The Centers for Medicare & Medicaid Services (CMS) requires Special Need Plans (SNP) to build a Model of Care (MOC) to ensure the unique needs of each enrollee are identified and addressed. SNPs are expected to make intentional efforts around member assessment and care coordination. The plan’s MOC outlines the framework for addressing the basic needs of its SNP population to drive quality improvement. Each plan’s MOC is assessed by the National Committee for Quality Assurance (NCQA) based on CMS scoring guidelines.
What is a Model of Care Document?
An MOC is a true framework of how the SNP will address the basic needs of the SNP population. The programs outlined must be a true reflection of what is happening in the health plan and can be demonstrated during an audit.
Medicare Advantage (MA) plans are required to submit an MOC if they plan to offer a new SNP plan, the plan’s MOC approval period ends or when CMS determines that a new MOC is necessary for compliance purposes, such as after a regulation change or audit. Designing and writing an MOC is a critical activity, since it becomes an MA plan’s CMS Compliance Mandate upon submission.
Once submitted for approval, an MOC is scored on a variety of criteria, both clinical and non-clinical. SNPs that receive less than 70% after scoring are considered to have failed and have one chance to revise for rescoring and approval. SNPs are approved for one, two or three years depending on their scores in their first MOC submission.
Model of Care Do’s
The NCQA and CMS are looking for specific elements in a plan’s MOC. What plans include must be strategic and forward thinking so they find themselves in the best position to meet MOC requirements and be successful when CMS holds plans accountable.
Three things you should include are:
- Programs that can be implemented to support reaching 4+ Stars.
- All impacted departments in the development of the MOC.
- Ongoing evaluations of the programs in the MOC to ensure compliance and readiness for audits.
Model of Care Don’ts
What not to do is almost as important as what to do. Since MOCs are posted publicly, plans want to be sure to set themselves up for success to demonstrate compliance with programs and processes outlined in the document.
Three things to avoid with your MOC are:
- A model of care that is idealistic but not realistic to implement.
- Producing it in a silo without input from all stakeholders.
- Waiting until the audit to assess whether the MOC is appropriately implemented.
Model of Care Auditing
CMS evaluates a plan’s implementation and performance related to their MOC as part of the audit process. During the 2022 audits, it was clear CMS had greater scrutiny specific to the Special Needs Plan-Care Coordination audit area, as the SNP MOC area had the second highest scores. In MOC audits, higher scores represent worse performance.
With this heightened scrutiny from CMS, SNP sponsors must ensure clinical operations are consistently aligned with the approved MOC.
Healthmine has a team of clinical experts who are skilled at working with plans to:
- Design clinical programs to address the unique needs of a SNP population, which includes tactical solutions to align an organization’s pursuit of a high Star Rating.
- Develop or enhance a plan’s Model of Care that meets the needs of the SNP population.
- Complete initial and ongoing MOC audit readiness assessments.
- Develop training for internal and external care teams regarding the MOC requirements and activities.
To learn more, contact Donna Simon at Donna.Simon@healthmine.com or Ana Berridge at Ana.Berridge@healthmine.com.
Donna is a Registered Nurse with over 28 years of clinical experience, 22 of which have been in healthcare administration. She focuses on using innovative approaches to improve the care delivery system by ensuring clinical teams understand and leverage data and information systems to identify, manage and provide quality-based care efficiently. She is passionate about developing strong and efficient teams that optimize patient outcomes and experiences.
She has worked with both large hospital systems and payers, which provides her with insight of multiple perspectives within the healthcare industry. She has worked closely with these providers and systems to promote value-based care opportunities and a medical neighborhood concept. Donna has also consulted with multiple organizations to provide expertise related to various NCQA accreditation and certification programs.
Ana brings more than 20 years of healthcare and health plan experience to Healthmine. She most recently came from WellSense Health Plan, formerly Boston Medical Center HealthNet Plan. She had oversight of work related to Stars, HEDIS®, NCQA, Quality Rating System, External Quality Review Organization, population health programs, new product implementation, value-based care programs, policy advocacy and health equity programs.
Ana developed multiple innovative member and provider interventions that were integral in the successful improvement of key HEDIS and Consumer Assessment of Healthcare Providers and Systems (CAHPS) quality measures and meeting corporate and contractual goals. She has experience with successfully identifying and implementing new to industry initiatives, such as texting, with proven quality and financial improvement. Ana is bilingual in English and Spanish and has used this in community initiatives to help engage members and improve the quality of care for the Medicaid, Medicare, Affordable Care Act, and Commercial populations.
Ana holds a master’s degree from Simmons University in Health Administration and a bachelor’s degree from the University of New Hampshire.
.svg)
