MHR's Guide to Planning Your Model of Care for CY2026: Consultant Tips Included

cmsmodelofcare ncqa Apr 29, 2024
MHR Model of Care

By Nancy Ross Bell, RN

Estimated time to read: 4 minutes

The CY2025 MOC review process will soon end on June 3, 2024, as the deadline by which all final bids for approval as a Special Needs Plan (SNP) will be announced by CMS.  Then, in about five short months, in October 2024, training is expected to begin on MOC development for organizations submitting a bid for an SNP for CY2026.

Looking back, MHR’s blog on MOC in March 2023 explained some of the details surrounding MOCs. This blog discusses some of the recurring problematic areas we have found and want to help you avoid. If you are new to SNPs, you may wish to read that blog first for foundational information.

What is a Model of Care (MOC)?

A MOC is a comprehensive document on quality improvement that an organization applying to CMS as a Special Needs Plan (SNP) must submit. The details within an MOC help the organization identify and meet the unique needs of each enrollee.

Each unique type of SNP, as listed below, must have its own comprehensive and detailed MOC that reflects its respective population. One MOC for all SNPs is NOT acceptable. The different types are:  

  • Chronic SNP (C-SNP): Chronic and disabling conditions
  • Dual Eligible SNP (D-SNP): Members are eligible for both Medicare and Medicaid due to age, disability, and/or ESRD
  • Institutional SNP (I-SNP): 90 days or longer

Four Elements Comprise a MOC:

  1. Population
  2. Care coordination
  3. Provider network
  4. Quality measurement and performance improvement

To achieve a passing score, each of the four Elements must be explained in substantial detail. How much detail?  When describing a process in your MOC, be sure to include the who, what, when, where, and how!

Why Does This Matter?  

SNPs with a passing score can implement their SNP products in January 2026.

Here is an example with estimated time frames.

  • October 2024>NCQA’s Training on MOC for CY2026 begins.
  • February-March 2025>NCQA downloads SNP submissions from CMS and reviews against the MOC Elements and Factors.
  • April 2025>NCQA uploads results. As appropriate, organizations are notified of any intent to deny their bid with an opportunity to cure their result.
  • May 2025>Cure results are uploaded, and CMS issues approvals or denials.
  • June 2025>Final bids are due to CMS.
  • January 2026>Approved plans implement their SNP products.

Detailed MOCs for each SNP population are critical to being approved by CMS as an SNP.

Organizations first submit their MOCs to CMS via the CMS portal as part of the SNP application. Then, CMS sends all the MOCs to NCQA for review and scoring according to CMS guidelines. Once scored by NCQA, the MOCs are returned to CMS for final approval and notification to the organizations.

Refer to NCQA’s website for CY 2025 scoring guidelines.

Organizations receive a percentage of the score for each Element according to the number of Factors that are scored as met.

Keep in mind that scoring guidelines could change for CY 2026. 

Organizations that receive a failing score for their initial MOC submission have just one cure opportunity to achieve a passing score.

  • MOCs must meet all requirements for each type of SNP to help avoid a cure or receive only a one-year approval for a Dual or Institutional SNP.
  • Chronic SNPs only receive approval for a one-year approval period per CMS standards.

Failing the opportunity to cure their MOC, their bid is denied by CMS.

Take the steps now to help ensure a passing score the first time you submit your bid for CY2026. Before you submit it to CMS, have your MOC reviewed by an MHR Consultant with expertise in MOCs.  

How Do You Measure Up On These Requirements?

Because MHR has consultants who are also independent reviewers of MOC for NCQA, we know where points are commonly lost and where challenges and questions may arise. Consider the questions below to assess how you measure up!

Please note: These tips do not represent the entirety of all Factors that must be met. Refer to the NCQA or CMS sites for a complete listing of requirements.

 Populations (Element 1)

  • Do you describe the process for re-verification of eligibility so members don’t lose their health care coverage in the SNP?
  • Is the data used no older than three years?
  • Is the data used relevant to the specific membership in the service area?
  • Are details on member health disparities included?
  • Have you described specific criteria, triggers, and the process for identifying the most vulnerable populations?
    • Examples may include data from claims, multiple ED visits, admissions, referrals, BH admissions, and members with ESRD.
  • Does your population description differentiate between the demographics of the general population in the SNP and the demographics of the most vulnerable population?
    • Data cannot be identical.

 Care Coordination (Element 2)

  • Are both employed and contracted staff included in the roles and responsibilities for care coordination?
    • Both administrative and clinical staff must be included.
  • Do clinical staff's roles and responsibilities include oversight functions that affect care for SNP members and their respective licensure requirements?
  • Does the description of face-to-face encounters include the purpose and outcomes the organization expects to see from these encounters?
    • Indicate that member consent is obtained and which staff are qualified for conducting the face-to-face encounters.
  • Do your Interdisciplinary Care Teams (ICT) include individuals trained and credentialed to address the health needs of the SNP members?
    • Are the roles and responsibilities of the ICT members defined?
  • Do you have documented processes that describe how outcomes are reviewed and how changes in members’ needs are managed?  
    • Does your process describe how and who reviews data?
    • Does your process describe what is given to ICTs and discussed with members/caregivers?
  • Do you monitor ALL care transitions for both in-network and out-of-network activities?
  • Is care coordination implemented for ALL members, not just those stratified at high risk?
  • Is care managed and documented before, during, and after a transition of care?

Provider Network (Element 3)

  • Is your process for credentialing both practitioners and providers (facilities) in sufficient detail?
  • Does your documented process for updating provider information state the FREQUENCY of updates?  
  • Do you train providers, both in-network and out-of-network, who see members routinely?
    • A sample of slides used for training practitioners and providers must be submitted for renewal surveys.
  • Does your documented process for training practitioners and providers describe actions that can be taken if they do NOT complete the training?
    • Organizations may NOT use another health plan’s MOC training as evidence of training for their own providers.
    • Organizations may NOT use a provider's compliance with another health plan's training to satisfy its own requirement.
    • Each SNP plan must have its own training program.

Quality Measurement and Performance Improvement (Element 4)

  • Does your SNP’s QI Plan include goals for health risk assessment (HRA), interdisciplinary care plans (ICP), and interdisciplinary care teams (ICT)?
    • Goals MUST be set at 100% or 5 stars for CMS; anything less than 100% and 5 stars is not acceptable.
    • Measures MUST focus on activities that lead to preventative health or chronic care maintenance that may improve members' health.
  • For Renewal SNPs, does your QI reporting process include the following?
    •  goals for established metrics
    •  results of measurement
    •  if goals were met or not met
    •  any actions taken by the organization to implement a causal analysis
    • interventions for implementation to have metrics met
    • a detailed description of the process to monitor if goals are met or not met
  • Do you explain the rationale for the survey tool selected, even if the CAHPS tool is utilized?
    • Explain the sample size so CMS understands how many members the plan will survey.
    • A plan may estimate the number of members to be surveyed or sent to for an Initial MOC submission.
    • Explain the methodology of survey completion, i.e., phone calls and mail.
  • Are ad-hoc or “as needed” communication methods with stakeholders described?

When Should You Contact MHR for CY2026 Assistance?

Contact MHR to schedule a consultation on your CY2026 MOC no later than the end of August 2024.

This will allow you time to work on the draft documents through the fall of 2024, with eventual submission around February 2025. We also work with organizations that wish to expand into a service area where they do not currently have members. One of our clients recently received a 100% on their MOC for an expansion area that had no membership.


NCQA MOC Video Training Elements 1 & 2

NCQA MOC Video Training Elements 3 & 4

Call to Action:     

  • Schedule a MOC review with MHR for a CY2026 submission.

This blog on Models of Care was developed with input from Jean Lockington, who reviews MOCs for NCQA scoring and works with MHR as an independent consultant, helping MHR clients develop CMS-compliant MOCs.  Jean follows all NCQA requirements on Conflict of Interest; she is not assigned MOCs by NCQA for whom she may have provided consulting services on their MOC on behalf of MHR.

Read more about Jean and MHR’s other consultants on our website.  

Contact Susan K. Moore at susan@managedhealthcare resources

Follow MHR on LinkedIn:

Connect with or Message Susan on LinkedIn:

MHR: Driving healthcare quality one NCQA accreditation at a time

 #NCQA #cmsmodelofcare

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