollees 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.	Deleted	Del	This element content was removed to streamline the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
Element B: Sub-Population: Most Vulnerable Enrollees A description of the internal health plan procedures for identifying the most vulnerable enrollees within the SNP. The identification and description of the established partnerships with community organizations that assist in identifying resources for the most vulnerable enrollees, including the process that is used to support continuity of community partnerships and facilitate access to community services by the most vulnerable enrollees and/or their caregiver(s).	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	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
	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.
Element B: Sub-Population: Most Vulnerable Enrollees A description of the relationship between the demographic characteristics of the most vulnerable enrollees and 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 enrollees.	Deleted	Del	This content was removed to streamline and eliminate redundancies from the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
New language	MOC Element 1B: Services for the Most Vulnerable Enrollees 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.	New	This is new language that has been added to Element 1B to clarify the requirements. Adding new factor based on comments to the 60-day package.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
New language	MOC Element 1B: Services for the Most Vulnerable Enrollees 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.	New	This is new language that has been added to Element 1B to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
2. Care Coordination Care coordination helps ensure that SNP enrollees’ healthcare needs, preferences for health services, and information sharing across healthcare staff and facilities are met over time. Care coordination maximizes the use of effective, efficient, safe, and high-quality patient services that ultimately lead to improved healthcare outcomes, including services furnished outside the SNP’s provider network as well as the care coordination roles and responsibilities overseen by the enrollees’ 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 SNP’s care coordination activities.	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:	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
Element A: SNP Staff Structure Fully define the SNP staff roles and responsibilities across all health plan functions that directly or indirectly affect the care coordination of SNP enrollees. This includes, but is not limited to, identification and detailed explanation of: Employed and/or contracted staff who perform clinical functions, such as: direct enrollee care and education on self-management techniques, care coordination, pharmacy consultation, behavioral health counseling, etc. Employed and/or contracted staff who perform 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 how staff responsibilities identified in the MOC are coordinated with job titles. 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. Identify the SNP contingency plan(s) used to ensure ongoing continuity of critical staff functions.	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.	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
Element A: SNP Staff Structure Employed and/or contracted staff who perform administrative functions, such as: enrollment and eligibility verification, claims verification and processing, etc.	Deleted	Del	This element content was removed to streamline the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
Element B: 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 enrollee. The content of, and methods used to conduct the HRAT have a direct effect on the development of the Individualized Care Plan (ICP) and ongoing coordination of Interdisciplinary Care Team (ICT) activities; therefore, it is imperative that the MOC include the following:	Deleted	Del	This element content was removed to streamline the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
Element B: Health Risk Assessment Tool (HRAT) A clear and detailed description of the policies and procedures for completing the HRAT, including: Description of how the HRAT is used to develop and update, in a timely manner, the ICP (MOC Element 2D) for each enrollee, and how the HRAT information is disseminated to and used by the ICT (MOC Element 2E). Detailed explanation for how the initial HRAT and annual reassessment are conducted for each enrollee. Description of how the SNP ensures that the results from the initial HRAT and the annual reassessment HRAT conducted for each individual are addressed in the ICP. Detailed plan and rationale for reviewing, analyzing, and stratifying (if applicable) the results of the HRAT, including the mechanisms to ensure communication of that	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. 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. 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	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
information to the ICT, provider network, enrollees and/or their caregiver(s), as well as other SNP personnel that may be involved with overseeing the SNP enrollee’s ICP. If stratified results are used, include a detailed description of how the SNP uses the stratified results to improve the care coordination process.	their caregiver(s) or designated representative, as well as other SNP personnel that may be involved with overseeing the SNP enrollee’s ICP.
New language	MOC Element 2B: Health Risk Assessment (HRA) How the HRA identifies the medical, functional, cognitive, psychosocial, mental health, and social determinants of health needs for each SNP enrollee. Describe how the SNP addresses challenges associated with enrollees who decline to participate in HRA completion or are unable to be reached. Describe how the SNP uses stratified results to improve the care coordination process.	New	This is new language that has been added to Element 2B to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
Element C: 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	Deleted	Rev	Deleted introductory paragraph to improve readability and to shorten document.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
the overall care management strategy, and as a result, the MOC must include the following:				approved by OMB.
Element C: Face-to-Face Encounter A clear and detailed description of the policies, procedures, purpose, and intended outcomes of the face-to-face encounter. A description of who will conduct the face-to- face encounter, employed and/or contracted staff. A description of the types of clinical functions, assessments, and/or services that may be provided during the face-to-face encounter. A description of how health concerns and/or active or potential health issues will be addressed during the face-to-face encounter. A description of how the SNP will conduct care coordination activities through appropriate follow-up, referrals, and scheduling as necessary.	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. 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.	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
New language	MOC Element 2C: Face-to-Face Encounter  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.	New	This is new language that has been added to Element 2C to clarify the requirements. Adding new text in response to comments to the 60-day package.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
Element D: Individualized Care Plan (ICP) The ICP components must include, but are not limited to: enrollee self-management goals and objectives; the enrollee’s personal healthcare preferences; description of services specifically tailored to the enrollee’s needs; roles of the enrollees’ caregiver(s); and identification of goals met or not met. When the enrollee’s goals are not met, provide a detailed description of the process employed to reassess the current ICP and determine appropriate alternative actions. Explain the process and which SNP personnel are responsible for the	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	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies. Adding new text in response to comments to the 60-day package.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
development of the ICP, how the enrollee and/or his/her caregiver(s) or representative(s) are involved in its development, and how often the ICP is reviewed and modified as the enrollee’s healthcare needs change. If a stratification model is used for determining SNP enrollees’ healthcare needs, then each SNP must provide a detailed explanation of how the stratification results are incorporated into each enrollee’s ICP. Describe how the ICP is documented and updated, including updates based on more recent HRAT information and where the documentation is maintained to ensure accessibility to the ICT, provider network, enrollee, and/or caregiver(s). Explain how updates and/or modifications to the ICP are communicated to the enrollee and/or their caregiver(s), the ICT, applicable network providers, other SNP personnel, and other stakeholders as necessary.	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.
New language	MOC Element 2D: Individualized Care Plan (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.	New	This is new language that has been added to Element 2D to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
Element E: Interdisciplinary Care Team (ICT) Provide a detailed and comprehensive description of the composition of the ICT; include 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 beneficiaries, and how the ICT members contribute to improving the health status of SNP 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 how the SNP facilitates the participation of beneficiaries and their caregivers as members of the ICT. Describe how the beneficiary’s HRAT (MOC Element 2B) and ICP (MOC Element 2C) 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 beneficiary. Explain how the ICT uses healthcare outcomes to evaluate established processes to manage changes and/or adjustments to the beneficiary’s health care needs on a continuous basis. Identify and explain the use of clinical managers, case managers or others who play critical roles in ensuring an effective	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 thefollowing: Describe how the SNP maintains	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
interdisciplinary care process is being conducted. Provide a clear and comprehensive description of the SNP’s communication plan that ensures exchanges of beneficiary information is occurring regularly within the ICT, including 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 how the SNP maintains effective and ongoing communication between SNP personnel, the ICT, beneficiaries, caregiver(s), community organizations and otherstakeholders. The types of evidence used to verify that communications have taken place, e.g., written ICT meeting minutes, documentation in the ICP, other.	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.)
New language	MOC Element 2E: Interdisciplinary Care Team (ICT) 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	New	This is new language that has been added to Element 2E to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
	that the plan does not cover, if applicable.
New language	MOC Element 2E: Interdisciplinary Care Team (ICT) 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.	New	This is a new requirement that has been added to Element 2E and applies only to D-SNPs.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
Element F: Care Transitions Protocols Explain how care transitions protocols are used to maintain continuity of care for SNP beneficiaries. Provide details and specify the process and rationale for connecting the beneficiary to the appropriate provider(s). Describe which personnel (e.g., case manager) are responsible for coordinating thecare transition process and ensuring that follow-up services and appointments are scheduled and performed as defined in MOC Element	MOC Element 2F: Care Transitions Protocols Describe how care transitions protocols are used to maintain continuity of care forSNP 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.	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
2A. Explain how the SNP ensures elements of the beneficiary’s ICP are transferred between healthcare settings when the beneficiary experiences an applicable transition in care. 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 beneficiary and/or caregiver(s) have access to and can adequately utilize the beneficiaries’ 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. Describe how the beneficiary and/or caregiver(s) will be educated about indicators that his/her condition has improved or worsened and how they will demonstrate their understanding of those indicators and appropriate self- management activities.	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.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
Element F: Care Transitions Protocols Describe how the beneficiary and/or caregiver(s) are informed about who their point of contact is throughout the transition process.	Deleted	Del	This element content was removed to streamline the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
New language	MOC Element 2F: Care Transitions Protocols D-SNP: Explain how the plan coordinates with providers of any Medicaid covered services during a care transition, where applicable.	New	This is new language that has been added to Element 2F to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
New language	MOC Element 2F: Care Transitions Protocols D-SNPs: Explain how the plan coordinates with providers of any Medicaid covered services during a care transition, where applicable.	New	This is a new requirement that has been added to Element 2E and applies only to D-SNPs.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
				OMB.
3. SNP Provider Network The SNP Provider Network is a network of healthcare providers who are contracted to provide health care services to SNP beneficiaries. The SNP is responsible for a network description that must include 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:	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:	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
Element A: Specialized Expertise Provide a complete and detailed description of the specialized expertise available to SNP beneficiaries in the SNP 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 that includes	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	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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providers with demonstrated experience and training in the applicable specialty, or area of expertise, in treating individuals that are similar to the target population. Explain 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 beneficiaries. Specialized expertise may include, but is not limited to: internal medicine, endocrinologists, cardiologists, oncologists, mental health specialists, other. Describe how providers collaborate with the ICT (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’ care needs to the ICT and other stakeholders; how specialized services are delivered to the SNP beneficiary in a timely and effective way; and how reports regarding services rendered are shared with the ICT and how relevant information is incorporated into the ICP.	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.

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New language	MOC Element 3A: Specialized Expertise 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.	New	This is new language that has been added to Element 3A to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
Element B: Use of Clinical Practice Guidelines & Care Transitions Protocols Explain the processes for ensuring that network providers utilize appropriate clinical practice guidelines and nationally- recognized protocols. This may include, but is not limited to: use of electronic databases, web technology, and manual medical record review to ensure appropriatedocumentation. Define any challenges encountered with overseeing patients with complex healthcare needs where clinical practice guidelines and nationally-recognized protocols may need to be modified to fit the unique needs of vulnerable SNP beneficiaries. Provide details regarding how these decisions are made, incorporated into the ICP (MOC Element 2C), communicated with the ICT (MOC Element 2D) and acted upon. Explain how SNP providers ensure care transitions protocols are being used to	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.	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
maintain continuity of care for the SNP beneficiary as outlined in MOC Element 2E.
Element C: MOC Training for the Provider Network Explain, in detail, how the SNP conducts initial and annual MOC training for network providers and out-of-network providers seen by beneficiaries on a routine basis. 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. Describe how the SNP documents and maintains training records as evidence of MOC training for their network providers. 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 attestation of MOC training. Explain any challenges associated with the completion of MOC training for network providers and describe what specific actions the SNP Plan will take when the	MOC Element 3C: MOC Training for 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. 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	Rev	These revisions are for clarity and streamlining. Also, the MOC training requirements in this section now target provider staff rather than direct care provider staff. This is aimed at decreasing provider burden.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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required MOC training has not been completed or is found to be deficient in some way.	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) .
New language	MOC Element 3C: MOC Training for Provider Network Staff 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.	New	This is new language that has been added to Element 3C to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
4. MOC Quality Measurement & Performance Improvement The goals of performance improvement and quality measurement are to improve the SNP’s ability to deliver healthcare services and benefits to its SNP beneficiaries in a high-quality manner. Achievement of those goals may result from increased organizational effectiveness and efficiency by incorporating quality measurement and performance improvement concepts used	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.	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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to drive organizational change. The leadership, managers and governing body of a SNP organization must have a comprehensive quality improvement program in place to measure its current level of performance and determine if organizational systems and processes must be modified based on performance results.
New language	MOC Element 4: MOC Quality Measurement & Performance Improvement 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:	New	This is new language that has been added to Element 4 to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
Element A: MOC Quality Performance Improvement Plan Explain, in detail, the quality performance improvement plan and how it ensures that appropriate services are being delivered to SNP beneficiaries. The quality performance improvement plan must be designed to detect whether the overall MOC structure effectively accommodates beneficiaries’ unique healthcare needs. The description must include, but is not limited to, the following: The complete process, by which the SNP continuously collects, analyzes, evaluates and reports on quality performance based on the MOC by using specified data sources, performance and outcome measures. The MOC must also describe the frequency of these activities.	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 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.	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
Element A: MOC Quality Performance Improvement Plan Details regarding 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	MOC Element 4A: MOC Quality Performance Improvement Plan Describe how the SNP leadership team and other SNP personnel and stakeholders are involved with the internal quality performance process. 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.	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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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 re- measurement plan for goals not achieved.	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.
Element B: Measurable Goals & Health Outcomes for the MOC Identify and clearly define the SNP’s measurable goals and health outcomes 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:	MOC Element 4A: MOC Quality Performance Improvement Plan 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.	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
New language	MOC Element 4B: Measurable Goals 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	New	This is new language that has been added to Element 4A to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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	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.
Element B: Measurable Goals & Health Outcomes for the MOC 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 appropriatedelivery 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	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	Rev	These revisions are to clarify requirements and distinguish between the overall MOC performance goals and enrollee health outcome goals.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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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.	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
Element C: Measuring Patient Experience of Care (SNP Enrollee Satisfaction) Describe the specific SNP survey(s) used and the rationale for selection of that particular tool(s) to measure SNP enrollee satisfaction. Explain how the results of SNP enrollee satisfaction surveys are integrated into the overall MOC performance improvement plan, including specific steps to be taken by the SNP to address issues identified in response to survey results.	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 enrollee satisfaction. 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.	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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2022 (Current version)	2025 (new version)	Type of	Reason for Change	Burden Change
New language	MOC Element 4C: Measuring Patient Experience of Care (SNP Member Satisfaction) Detail the methodology used to collect survey data and specify the sample size for each survey used.	New	This is new language that has been added to Element 4C to clarify the requirements.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
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.	Deleted	Del	Element D was deleted as the requirements were subsumed into MOC element 4B and the former MOC Element 4E, now renamed as 4D. In other words, these requirements were moved to new locations, not completely eliminated.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.

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Element E: Dissemination of SNP Quality Performance related to the MOC Explain 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, SNP management groups, SNP boards of directors, SNP personnel and staff, SNP provider networks, SNP enrollees and caregivers, the general public, and regulatory agencies. 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 webpage for announcements, printed newsletters, bulletins, and other announcement mechanisms. Identify the individual(s) responsible for communicating performance updates in a timely manner as described in MOC Element 2A.	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.	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently approved by OMB.
Element D: Ongoing Performance Improvement Evaluation of the MOC Describe how the performance improvement evaluation of the MOC will be documented and shared with key stakeholders.	MOC Element 4D: Dissemination of MOC Quality Performance Results Describe how the performance improvement updates/results will be documented and shared with key stakeholders.	Rev	These are revisions in order to streamline, clarify, and eliminate redundancies.	Budget Neutral This requirement is consistent with currently approved information tracking practices & does not impose any new or revised burden beyond what is currently

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				approved by OMB.

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