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SNP Approval Model of Care Training
Elements 1-2January 21, 2014 2:00 – 4:00PM EST
Brett Kay, NCQASusan Radke, CMS
Sandra Jones, NCQA
2SNP Approval MOC Training, Elements 1-2 January 21, 2014
Objectives of SNP MOC Scoring Guidelines
• Revise structure of the MOC to help plans better understand and meet the requirements
• Model after S&P measures format– Approach familiar to the SNPs – SNPs have publicly requested such a
change– Supports consistent scoring of MOCs
3SNP Approval MOC Training, Elements 1-2 January 21, 2014
• Used revised Appendix 1 of the MA application Model of Care Upload document—kept requirements intact, but revised formatting
• Received input from stakeholders: Public Comment process– 222 comments– Health plans, trade associations,
provider groups, others
MOC Scoring Guidelines
4SNP Approval MOC Training, Elements 1-2 January 21, 2014
• Scoring will be similar to previous years
• MOC elements worth 0-4 points, based on # of factors met.
• Total of 60 points (15 elements)• converted to percentage scores
– E.g., 50 points = 83.33% (2-year approval)
How will NCQA Score the MOC?
5SNP Approval MOC Training, Elements 1-2 January 21, 2014
Scoring GuidelinesPrevious MOC Scoring Guidelines
Element Maximum Score
MOC 1: SNP-specific Population 4
MOC 2: Measurable Goals 12
MOC 3: staff Structure/roles 12
MOC 4: ICT 12
MOC 5: Provider Network 20
MOC 6: MOC Training 16
MOC 7: HRA 16
MOC 8: ICP 20
MOC 9: Communication Network
16
MOC 10: Vulnerable Populations 8
MOC 11: Outcome Measurement
24
Total 160
New MOC Scoring GuidelinesElement Maximum Score
MOC 1: SNP Population 8
MOC 2: Care Coordination 20
MOC 3: Provider Network 12
MOC 4: Quality Measurement 20
Total 60
6SNP Approval MOC Training, Elements 1-2 January 21, 2014
Crosswalk to New ElementsOld ElementsNew Elements
• MOC 1: SNP Population
• MOC 2: Care CoordinationCare Transitions Protocol NEW!
• MOC 3: Provider Network
• MOC 4: Quality Measurement
MOC 1: SNP-specific Population
MOC 10: Vulnerable Populations
MOC 3: Staff Structure/Care Management Roles
MOC 4: Interdisciplinary Care Team
MOC 7: Health Risk Assessment
MOC 8: Individual Care Plan
MOC 9: Communication Network
MOC 5: Provider Network & Use of Clinical Practice Guidelines
MOC 6: MOC Training
MOC 2: Measurable Goals
MOC 11: Outcome Measurement
7SNP Approval MOC Training, Elements 1-2 January 21, 2014
Project Time Line
• February 25 – MA/SNP & Medicare-Medicaid Plans (MMP) Applications submitted to CMS via HPMS
• March 11 –MMP application results to CMS
• MA/SNP reviews continue
• March 17 – CMS issues Deficiency Notices to MMPs
-- Begin “Cure Process” - Plans have 7-10 calendar days to submit additional information
• March 18 MMP Cure 1 TA call for Plans scoring <70%
8SNP Approval MOC Training, Elements 1-2 January 21, 2014
Project Time Line
• March 24 Cure 1 MMP Apps due to CMS
• April 28 – CMS issues Notice of Intent to Deny
• April 30 – MA/SNPs & MMP TA call for Plans scoring <70%
• May 8 - MA/SNP & MMP Cure Apps due
• May 28 – CMS issues MA/SNP Denial Notices & MMP Status Notices
• June 2 - SNP bids due to CMS
10SNP Approval MOC Training, Elements 1-2 January 21, 2014
Intent: Identify and describe the target population, including health and social factors, and unique characteristics of each SNP type– Focus is on a description that:
• Provides a foundation upon which the remaining measures build a complete continuum of care (e.g. end-of-life & special considerations) for current and potential members the plan intends to serve.
• Includes specially tailored services for members considered “most vulnerable” (e.g. multiple hospital admissions or excessive spending on medications above set limits)
MOC 1: Description of SNP Population
11SNP Approval MOC Training, Elements 1-2 January 21, 2014
MOC 1 Element A: Overall SNP Population
Factor 1• MOC Description: Emphasis is on
process* and relevant resources used, not care coordination:– Member identification
– Verification of eligibility
– Tracking
*Process includes information on systems or data collection methodology used to identify and track eligible beneficiaries
12SNP Approval MOC Training, Elements 1-2 January 21, 2014
MOC 1 Element A: Overall SNP Population
Factor 2Separated social and medical/health factors; the focus is on social, cognitive and environmental factors*.• MOC description must also include
– Social & environmental factors; living conditions
– Cultural or linguistic challenges– Barriers to health care delivery– Caregiver concerns
*Potential factors that may interfere with provision of health care or services, caregiver considerations or other concerns.
13SNP Approval MOC Training, Elements 1-2 January 21, 2014
MOC 1 Element A: Overall SNP Population
Factor 3Focus is on medical/health/cognitive factors* • MOC description must also include
– Current health status of members– Associated behavioral health issues– Co-morbidities
*Disease characteristics that could impact present status
14SNP Approval MOC Training, Elements 1-2 January 21, 2014
MOC 1 Element A: Overall SNP Population
Factor 4• Characteristics of population per SNP
type– Includes limitations & barriers that affect
overall health
• C- SNP – chronic conditions, incidence & prevalence
• D-SNP – Full/partial; including limitations & barriers
• I-SNP –Facility type; specialty providers & services; limitations & barriers
15SNP Approval MOC Training, Elements 1-2 January 21, 2014
Intent: Describe the most vulnerable beneficiaries and how their medical/social factors affect health outcomes and what services/resources the SNP provides to address these
– Focus:• Important to note that the focus is on
population-level, not individual members
• Simply put, what makes them “different”?
MOC 1B: Most Vulnerable Beneficiaries
16SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 1• Plan definition of “most vulnerable” and
includes:– Robust & comprehensive description of
members
– Methodology used for identification (e.g. specify data collected from various resources, multiple admits/readmits, high pharmacy utilization, high risk stratification, specific diagnosis & subsequent treatment required)
– Medical, psychosocial, cognitive or functional challenges
– Any specially tailored services geared towards this population
MOC 1 Element B: Most Vulnerable Beneficiaries
17SNP Approval MOC Training, Elements 1-2 January 21, 2014
MOC includes a description of the most vulnerable members specifically:Factor 2• Explain how certain characteristics (e.g.
average age, gender, ethnicity, language barriers, etc.) affect health outcomes of the “most vulnerable”:– Demographic characteristics (e.g. average age,
gender, ethnicity, language barriers, health literacy, socioeconomic status
Factor 3• Draw a correlation between demographic
characteristics and clinical requirements:• Specify how the characteristics adversely affect
health status & outcomes and the need for unique clinical intervention
MOC 1 Element B: Most Vulnerable Beneficiaries
18SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 4• Establish relationships with community
partners– Describe the process for partnering with
community providers to deliver needed services:
• Type of specialized resources and services
• How the Plan facilitates member/caregiver access
• Guarantee provision of continuity of eligible services
MOC 1 Element B: Most Vulnerable Beneficiaries
21SNP Approval MOC Training, Elements 1-2 January 21, 2014
Intent: Describe admin/clinical staff roles and responsibilities
–Focus: • How care coordination (e.g. health care needs, preferences and sharing information across health care staff and facilities) occurs
• All elements must address the SNP’s care coordination activities in detail
MOC 2: Element A: SNP Staff Structure
22SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 1: Describe the administrative staff roles, responsibilities, and oversight functions.
– Identify & describe employed or contracted staff that perform administrative functions:• Enrollment and eligibility verification
• Claims processing
• Administrative oversight
MOC 2: Element A: SNP Staff Structure
23SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 2: Describe the clinical staff roles, responsibilities and oversight functions
– Identify & describe employed or contracted staff that perform clinical functions including:• Directing beneficiary care & education
• Care coordination
• Pharmacy consultation
• Behavioral health counseling
• Clinical oversight (e.g., describe how license/competency verification relates to specific population being served)
MOC 2: Element A: SNP Staff Structure
24SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 3: Coordination of responsibilities and job title
–Describe how identified staff responsibilities coordinate with job title e.g. impact of staff changes:• Title or position
• Levels of accountability
MOC 2: Element A: SNP Staff Structure
25SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 4: Contingency plan– Identify & describe contingency
plans to ensure continuity of staff functions.
Factor 5: Initial & annual MOC training
– Describe the process for conducting initial & annual MOC training
• Training content & strategies
• Employed & contracted staff*
*Contracted staff do not include physicians or other providers
MOC 2: Element A: SNP Staff Structure
26SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 6: Maintaining training records• Describe how the plans documents
& maintains training records:– Process for documenting completion
of required training; and
– How/where the Plan maintains training records
MOC 2: Element A: SNP Staff Structure
27SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 7: Corrective actions:• Describe the actions taken if staff
do not complete required MOC training– Explain challenges to completing
training for employed and contracted staff
– Actions taken for missed or deficient training
MOC 2: Element A: SNP Staff Structure
28SNP Approval MOC Training, Elements 1-2 January 21, 2014
Intent: Describe how the HRAT collects and uses data to assess medical, functional, cognitive, psychosocial and mental health needs of members.• Focus:
– How the HRAT is used to develop the ICP– Dissemination of information to ICT– Process for conducting the initial and
annual assessments– Methodology used to review, analyze and
stratify HRA results
MOC 2: Element B: Health Risk Assessment Tool
29SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 1: Describe the use and dissemination of HRAT information:• Describe the data collected:
– Medical– Functional– Cognitive– Psychosocial; and – mental health needs of members
• Process for developing and updating the ICP in a timely basis
MOC 2: Element B: Health Risk Assessment Tool
30SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 2: Disseminating HRAT information• Describe the process for sharing HRAT
information with the ICT• ICT use of HRAT information
– Integration of results into the ICP
Factor 3: Initial HRA & annual reassessment• Describe the process including:
– Timeframe for conducting (e.g. initial & annual)
– Methodology (mailed, in-person, phone interview)
– Contacting members not responding to mailings or calls
MOC 2: Element B: Health Risk Assessment Tool
31SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 4: Plan & rationale • Describe the process used to review,
analyze and stratify HRAT results– Detail stratification process– Communication of stratification results:
• ICT• Provider network (e.g. specialty providers,
allied or behavioral health practitioners)• Members/caregivers; other SNP personnel
as applicable– Explain how the SNP uses results to
improve care coordination
MOC 2: Element B: Health Risk Assessment Tool
32SNP Approval MOC Training, Elements 1-2 January 21, 2014
Intent: Describe how the ICP is developed and communicated• Focus
– Describing the essential elements of the ICP
– Detail the process for development/modification
– Identify staff responsible – How updates to the ICP are:
• Documented• Maintained; and • Communicated.
MOC 2: Element C: Individualized Care Plan (ICP)
33SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 1: ICP essential components• Description includes:
– Member’s self management goals & objectives
– Personal health care preferences– Services specifically tailored to
beneficiary’s needs
MOC 2: Element C: Individualized Care Plan (ICP)
34SNP Approval MOC Training, Elements 1-2 January 21, 2014
Description includes:• Factor 2: ICP development process & staff
responsible – Process for ICP development– Details staff responsible e.g. role &
functions, professional requirements and credentials
• Factor 3– Personnel responsible for development of
ICP, including involvement of member/caregiver
MOC 2: Element C: Individualized Care Plan (ICP)
35SNP Approval MOC Training, Elements 1-2 January 21, 2014
• Factor 4– Process for determining the frequency
for review & modification when changes occur
• Factor 5– Communication of updates and
modifications to the ICP
MOC 2: Element C: Individualized Care Plan (ICP)
36SNP Approval MOC Training, Elements 1-2 January 21, 2014
Intent: Describe the key components of the ICT• Focus:
– Key members of ICT – Roles/responsibilities – How the ICT contributes to improving
beneficiary health status – Communications within the ICT
MOC 2: Element D: Interdisciplinary Care Team (ICT)
37SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 1: ICT membership• Description includes:
– How the SNP determines key members of ICT e.g. specialized expertise requirements
– Process for facilitating participation of beneficiary/caregiver
– Use of member HRAT results & ICP to identify ICT membership
– Explain how ICT uses health care outcomes to evaluate established processes
MOC 2: Element D: Interdisciplinary Care Team (ICT)
38SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factors 2 & 3: ICT Roles & responsibilities• Description includes:
– Use of clinical managers, case managers & others to provide interdisciplinary care
– How the SNP includes member/caregiver in the process
– Provision of needed resources– How the SNP facilitates
member/caregiver access to ICT members
MOC 2: Element D: Interdisciplinary Care Team (ICT)
39SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 4: Communication plan• Description includes:
– Evidence of an established communication plan
– Process for maintaining effective and ongoing communication
– Verification of communication e.g. ICT meeting minutes, ICP documentation
– Communication with members identified with challenges e.g. hearing impairments, language barriers or cognitive deficiencies
MOC 2: Element D: Interdisciplinary Care Team (ICT)
40SNP Approval MOC Training, Elements 1-2 January 21, 2014
Intent: Describe the SNP’s processes to coordinate care transitions and facilitate timely communications across settings and providers. • Focus:
– Factor 1: The process for coordinating transitions– Factor 2: Personnel responsible for coordination efforts– Factor 3: Description of coordination between settings
during a care transition– Factor 4: How beneficiaries have access to personal
health information to facilitate communication with providers
– Factor 5: Education provided to members/caregivers to manage conditions and avoid transitions
– Factor 6: Process used to notify members/caregivers of staff assigned to support member through transitions
MOC 2: Element E: Care Transition Protocols
41SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 1: Process for coordinating transitions• The description must specify:
– Process & rationale used to connect members with appropriate providers
• Factor 2: Personnel responsible for coordination efforts– Identify & describe staff responsible for:
• Coordinating care transition process• Ensuring follow-up services e.g. scheduling
appointments, needed resources
MOC 2: Element E: Care Transition Protocols
42SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 3: Applicable transitions• Description of the steps staff managing
transitions take before, during & after transitions
Factor 4: Access to health information • Process for facilitating
member/caregiver access to health information necessary to communicate with providers in other healthcare settings or outside the network.
MOC 2: Element E: Care Transition Protocols
43SNP Approval MOC Training, Elements 1-2 January 21, 2014
Factor 5: Self-management activities• Education provided to
members/caregivers to manage conditions and avoid transitions– Signs & symptoms of worsening condition– How to respond to changes
Factor 6: Notification of point of contact • Process used to notify
members/caregivers of staff assigned to support member through transitions
MOC 2: Element E: Care Transition Protocols
44SNP Approval MOC Training, Elements 1-2 January 21, 2014
Training & Education• Sessions focus on MOC Requirements
& Technical Assistance
-- MOC Elements 1 & 2 (1 training)o January 21* 2:00-4:00pm ET
-- MOC Elements 3 & 4 (1 training)o January 23* 2:00-4:00pm ET
-- Technical Assistance Calls 2:00 – 3:30 pm ETo February 11o March 18 for MMP scored <70%o April 30 MA/SNPs & MMPs scored <70%
* Recordings and slides available on NCQA SNP Approval website within one week of call
45SNP Approval MOC Training, Elements 1-2 January 21, 2014
For technical inquires related to the MOC program plan requirements, appeals/denials or other issues related to the SNP/MMP approval proposal in the regulations, please contact CMS at:
CMS SNP [email protected] Subject line: SNP MOC Inquiry
CMS MMP [email protected] line: MMP MOC Inquiry
NCQA SNP Approval Website for training recordings and slides: www.ncqa.org/snpapproval
CMS Contacts