CMS Pub. 100-16, ch. 5, § 20.2.1

1. Description of the 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. 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. The description of

the SNP population must include, but not be limited to, the following:

 Clear documentation of how the health plan staff determines or will determine, verify, and

track eligibility of SNP beneficiaries.

 A detailed profile of the medical, social, cognitive, environmental, living conditions, and

co-morbidities associated with the SNP population in the plan’s geographic service area.

 Identification and description of the health conditions impacting SNP beneficiaries,

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 such as: language barriers, deficits in health

literacy, poor socioeconomic status, cultural beliefs/barriers, caregiver considerations,

other).

 Define unique characteristics for the SNP population served:

 C-SNP: What are the unique chronic care needs for beneficiaries enrolled in a C-SNP?

Include limitations and barriers that pose potential challenges for these C-SNP

beneficiaries.

 D-SNP: What are the unique health needs for beneficiaries enrolled in a D-SNP? Include

limitations and barriers that pose potential challenges for these D-SNP beneficiaries.

 I-SNP: What are the unique health needs for beneficiaries enrolled in an I-SNP? Include

limitations and barriers that pose potential challenges for these I-SNP beneficiaries as

well as information about the facilities and/or home and community-based services in

which your beneficiaries reside.

A. Sub-Population: Most Vulnerable Beneficiaries

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”). Other information specific to the description of the most vulnerable

beneficiaries must include, but not be limited to, the following:

 A description of the internal health plan procedures for identifying the most vulnerable

beneficiaries within the SNP.

 A description of the relationship between the demographic characteristics of the most

vulnerable beneficiaries with 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 beneficiaries.

 The identification and description of the established partnerships with community

organizations that assist in identifying resources for the most vulnerable beneficiaries,

including the process that is used to support continuity of community partnerships and

facilitate access to community services by the most vulnerable beneficiaries and/or their

caregiver(s).

2. Care Coordination:

Care coordination helps ensure that SNP beneficiaries’ 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 beneficiaries’ 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 SNPs’ care coordination

activities.

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 beneficiaries enrolled in the SNP.

This includes, but is not limited to, identification and detailed explanation of:

 Specific employed and/or contracted staff responsible for performing administrative

functions, such as: enrollment and eligibility verification, claims verification and

processing, other.

 Employed and/or contracted staff that perform clinical functions, such as: direct

beneficiary care and education on self-management techniques, care coordination,

pharmacy consultation, behavioral health counseling, other.

 Employed and/or contracted staff that performs 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.

 Describe how the SNP conducts initial and annual MOC training for its employed and

contracted staff, which may include, but not be limited to, printed instructional materials,

face-to-face training, web-based instruction, and audio/video-conferencing.

 Describe how the SNP documents and maintains training records as evidence to ensure

MOC training provided to its employed and contracted staff was completed. For

example, documentation may include, but is not limited to: copies of dated attendee lists,

results of MOC competency testing, web-based attendance confirmation, and electronic

training records.

 Explain any challenges associated with the completion of MOC training for SNP

employed and contracted staff and describe what specific actions the SNP will take when

the required MOC training has not been completed or has been found to be deficient in

some way.

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 beneficiary. The content of, and methods

used to conduct the HRAT have a direct effect on the development of the Individualized Care

Plan and ongoing coordination of Interdisciplinary Care Team activities; therefore, it is

imperative that the MOC include the following:

 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

Individualized Care Plan (MOC Element 2C) for each beneficiary and how the HRAT

information is disseminated to and used by the Interdisciplinary Care Team (MOC

Element 2D).

 Detailed explanation for how the initial HRAT and annual reassessment are conducted

for each beneficiary.

 Detailed plan and rationale for reviewing, analyzing, and stratifying (if applicable) the

results of the HRAT, including the mechanisms to ensure communication of that

information to the Interdisciplinary Care Team, provider network, beneficiaries and/or

their caregiver(s), as well as other SNP personnel that may be involved with

overseeing the SNP beneficiary’s plan of care. If stratified results are used, include a

detailed description of how the SNP uses the stratified results to improve the care

coordination process.

C. Individualized Care Plan (ICP)

 The ICP components must include, but are not limited to: beneficiary self-management

goals and objectives; the beneficiary’s personal healthcare preferences; description of

services specifically tailored to the beneficiary’s needs; roles of the beneficiaries’

caregiver(s); and identification of goals met or not met.

 When the beneficiary’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 development of the

ICP, how the beneficiary and/or his/her caregiver(s) or representative(s) is involved in its

development and how often the ICP is reviewed and modified as the beneficiary’s

healthcare needs change. 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 incorporated into each beneficiary’s ICP.

 Describe how the ICP is documented and updated as well as, where the documentation is

maintained to ensure accessibility to the ICT, provider network, beneficiary and/or

caregiver(s).

 Explain how updates and/or modifications to the ICP are communicated to the beneficiary

and/or their caregiver(s), the ICT, applicable network providers, other SNP personnel and

other stakeholders as necessary.

D. 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 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 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 other stakeholders.

 The types of evidence used to verify that communications have taken place, e.g., written

ICT meeting minutes, documentation in the ICP, other.

 How communication is conducted with beneficiaries who have hearing impairments,

language barriers and/or cognitive deficiencies.

E. 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 the care

transition process and ensuring that follow-up services and appointments are scheduled

and performed as defined in MOC Element 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 beneficiary and/or caregiver(s) are informed about who their point of

contact is throughout the transition process.

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. Each SNP is responsible for ensuring their MOC

identifies, fully describes, and implements the following for its SNP Provider Network:

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.

 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.

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 appropriate documentation.

 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 maintain

continuity of care for the SNP beneficiary as outlined in MOC Element 2E.

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’ Web site.

 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 required

MOC training has not been completed or is found to be deficient in some way.

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 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.

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.

 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 performance improvement plan (MOC Element 4B).

B. Measureable Goals & Health Outcomes for the MOC

 Identify and clearly define the SNP’s measureable goals and health outcomes and

describe how identified measureable goals and health outcomes are communicated

throughout the SNP organization. Responses should include but not be limited to, the

following:

 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 appropriate delivery 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 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.

 Explain the specific steps the SNP will take if goals are not met in the expected time

frame.

C. Measuring Patient Experience of Care (SNP Member Satisfaction)

 Describe the specific SNP survey(s) used and the rationale for selection of that particular

tool(s) to measure SNP beneficiary satisfaction.

 Explain how the results of SNP member 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.

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.

 Describe how the performance improvement evaluation of the MOC will be documented

and shared with key stakeholders.

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 to its multiple stakeholders, which may include,

but not be limited to: SNP leadership, SNP management groups, SNP boards of directors,

SNP personnel & staff, SNP provider networks, SNP beneficiaries and caregivers, the

general public, and regulatory agencies on a routine basis.

 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.