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Here’s something I hear all the time from SNP leaders after a Model of Care review doesn’t go well: “We’ve been doing this for years. How did we miss that?”

The honest answer? It’s rarely about misunderstanding the standards. After working with health plans across the country, we consistently see the same patterns. The MOC looks fine on the surface—until a reviewer starts asking how things actually work. Then the gap between the written narrative and the day-to-day operational reality becomes painfully visible.

For Medicare Advantage Special Needs Plans, the Model of Care isn’t just a required submission. It’s the framework CMS and NCQA use to evaluate whether your plan can actually deliver coordinated, high-quality care to some of Medicare’s most vulnerable populations. That’s a high bar. And the stakes are real.

Below are the seven most common reasons SNPs fall short during MOC reviews—and what you can do about it before submission.

1. The Population Description Is Generic Instead of Plan-Specific

Picture this: a reviewer opens your MOC and the population description reads like it was pulled from a public health textbook. National statistics. Generic chronic condition language. No real connection to the people your plan actually serves.

We see this constantly. Plans lean heavily on broad data because it’s available and feels thorough. But reviewers expect to see detailed, plan-specific information: your enrolled population’s demographics, health status, co-morbidities, and the social determinants of health that are specific to your geographic service area. They also want a clear distinction between your general SNP population and your most vulnerable enrollees.

When that differentiation is missing, the rest of your MOC—care coordination, provider network, quality improvement—reads as disconnected from the population it’s supposed to serve. The whole story falls apart.

How to fix it

Build your population description using plan-specific data and local health indicators. And here’s the part people often miss: use those same population definitions consistently throughout the entire MOC. Reviewers notice when the numbers and descriptions drift from section to section.

2. The “Most Vulnerable Population” Is Poorly Defined

Almost every plan acknowledges that some enrollees need more intensive support. That’s not the problem.

The problem is that many MOCs stop right there, without clearly explaining:

• The criteria used to identify vulnerable members
• The methodology used to stratify them
• The additional services provided beyond standard care management

Without that level of detail, a reviewer simply cannot determine how your plan operationalizes support for its highest-risk members. Saying you prioritize vulnerable members isn’t enough. You have to show how.

How to fix it

Document the specific criteria used to identify vulnerable members—hospitalization patterns, functional limitations, social risk factors—and demonstrate how those criteria drive targeted care interventions. The “how” is everything.

3. The Health Risk Assessment Is Treated as a Compliance Exercise

The Health Risk Assessment is the engine that should be driving your entire care coordination model. Too often, organizations treat it like a data collection checkbox—something to complete and file away—rather than the tool that feeds everything that follows.

When the HRA is disconnected from risk stratification, care planning, and Interdisciplinary Care Team activities, the entire care model appears fragmented. And a fragmented care model is a very hard thing to defend in a review.

How to fix it

The HRA should clearly feed into:

• Risk stratification processes
• Individualized Care Plans (ICPs)
• Interdisciplinary Care Team (ICT) composition
• Care management intensity decisions

Plans that can clearly demonstrate these connections score significantly better in MOC reviews. It’s not about having more data. It’s about showing the reviewer exactly how that data is put to work.

4. Individualized Care Plans Are Static Instead of Dynamic

Individualized Care Plans are intended to evolve as enrollee needs change. They’re meant to be living care management tools—not documents that get created once and never touched again.

Common weaknesses we see in MOC reviews:

• Limited documentation of goal updates over time
• Minimal evidence of enrollee or caregiver participation
• Unclear communication with providers or ICT members

When ICPs appear disconnected from real-time care management activities, reviewers start asking a harder question: is care coordination actually happening—or is this just documentation?

How to fix it

Demonstrate clear processes for:

• Updating care plans based on new information
• Documenting ICT involvement
• Communicating updates to enrollees and providers

5. Care Transition Processes Are Incomplete

Care transitions—particularly hospital discharges—are among the highest-risk moments for vulnerable patients. And yet, many MOCs fail to fully describe how the plan coordinates what happens when an enrollee moves between care settings.

Common gaps we find:

• No clear ownership of the transition process
• Insufficient follow-up procedures after discharge
• Limited coordination with community services

How to fix it

Effective MOCs clearly describe how transitions are managed before, during, and after they occur—including how enrollees access transportation, medication support, or other social services when needed. If a reviewer can’t visualize the handoff, your description isn’t detailed enough.

6. Provider Network Oversight Is Assumed Rather Than Demonstrated

SNP provider networks must include clinicians with expertise relevant to the target population. That’s not optional—it’s foundational. But many MOCs describe provider qualifications in general terms without demonstrating how the plan actually verifies expertise or how providers collaborate within the care coordination model.

Reviewers want to see evidence that providers:

• Participate in ICT activities
• Contribute to care plans
• Follow appropriate clinical guidelines

How to fix it

Describe how provider expertise is verified, how collaboration occurs within your care coordination model, and how clinical guidelines are monitored and applied. Don’t just assert that your network is strong—show the structure that makes it work.

7. Quality Measurement Doesn’t Close the Loop

This one might be the most common failure point of all, and it shows up in MOC Element 4: Quality Measurement and Performance Improvement.

Many plans describe ambitious quality goals. Reviewers love seeing ambitious goals. The problem is that ambition without evidence is just wishful thinking.

Plans often fail to show:

• How performance is actually measured
• Whether prior goals were achieved
• What corrective actions were taken when goals were not met

Without that feedback loop, quality improvement appears theoretical rather than operational. And theoretical quality improvement doesn’t score well. One of my favorite quotes that I state often: “In theory there is no difference between theory and practice, and in practice there is.”

How to fix it

Your MOC should demonstrate a continuous improvement cycle: measurable goals, performance monitoring, leadership oversight, and clear action plans when results fall short. Show the full loop—not just the intent.

The Bigger Lesson: MOC Reviews Test Operations, Not Writing Skills

Here’s what I want you to walk away with: most plans that struggle with MOC reviews don’t lack regulatory knowledge. They struggle to align the MOC narrative with the operational processes used to deliver care.

Did you notice how many times the word “how” appeared in this blog? That’s intentional. It’s the single most common gap we find. Organizations write beautifully about what they do, but leave out how they do it. When I read a document and I can’t visualize the activity being described, it’s because the “how” isn’t there.

Remember what you were taught about good documentation? Who, what, when, where, how, and how much. Those six words should be your mental checklist every time you write a section of your MOC.

 The strongest submissions tell a consistent story across all four pillars:

• Population analysis
• Care coordination
• Provider engagement
• Quality oversight

When those elements work together—when the narrative reflects the real operation—the MOC becomes what it was intended to be: a genuine blueprint for delivering coordinated care to complex populations.

How to Strengthen Your MOC Before Submission

If you’re reading this and thinking, “I’m not sure our MOC would hold up to that kind of scrutiny”—that’s actually the right place to start. Organizations that conduct a structured readiness assessment before submission consistently come out stronger on the other side.

A readiness review evaluates both documentation and operational workflows, identifying gaps in areas such as:

•  Population analytics and data specificity
• Risk stratification methodology
• Care coordination infrastructure
• Quality governance and improvement cycles

Addressing these issues early doesn’t just improve your likelihood of approval. It strengthens your organization’s actual ability to deliver effective care to vulnerable populations. The MOC review process, when taken seriously, makes you better at what you do.

Final Thought

The Model of Care is not simply a regulatory requirement. It is a reflection of how well your plan understands and supports the needs of its members and these are the most vulnerable members and need your focus and your strong efforts to make sure they receive the best care.

When the narrative accurately reflects the real-world care model—and when that model is supported by strong processes and data—the MOC becomes far more than a submission. It becomes a roadmap for better care.

We’ve been doing this long enough to know the difference between a MOC that’s technically complete and one that’s operationally defensible. If you’re not sure which category yours falls into, that’s exactly the kind of question MHR can help you answer.

MHR Support

MHR offers MOC readiness reviews and structured gap assessments for SNPs preparing for submission or renewal. Our consultants have firsthand experience with NCQA review processes and can help you close the gap between your narrative and your operations—before it becomes a problem.

Connect with us at [email protected] or visit managedhealthcareresources.com/contact to schedule a conversation.