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
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC Scoring Guidelines
• 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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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How will NCQA Score the MOC?
• 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)
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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Scoring Guidelines
Previous MOC Scoring Guidelines
Element
New MOC Scoring Guidelines
Maximum Score
Element
Maximum Score
MOC 1: SNP-specific Population
4
MOC 1: SNP Population
8
MOC 2: Measurable Goals
12
MOC 2: Care Coordination
20
MOC 3: staff Structure/roles
12
MOC 3: Provider Network
12
MOC 4: ICT
12
MOC 4: Quality Measurement
20
MOC 5: Provider Network
20
Total
60
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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Crosswalk to New Elements
New Elements
• MOC 1: SNP Population
Old Elements
MOC 1: SNP-specific Population
MOC 10: Vulnerable Populations
MOC 3: Staff Structure/Care Management Roles
• MOC 2: Care Coordination
Care Transitions Protocol NEW!
MOC 4: Interdisciplinary Care Team
MOC 7: Health Risk Assessment
MOC 8: Individual Care Plan
MOC 9: Communication Network
• MOC 3: Provider Network
MOC 5: Provider Network & Use of Clinical
Practice Guidelines
MOC 6: MOC Training
• MOC 4: Quality
Measurement
MOC 2: Measurable Goals
MOC 11: Outcome Measurement
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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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%
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 1: Description of SNP Population
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)
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 1 Element A: Overall SNP Population
Factor 2
Separated 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.
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 1 Element A: Overall SNP Population
Factor 3
Focus 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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 1B:
Most Vulnerable Beneficiaries
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 populationlevel, not individual members
• Simply put, what makes them “different”?
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 1 Element B:
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 1 Element B:
Most Vulnerable Beneficiaries
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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QUESTIONS
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Care Coordination
Brett Kay
MOC 2: Element A: SNP Staff Structure
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element A: SNP Staff Structure
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)
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element A: SNP Staff Structure
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element A: SNP Staff Structure
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element A: SNP Staff Structure
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element A: SNP Staff Structure
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element B:
Health Risk Assessment Tool
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element B:
Health Risk Assessment Tool
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element B:
Health Risk Assessment Tool
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element C:
Individualized Care Plan (ICP)
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.
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element C:
Individualized Care Plan (ICP)
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element C:
Individualized Care Plan (ICP)
• Factor 4
– Process for determining the frequency for
review & modification when changes occur
• Factor 5
– Communication of updates and
modifications to the ICP
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element D:
Interdisciplinary Care Team (ICT)
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element D:
Interdisciplinary Care Team (ICT)
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element D:
Interdisciplinary Care Team (ICT)
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element E:
Care Transition Protocols
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element E:
Care Transition Protocols
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.
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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MOC 2: Element E:
Care Transition Protocols
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
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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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 ET
o
o
o
February 11
March 18 for MMP scored <70%
April 30 MA/SNPs & MMPs scored <70%
* Recordings and slides available on NCQA SNP Approval website within one week of call
SNP Approval MOC Training, Elements 1-2 January 21, 2014
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CMS Contacts
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 mailbox
SNP_mail@cms.hhs.gov
Subject line: SNP MOC Inquiry
CMS MMP mailbox
mmcocapsmodel@cms.hhs.gov
Subject line: MMP MOC Inquiry
NCQA SNP Approval Website for training recordings and slides:
www.ncqa.org/snpapproval
SNP Approval MOC Training, Elements 1-2 January 21, 2014
45
QUESTIONS
SNP Approval MOC Training, Elements 1-2 January 21, 2014
46