SNP Approval Model of Care Training Elements 1-2 January 21, 2014 2:00 – 4:00PM EST Brett Kay, NCQA Susan Radke, CMS Sandra Jones, NCQA

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


• 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


• 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?


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


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


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%


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

Sandra Jones

MOC 1: Description of SNP Population


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


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



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.



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



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


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


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


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



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



QUESTIONS

MOC 2: Care Coordination

Brett Kay


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


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



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)



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



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



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



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



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


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



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



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



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)


Factor 1: ICP essential components• Description includes:

– Member’s self management goals & objectives

– Personal health care preferences– Services specifically tailored to

beneficiary’s needs



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



• Factor 4– Process for determining the frequency

for review & modification when changes occur

• Factor 5– Communication of updates and

modifications to the ICP



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)


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



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



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



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


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



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.



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



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


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

mailto:[email protected]

mailto:[email protected]

http://www.ncqa.org/snpapproval


QUESTIONS

Documents

SNP Approval Model of Care Training Elements 1-2 January 21, 2014 2:00 – 4:00PM EST Brett Kay, NCQA Susan Radke, CMS Sandra Jones, NCQA