CMS Pub. 100-16, ch. 5, § 20.2.2

The NCQA scoring approval process is based on scoring each of the clinical and non-clinical

elements of the MOC as part of the SNP application. The scoring guidelines were revised to

align with the new MOC structure to be utilized starting with the CY 2015 application cycle and

are modeled after the Structure & Process Measures format. The revised scoring guidelines

complement the new MOC structure and help SNPs better understand and meet the requirements

of the revised MOC element structure.

MOC 1: Description of SNP Population (General Population)

Identification and a comprehensive description of the SNP-specific population are integral

components of the MOC. All elements in this standard depend on a complete population

description that addresses the full continuum of care of current and potential SNP beneficiaries,

including end-of-life needs and considerations (if relevant).

SNPs must include a complete description of specially tailored services for beneficiaries

considered especially vulnerable (refer to Element 1B), using specific terms and details (e.g.,

members with multiple hospital admissions within three months, “medication spending above

$4,000”).

Element A: Description of Overall SNP Population

The organization’s MOC description of its target SNP population must:

1. Describe how the health plan staff will determine, verify and track eligibility of SNP

beneficiaries.

2. Describe the social, cognitive and environmental factors, living conditions and

co-morbidities associated with the SNP population.

3. Identify and describe the medical and health conditions impacting SNP beneficiaries.

4. Define the unique characteristics of the SNP population served.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 4

factors

The

organization

meets 3

factors

The

organization

meets 2

factors

The

organization

meets 1

factor

The

organization

meets no

factors

Explanation Element Target population characteristics

The organization’s description of its target population is an integral component

of the MOC narrative that provides a fundamental foundation on which the

other elements build to develop a comprehensive program that fully addresses

the continuum of care for its beneficiaries.

The organization’s MOC must show how it identifies its members and must

describe the target population that includes specific information on the

characteristics of the population it intends to serve. This information must

include specific components that characterize its beneficiaries, such as average

age, gender and ethnicity profiles, the incidence and prevalence of major

diseases, chronic conditions and other significant barriers faced by the target

population.

The organization may use beneficiary information from other product lines

(e.g., Medicare Advantage or Medicaid plans) as an example of the intended

target population if the plan does not have members, or it must provide details

compiled from the intended plan service area.

Factor 1: Determine, verify and track eligibility

The organization must have a process for identifying, verifying and tracking

SNP beneficiaries to ensure eligibility for appropriate care coordination

services. The MOC description must include information on the relevant

resources (systems or data collection methodology) used to perform these

tasks.

Factors 2, 3: Identify health conditions

The MOC description includes specific information on the current health status

of its SNP beneficiaries and characteristics that may impact their status. Factor

2 should include descriptions of the demographic, social and environmental

factors, and living conditions associated with the SNP population such as

average age, gender, ethnicity and potential health disparities associated with

certain groups, such as language barriers, deficits in health literacy, poor

socioeconomic status, cultural beliefs or barriers that may interfere with

conventional provision of health care or services, caregiver considerations or

other concerns. Factor 3 should identify and describe the medical and cognitive

factors, co-morbidities and other health conditions that affect SNP

beneficiaries.

Factor 4: Define unique characteristics of the SNP population (plan type)

Each SNP type (Chronic [C-SNP], Dual-Eligible [D-SNP] or Institutional [I-SNP]) description must include the unique health needs of beneficiaries

enrolled in each plan as well as limitations and barriers that may pose

challenges affecting their overall health:

• C-SNPs:

– Describe chronic conditions, incidence and prevalence as related to the

target population covered by this SNP.

• The description must include information on limitations and barriers

that pose potential challenges for beneficiaries (e.g., multiple co-morbidities, lack of care coordination between multiple providers)

• D-SNPs:

– Describe dual-eligible members, such as full duals or partial duals.

• The description must include information on limitations and barriers

that pose potential challenges for beneficiaries (e.g., gaps in

coordination of benefits between Medicare and Medicaid, poor health

literacy).

• I-SNPs:

– Specify the facility type and provide information about facilities where

SNP beneficiaries reside (e.g., long term care facility, home or

community-based services).

– Include information about the types of services, as well as about the

providers of specialized services.

• The description must include information on limitations and barriers

that pose potential challenges for beneficiaries (e.g., dementia, frailty,

lack of family/caregiver resources or support).

Element B: Subpopulation—Most Vulnerable Beneficiaries

The organization must have a complete description of the specially tailored services it

provides to its most vulnerable members that:

1. Defines and identifies the most vulnerable beneficiaries within the SNP population and

provides a complete description of specially tailored services for such beneficiaries.

2. Explains how the average age, gender, ethnicity, language barriers, deficits in health

literacy, poor socioeconomic status, as well as other factors, affect the health outcomes

of the most vulnerable beneficiaries.

3. Illustrates a correlation between the demographic characteristics of the most vulnerable

beneficiaries and their unique clinical requirements.

4. Identifies and describes established relationships with partners in the community to

provide needed resources.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 4

factors

The

organization

meets 3

factors

The

organization

meets 2

factors

The

organization

meets 1

factor

The

organization

meets no

factors

Explanation Factor 1: Define most vulnerable beneficiaries

Although the definition of “SNP beneficiary” typically implies members

requiring additional care and services, the description focuses on the sickest or

most vulnerable SNP members.

The organization’s MOC must include a robust and comprehensive definition

that describes who these members are (i.e., what sets them apart from the

overall SNP population), the methodology used to identify them (e.g., data

collected on multiple hospital admissions within a specified time frame; high

pharmacy utilization; high risk and resultant costs; specific diagnoses and

subsequent treatment; medical, psychosocial, cognitive or functional

challenges) and specially tailored services for which these beneficiaries are

eligible.

The organization may use beneficiary information from other product lines

(e.g., Medicare Advantage or Medicaid plans) as an example of the intended

target population if the plan does not have members, or it must provide details

compiled from the intended plan service area.

Factors 2 & 3: Correlation between demographic characteristics and

clinical requirements

The organization’s MOC definition of its most vulnerable beneficiaries must

describe the demographic characteristics of this population (i.e., average age,

gender, ethnicity, language barriers, deficits in health literacy, poor

socioeconomic status and other factors) and specify how these characteristics

combine to adversely affect health status and outcomes and affect the need for

unique clinical interventions.

The definition must include a description of special services and resources the

organization anticipates for provision of care to this vulnerable population.

Factor 4: Establish relationships with community partners

The organization’s MOC must describe its process for partnering with

providers within the community to deliver needed services to its most

vulnerable members, including the type of specialized resources and services

provided and how the organization works with its partners to facilitate member

or caregiver access and maintain continuity of services.

MOC 2: Care Coordination

Care coordination helps ensure that SNP beneficiaries’ health care needs, preferences for health

services and information sharing across health care staff and facilities are met over time. Care

coordination maximizes the use of effective, efficient, safe, high-quality patient services

(including services furnished outside the SNP’s provider network) that ultimately lead to

improved health care outcomes.

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. Taken together, all five sub-elements must address the SNP’s

care coordination activities comprehensively.

Element A: SNP Staff Structure

The organization’s MOC must:

1. Describe the administrative staff’s roles and responsibilities, including oversight

functions.

2. Describe the clinical staff’s roles and responsibilities, including oversight functions.

3. Describe how staff responsibilities coordinate with the job title.

4. Describe contingency plans used to address ongoing continuity of critical staff functions.

5. Describe how the organization conducts initial and annual MOC training for its

employed and contracted staff.

6. Describe how the organization documents and maintains training records as evidence

that employees and contracted staff completed MOC training.

7. Describe actions the organization takes if staff do not complete the required MOC

training.

Scoring 100% 80% 50% 20% 0%

The

organization

meets 6-7

factors

The

organization

meets 4-5

factors

The

organization

meets 3

factors

The

organization

meets 1-2

factors

The

organization

meets no

factors

Explanation Factor 1: Administrative staff roles and responsibilities

The organization’s MOC defines staff roles and responsibilities across all

health plan functions for personnel that directly or indirectly affect the care

coordination of SNP beneficiaries.

The organization’s MOC must identify and describe the specific employed and

contracted staff responsible for performing administrative functions, including:

• Enrollment and eligibility verification.

• Claims processing.

• Administrative oversight.

Factor 2: Clinical staff roles and responsibilities

The organization must identify and describe the employed and contracted staff

that perform clinical functions, including:

• Direct beneficiary care and education on self-management techniques.

• Care coordination.

• Pharmacy consultation.

• Behavioral health counseling.

• Clinical oversight.

Staff oversight responsibilities must include any license and competency

verification that relates to the specific population being served by the

organization (e.g., geriatric training for I-SNP providers or special training for

physicians and other clinical staff for a C-SNP services beneficiaries with

HIV/AIDs; data analyses for utilization of appropriate and timely health care

services; utilization review; and provider oversight to ensure use of appropriate

clinical practice guidelines and integration of care transition protocols.

Factor 3: Coordination of responsibilities and job title

To show how staff responsibilities identified in the MOC are coordinated with

job title, the organization must provide a copy of its organization chart and, if

applicable, a description of instances when a change to staff title/position or

level of accountability is required to accommodate operational changes in the

SNP.

Factor 4: Contingency plan

The organization must have a contingency plan (or plans) in place to avoid a

disruption in care and services when existing staff can no longer perform their

roles and meet their responsibilities. The organization’s MOC must identify

and describe contingency plans to ensure ongoing continuity of staff functions.

Factors 5, 6: Initial and annual MOC training; maintaining training

records

The organization must conduct initial and annual MOC training for its

employed and contracted staff. The MOC must describe the training strategies

and content, as well as the methodology the organization uses to document and

maintain training records as evidence that staff have completed MOC training.

Contracted staff does not include physicians or other providers that the

organization contracts with as part of the provider network.

The description must include types of trainings and specific examples of slides

or training materials. If the training plan is not currently operational, the

organization’s MOC must provide a description of the plan’s contents.

Factor 7: Actions if training is not completed

The organization’s MOC must explain challenges associated with employed

and contracted staff completing training and must describe actions the

organization will take when the required MOC training has not been completed

or has been found to be deficient.

Element B: Health Risk Assessment Tool (HRAT)

The organization’s MOC includes a clear and detailed description of the policies and

procedures for completing the HRAT that addresses:

1. How the organization uses the HRAT to develop and update the Individualized Care

Plan (ICP) for each beneficiary (Element 2C).

2. How the organization disseminates the HRAT information to the Interdisciplinary Care

Team (ICT) and how the ICT uses that information (Element 2D).

3. How the organization conducts the initial HRAT and annual reassessment for each

beneficiary.

4. The detailed plan and rationale for reviewing, analyzing and stratifying (if applicable),

the HRA results.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 4

factors

The

organization

meets 3

factors

The

organization

meets 2

factors

The

organization

meets 1

factor

The

organization

meets no

factors

Explanation The content of and methods used to conduct the HRAT have a direct effect on

the development of the ICP and ongoing coordination of ICT activities. The

HRAT must assess the medical, functional, cognitive, psychosocial and mental

health needs of each SNP beneficiary.

Factors 1&2: Use and dissemination of HRAT information

The organization must include a description of how the HRAT is used to

develop and update, in a timely manner, the ICP for each beneficiary and how

the HRAT information is disseminated to and used by the ICT.

Factor 3: Initial HRA and annual reassessment

The organization must complete the HRAT for each beneficiary, for initial

assessment, and must complete an HRAT annually thereafter. At minimum, the

organization must conduct initial assessment within 90 days of enrollment and

must conduct annual reassessment within one year of the initial assessment.

The description must include the methodology used to coordinate the initial and

annual HRAT for each beneficiary (e.g., mailed questionnaire, in-person

assessment, phone interview) and the timing of the assessments. There must be

a provision to reassess beneficiaries, if warranted by a health status change or

care transition (e.g., hospitalization, change in medication, multiple falls). The

organization must describe its process for attempting to contact beneficiaries

and have them complete the HRAT, including provisions for beneficiaries that

cannot or do not want to be contacted or complete the HRAT.

Factor 4: Plan and rationale

The organization’s MOC must describe its plan and explain its rationale for

reviewing, analyzing and stratifying HRAT results. It must include the

mechanisms for communicating information to the ICT, provider network,

beneficiaries and/or their caregiver(s) and other SNP personnel who may be

involved with overseeing a beneficiary’s plan of care. If the organization uses

stratified results, the MOC must explain how the SNP uses the results to

improve the care coordination process.

Element C: Individualized Care Plan (ICP)

The description of the organization’s ICP must include:

1. The essential components of the ICP.

2. The process to develop the ICP, including how often the ICP is modified as

beneficiaries’ health care needs change.

3. The personnel responsible for development of the ICP, including how the beneficiary

and/or caregiver(s) are involved.

4. How the ICP is documented, updated and where it is maintained.

5. How updates and modifications to the ICP are communicated to the beneficiary and

other stakeholders.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 5

factors

The

organization

meets 4

factors

The

organization

meets 2-3

factors

The

organization

meets 1

factors

The

organization

meets no

factors

Explanation Factor 1: ICP essential components

The organization must develop an ICP for each beneficiary, to deliver

appropriate care to the beneficiary. The organization’s ICP must include, but is

not limited to:

• The beneficiary’s self-management goals and objectives.

• The beneficiary’s personal healthcare preferences.

• A description of services specifically tailored to the beneficiary’s needs.

• Identification of goals (met or not met).

– If the beneficiary’s goals are not met, the organization’s MOC must

describe the process for reassessing the current ICP and determining

the appropriate alternative actions.

Factors 2, 3: ICP development process and personnel

The organization’s MOC must describe the process for developing the ICP and

must detail the personnel responsible for developing the ICP. The description

of responsible staff must include roles and functions, professional requirements

and credentials necessary to perform these tasks, as well as how the beneficiary

or their caregiver/ representative is involved in the ICP development. The MOC

must also include a description of how the organization determines how often

to review and modify, as appropriate, the ICP as the beneficiary’s health care

needs change.

Factor 4: ICP documentation and maintenance

The organization’s MOC must describe how the ICP is documented and

updated and where the documentation is maintained so it is accessible to the

ICT, provider network and beneficiaries and/or their caregiver(s).

Factor 5: Updates and modifications

The organization’s MOC must describe how the organization communicates

ICP updates and modifications to beneficiaries and/or their caregiver(s), the

ICT, applicable network providers, other SNP personnel and other

stakeholders, as necessary.

Element D: Interdisciplinary Care Team (ICT)

The organization’s MOC must describe the critical components of the ICT, including:

1. How the organization determines the composition of ICT membership.

2. How the roles and responsibilities of the ICT members (including beneficiaries and/or

caregiver[s]) contribute to the development and implementation of an effective

interdisciplinary care process.

3. How ICT members contribute to improving the health status of SNP beneficiaries.

4. How the SNP’s communication plan to exchange beneficiary information occurs

regularly within the ICT, including evidence of ongoing information exchange.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 4

factors

The

organization

meets 3

factors

The

organization

meets 2

factors

The

organization

meets 1

factor

The

organization

meets no

factors

Explanation Factor 1: ICT membership

The organization’s MOC must describe the composition of the ICT, including

how the SNP determines ICT membership and the roles and responsibilities of

each member. The description must specify how the expertise and capabilities

of the ICT members align with the identified clinical and social needs of the

SNP beneficiaries.

The organization must:

• Explain how the SNP facilitates the participation of beneficiaries and their

caregiver(s) as members of the ICT.

• Describe how the beneficiary’s HRAT and ICP are used to determine the

composition of the ICT; including where additional team members are

needed to meet the unique needs of a beneficiary.

• Explain how the ICT uses health care outcomes to evaluate processes

established to manage changes or adjustments to the beneficiary’s health

care needs on a continuous basis.

Factors 2 and 3: ICT member roles and responsibilities

The organization’s MOC must describe how it uses clinical managers, case

managers and others who play critical roles in providing an effective

interdisciplinary care process; and how beneficiaries and/or their caregiver(s)

are included in the process, are provided with needed resources and how the

organization facilitates access for beneficiaries to ICT team members.

Factor 4: Communication plan

The MOC must describe the SNP’s communication plan for promoting regular

exchange of beneficiary information within the ICT. The MOC must show:

• 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.

• How the SNP maintains effective and ongoing communication among

SNP personnel, the ICT, beneficiaries and/or their 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).

• How communication is conducted with beneficiaries who have hearing

impairments, language barriers and cognitive deficiencies.

Element E: Care Transition Protocols

The organization’s MOC describes the following care transition protocols:

1. How the organization uses care transition protocols to maintain continuity of care for

SNP beneficiaries.

2. The personnel responsible for coordinating the care transition process.

3. How the organization transfers elements of the beneficiary’s ICP between health care

settings when the beneficiary experiences an applicable transition in care.

4. How beneficiaries have access to personal health information to facilitate

communication with providers in other healthcare settings.

5. How beneficiary and/or caregiver(s) will be educated about the beneficiary’s health

status to foster appropriate self-management activities.

6. How the beneficiary and/or caregiver(s) are informed about the point of contact

throughout the transition process.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 6

factors

The

organization

meets 4-5

factors

The

organization

meets 3

factors

The

organization

meets 1-2

factors

The

organization

meets no

factors

Explanation Definitions

• Health care setting: The provider from whom or setting where a member

receives health care and health-related services. In any setting, a designated

practitioner has ongoing responsibility for a member’s medical care.

– Settings include home, home health care, acute care, skilled nursing

facility, custodial nursing facility, rehabilitation facility and

outpatient/ambulatory care/surgery centers.

• Transition: Movement of a member from one care setting to another as the

member’s health status changes.

– For example, moving from home to a hospital as the result of an

exacerbation of a chronic condition or moving from the hospital to a

rehabilitation facility after surgery.

• Transition process: The period from identification of a member who is at

risk for a care transition through completion of a transition.

– This process includes planning and preparation for transitions and the

follow-up care after transitions are completed.

Factor 1: Continuity of care

Older or disabled adults moving between different health care settings are

particularly vulnerable to receiving fragmented and unsafe care when

transitions are poorly coordinated; thus, an organization must work actively to

coordinate transitions. The organization must specify the process and rationale

for connecting beneficiaries with the appropriate providers.

Factor 2: Care transition personnel

The organization must identify and describe the personnel (e.g., case manager)

responsible for coordinating the care transition process and for ensuring that

follow-up services and appointments are scheduled and performed.

Factor 3: Applicable transitions

The organization must ensure that elements of the beneficiary’s ICP are

transferred between health care settings when the beneficiary experiences a

transition in care. The MOC must describe the steps that take place before,

during and after a transition in care has occurred for this process.

Factor 4: Beneficiary Personal Health Information

Beneficiaries and/or their caregiver(s) need access to beneficiaries’ personal

health information in order to communicate about care with healthcare

providers in other healthcare settings and/or health specialists outside their

primary care network. The organization must describe the process for ensuring

that SNP beneficiaries and/or their caregiver(s) have access to and can

adequately use personal health information to coordinate care for the

beneficiary.

Factor 5: Self-management activities

The MOC must describe how beneficiaries and/or their caregiver(s) will be

educated about their condition, how they will demonstrate understanding of

changes in their condition (improvement, stable or worsening), and use of

appropriate self-management activities. For example, they should be educated

about signs and symptoms signaling a change in their condition and how to

respond to such changes. Self-management activities can include regular

assessment of progress, goal setting and problem solving support to reduce

crises and improve health outcomes.

Factor 6: Notification of point of contact

The organization must describe the process it uses to notify beneficiaries and/or

their caregiver(s) of the personnel responsible for supporting them through

transitions between any two care settings.

MOC 3: Provider Network

The SNP provider network is a network of health care providers who are contracted to provide

health care services to SNP beneficiaries. SNPs must ensure that their MOC identifies, fully

describes and implements the following elements for their SNP provider networks.

Element A: Specialized Expertise

The organization must establish a provider network with specialized expertise that

describes the following components of the network:

1. How providers with specialized expertise correspond to the target population identified

in MOC 1.

2. How the SNP oversees its provider network facilities and oversees that its providers are

competent and have active licenses.

3. How the SNP documents, updates and maintains accurate provider information.

4. How providers collaborate with the ICT and contribute to a beneficiary’s ICP to

provide necessary specialized services.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 4

factors

The

organization

meets 3

factors

The

organization

meets 2

factors

The

organization

meets 1

factor

The

organization

meets no

factors

Explanation The organization must have an adequate and specialized provider network that

maintains the appropriate licensure and competency to address the needs of the

target population.

Factor 1: Specialized network

The provider network’s specialized expertise may include, but is not limited to,

internal medicine, endocrinologists, cardiologists, oncologists, mental health

specialists and other specialists that address the needs of the SNP’s target

population identified in MOC 1.

Factors 2 and 3: Licensure and certification

The organization must describe how it determines that its providers have active

licenses and are competent to provide specialized health care services to SNP

beneficiaries (e.g., confirmation of applicable board certification), The MOC

should describe how it maintains current information on providers to maintain

an accurate provider network directory.

Factor 4: Collaboration with the ICT/ICP

The MOC must describe how providers in the network collaborate with

members of the ICT and help contribute to each beneficiary’s ICP, including

how providers either deliver or coordinate care, particularly specialized

services. The MOC must describe how providers communicate beneficiary care

needs to the ICT and to other stakeholders or providers, how the organization

shares information (e.g., as reports on services) with the ICT and how providers

incorporate relevant clinical information into beneficiaries’ ICPs.

Element B: Use of Clinical Practice Guidelines and Care Transition Protocols

The organization must oversee how network providers use evidence-based medicine, when

appropriate, by:

1. Explaining the processes for monitoring how network providers utilize appropriate

clinical practice guidelines and nationally recognized protocols appropriate to each

SNP’s target population.

2. Identifying challenges where the use of clinical practice guidelines and nationally

recognized protocols need to be modified or are inappropriate for specific vulnerable

SNP beneficiaries.

3. Providing details regarding how decisions to modify clinical practice guidelines or

nationally recognized protocols are made, incorporated into the ICP, communicated to

the ICT and acted upon by the ICT.

4. Describing how SNP providers maintain continuity of care using the care transition

protocols outlined in MOC 2, Element E.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 4

factors

The

organization

meets 3

factors

The

organization

meets 2

factors

The

organization

meets 1

factor

The

organization

meets no

factors

Explanation Factor 1: Utilization of guidelines and protocols

Evidence-based clinical guidelines and protocols promote the use of nationally

recognized and accepted practices for providing the right care at the right time.

The organization must monitor how network providers utilize these guidelines,

when appropriate. The organization may use electronic databases, Web

technology, manual medical record review or other methods to oversee use of

clinical practice guidelines.

Factors 2 and 3: Exceptions to guidelines

Certain clinical practice guidelines and protocols may not always be

appropriate for some patients with complex health care needs. In these cases,

the organization must identify challenges to using clinical practice guidelines

and nationally recognized protocols for certain beneficiaries with complex

healthcare needs and detail how the decision to modify or ignore such

guidelines is made, incorporated into the patient’s ICP, communicated with the

ICT and acted on by the patient’s ICT or by other providers.

Factor 4: Care transition protocols

Care transitions offer challenges for organizations to maintain continuity of

care. The organization must explain how it oversees network providers to

ensure that they follow the required care transition protocols outlined in MOC

2, Element E.

Element C: MOC Training for the Provider Network

The organization’s description of oversight of provider network training on the MOC must

include:

1. Requiring initial and annual training for network providers and out-of-network

providers seen by beneficiaries on a routine basis.

2. Documenting evidence that the organization makes available and offers training on the

MOC to network providers.

3. Explaining challenges associated with the completion of MOC training for network

providers.

4. Taking action when the required MOC training is deficient or has not been completed.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 4

factors

The

organization

meets 3

factors

The

organization

meets 2

factors

The

organization

meets 1

factor

The

organization

meets no

factors

Explanation Factor 1: Initial and annual training

The MOC must describe how the organization provides initial and annual

training for network providers and any out-of-network providers seen by

beneficiaries on a routine basis; and must describe the process for annual

training for current providers, including how training is conducted (e.g., in-person meetings, computer-based training), how often training occurs, training

materials and examples of training content.

Factor 2: Evidence of training

The MOC must describe how the organization documents and maintains

records

(e.g., copies of dated attendee lists, Web-based training confirmation, electronic

training records, physician attestation) as evidence that it makes training on the

MOC available and offers it to all network providers.

Factors 3 and 4: Deficient or incomplete training

The MOC must describe specific actions taken by the organization if providers

do not receive the required training and must explain challenges (e.g.,

geographically distant network, very large number of providers in network)

associated with completion of the MOC trainings for network providers. The

MOC may also describe actions the organization takes to offer incentives or

other best practices to encourage provider training participation and

compliance.

MOC 4: MOC Quality Measurement and Performance Improvement

The goal of performance improvement and quality measurement is to improve the SNP’s ability

to deliver high-quality health care services and benefits to its SNP beneficiaries. Achievement of

this goal may be the result of increased organizational effectiveness and efficiency through

incorporation of quality measurement and performance improvement concepts that 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.

Element A: MOC Quality Performance Improvement Plan

The organization must develop a MOC quality performance improvement plan that:

1. Describes the overall quality improvement plan and how the organization delivers or

provides for appropriate services to SNP beneficiaries, based on their unique needs.

2. Describes specific data sources and performance and outcome measures used to

continuously analyze, evaluate and report MOC quality performance.

3. Describes how its leadership, management groups, other SNP personnel and

stakeholders are involved with the internal quality performance process.

4. Describes how SNP-specific measureable goals and health outcomes objectives are

integrated in the overall performance improvement plan, as described in MOC 4,

Element B.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 4

factors

The

organization

meets 3

factors

The

organization

meets 2

factors

The

organization

meets 1

factor

The

organization

meets no

factors

Explanation Definition

Quality measurement and performance improvement: A collaborative

process for improving an organization’s ability to deliver high-quality health

care services and benefits to SNP beneficiaries.

Factors 1–4

The organization’s MOC must describe how the quality performance

improvement plan specific to the MOC, is designed to detect whether the

overall MOC structure effectively accommodates beneficiaries’ unique health

care needs.

The MOC must describe the SNP’s process for continuous collection, analysis,

evaluation and reporting on quality performance based on the MOC. The MOC

should describe the frequency of these activities.

The MOC must provide details about how the key personnel listed in factor 3

are involved in internal quality performance processes. It should provide

information about which personnel are involved, their role in analyzing quality

performance information and the decision-making authority given to such

personnel.

The organization must specify data used for analyses, and must identify clear

measures to determine if stated goals or outcomes are achieved. Measures must

have a benchmark or goal, specify time frames for achieving outcomes and

state a plan for re-measurement if the goal is not achieved.

Element B: Measureable Goals and Health Outcomes for the MOC

The organization must identify and clearly define measureable goals and health outcomes

for the MOC and:

1. Identify and define the measurable goals and health outcomes used to improve the

health care needs of SNP beneficiaries.

2. Identify specific beneficiary health outcome measures used to measure overall SNP

population health outcomes at the plan level.

3. Describe how the SNP establishes methods to assess and track the MOC’s impact on

SNP beneficiaries’ health outcomes.

4. Describe the processes and procedures the SNP will use to determine if health outcome

goals are met.

5. Describe the steps the SNP will take if goals are not met in the expected time frame.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 5

factors

The

organization

meets 4

factors

The

organization

meets 2-3

factors

The

organization

meets 1

factor

The

organization

meets 0

factors

Explanation Factor 1

A description of measurable goals must include benchmarks, specific time

frames

and how achieving goals will be determined. Responses should include, but not

be limited to:

• Specific goals for improving access and affordability of the healthcare

needs outlined for the SNP population described in MOC 1.

• Improvements made in coordination of care and appropriate delivery of

services through the direct alignment of the HRAT, ICP and ICT.

• Enhanced care transitions across all health care settings and providers for

SNP beneficiaries.

• Ensuring appropriate utilization of services for preventive health and

chronic conditions.

Factor 2

For the stated health outcome measures, the organization must include the

specific data sources it will use for measurement. The MOC should describe

the specific measures the organization will use to meet the overall quality goals

detailed in factor 1, including expected timeframes for meeting those goals.

Factors 3&4

The MOC must describe the methods the organization uses to assess and track

how its overall quality program, including the goals and specific measures it

uses, affect the health outcomes of its beneficiaries. This may include the data

collected, how it is collected and analyzed and how often it is collected and

analyzed.

For factor 4, the MOC must describe how it determines if the goals described in

factor 1 are met.

Factor 5

The organization must describe the actions it will take if it determines that goals

are not met within the specified timeframes.

Element C: Measuring Patient Experience of Care (SNP Member Satisfaction)

The organization’s MOC must address the process of measuring SNP member satisfaction

by:

1. Describing the specific SNP survey used.

2. Explaining the rationale for the selection of a specific tool.

3. Describing how results of patient experience surveys are integrated into the overall

MOC performance improvement plan.

4. Describing steps taken by the SNP to address issues identified in survey responses.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 4

factors

The

organization

meets 3

factors

The

organization

meets 2

factors

The

organization

meets 1

factor

The

organization

meets no

factors

Explanation Factors 1–4

The MOC must describe the types of surveys used to assess SNP member

experience, the rationale for the use of a specific tool and how results are

integrated into the overall performance improvement plan.

Member feedback can include information about the overall SNP program or

program staff (e.g., ICT or case managers), the usefulness of the information

disseminated by the organization and the member’s ability to adhere to

recommendations.

Methodology. The organization must describe how it receives feedback from a

broad sample of members, not only those who contact the organization to share

feedback. Member feedback may be obtained by conducting focus groups or

through member experience surveys. The organization must describe how it

analyzes feedback to identify and address issues. Feedback must be specific to

the experience with the SNP overall programs being evaluated.

The organization must be able to describe the methodology it uses to collect

patient experience surveys, including the sample size used.

Element D: Ongoing Performance Improvement Evaluation of the MOC

The organization’s MOC description must describe:

1. How the organization will use the results of the quality performance indicators

and measures to support ongoing improvement of the MOC.

2. How the organization will use the results of the quality performance indicators

and measures to continually assess and evaluate quality.

3. The organization’s ability for timely improvement of mechanisms for

interpreting and responding to lessons learned through the MOC performance

evaluation.

4. How the performance improvement evaluation of the MOC will be documented

and shared with key stakeholders.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 4

factors

The

organization

meets 3

factors

The

organization

meets 2

factors

The

organization

meets 1 factor

The

organization

meets no

factors

Explanation Factors 1–4

The organization must provide a written description of the ongoing performance

improvement evaluation of its MOC. This process must describe how the

organization will use the results to assess and evaluate its quality performance

indicators on a continual basis, including how the organization improves its

ongoing performance by incorporating lessons learned. Lessons learned must be

documented and communicated with key stakeholders.

Element E: Dissemination of SNP Quality Performance Related to the MOC

The organization must address the process for communicating its quality

improvement performance by:

1. Describing how performance results and other pertinent information are shared

with multiple stakeholders.

2. Stating the scheduled frequency of communications with stakeholders.

3. Describing the methods for ad hoc communication with stakeholders.

4. Identifying the individuals responsible for communicating performance updates

in a timely manner.

Scoring 100% 80% 50% 20% 0%

The

organization

meets all 4

factors

The

organization

meets 3

factors

The

organization

meets 2

factors

The

organization

meets 1 factor

The

organization

meets no

factors

Explanation Factors 1–4

The organization describes how quality performance results are routinely shared

with stakeholders, and specifies the frequency of these communications and how

ad hoc and other unplanned communications are disseminated.

The organization’s plan to disseminate information must include individuals

responsible for providing communication (as described in MOC 2, Element A).

The MOC must describe methods for communication (regular and ad hoc) with

stakeholders and time frame for communication with stakeholders, who may

include, but are not limited to:

• SNP leadership.

• SNP management groups.

• SNP boards of directors.

• SNP personnel and staff.

• SNP provider networks.

• SNP beneficiaries and caregiver(s).

• The general public.

• Regulatory agencies.