Medicare Parts C and D Universal Audit Guide

ATTACHMENT IX
Special Needs Plans – Model of Care Implementation
Audit Process and Universe Request
Purpose: To evaluate the implementation of the SNP MOC. The Centers for Medicare and Medicaid
Services will perform its audit activities using these instructions (unless otherwise noted). The elements
addressed in this review are:
I.
II.
III.

Population to be Served – Enrollment Verification
Health Risk Assessment (HRA), Interdisciplinary Care Team (ICT), Implementation of the
Individualized Care Plan (ICP) and Use of Evidence-Based Clinical Guidelines
Plan Performance Monitoring and Evaluation of the MOC

Review Period: For beneficiary information, if the SNP Model of Care (MOC) was approved for three
years, the review period will be the thirteen (13) month period preceding the date of the audit engagement
letter (Month, Day, Year). CMS reserves the right to expand the review period to ensure a sufficient
universe size. If the MOC was approved for one year, the audit period may cover a shorter time span, as
specified in the engagement letter.
Note: The plan is expected to provide accurate and timely universe submissions. In addition, the
plan is expected to present its supporting documentation during the audit and upload it to the secure site
using the designated naming convention within the timeframe specified by the reviewers. If the plan fails
to provide accurate and timely universe submissions or fails to submit the supporting documentation
using the designated naming convention and within the timeframe specified by the reviewers, CMS will
document this as an Observation in the plan’s program audit report.
Universe Submission and Sample Selection
Part I: Background Information
Obtain Evidence: The plan will provide the following documentation:
x A copy of the approved Model of Care (MOC) and any updates to the original submission.
x A copy of the Health Risk Assessment Tool used by the SNP
x A copy of policies and procedures for administration of the Health Risk Assessment Tool, the
development of the Individual Care Plan and the composition and functions of the
Interdisciplinary Care Team
x Copies of evidence-based guidelines and nationally recognized protocols used for the SNP
x Copies of policies and procedures on the monitoring and evaluation of the MOC
This documentation will have the same submission deadline as the universe. CMS will conduct a desk
review of these materials prior to the audit start date to gain an understanding of the criteria and
protocols the plan’s SNPs implement. The background information to be submitted may have been
implemented outside of the audit period, but must be in effect during the audit period.
Part II: Select Universe and submit to CMS
In addition to the background information in Part I, the plan will pull a universe consisting of all SNP
beneficiaries who have been continuously enrolled for a period of at least 13 months as of the engagement
letter date.
1. Submit Universe in Attachment IX-A Universe Template. The plan should submit its universe in
whole and not separately for each SNP contract. If the file is too large for Excel, a CSV or a text file
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ATTACHMENT IX
Special Needs Plans – Model of Care Implementation
Audit Process and Universe Request
is acceptable. The requested universe in Attachment IX should be submitted through the CMS
Enterprise File Transfer (EFT) in one zip file. The universe should consist of the following:
1.1. All SNP beneficiaries continuously enrolled for a period of at least 13 months as of the
engagement letter date.
2. Select 30 cases: CMS will pull a tracer sample of 30 beneficiaries from the plan-submitted universe
as follows:
x 10 D-SNP beneficiaries
x 10 C-SNP beneficiaries
x 10 I-SNP beneficiaries
If the plan does not offer all three types of SNPs, CMS will increase the number of beneficiaries in
SNPs the plan does offer to obtain a total sample size of 30. The same sample will be evaluated for
the first three elements of the audit (referenced in the purpose section). The sample selection will be
provided to the sponsor by the close of business of the Thursday before the Monday of the audit
week.
I. Population to Be Served - Enrollment Verification
1. Obtain Evidence: – This section will apply to members of D-SNP, C-SNP and I-SNP Plans. CMS will
review for correct processing of SNP enrollments and involuntary disenrollments. For each case, the
plan must produce all relevant documentation including, but not limited to:
x

For C-SNP Plan beneficiaries:
o Treating physician verification that the enrollee has the qualifying condition.
o The date(s) on which the verification was received.
o The type of tool used to document eligibility.

x

For I-SNP Plan beneficiaries:
o Confirmation that the individual requires an institutional (skilled nursing facility (SNF),
nursing facility (NF), intermediate care facility for the mentally retarded (ICF/MR) or
inpatient psychiatric facility) level-of-care, and that the need for an institutional level-ofcare has lasted 90 days or longer.
o If the institutional SNP opts to enroll special needs individuals prior to a 90 day lengthof-stay, the needs-assessment (pre-approved by CMS) must show that the individual’s
condition makes it likely that the length-of-stay (or need for an institutional level-of-care)
will be at least 90 days.
o If the I-SNP elects to enroll community based beneficiaries into the I-SNP, the State
approved Level of Care Assessment administered by a third party will be required.

x

For D-SNP Plan beneficiaries:
o Copy of enrollment request documentation (e.g., copy of the enrollment form or
documentation of other enrollment mechanism, such as telephonic or Online Enrollment
Center request) with evidence of receipt date and beneficiary’s attestation of eligibility
for the election period submitted by the sponsor;
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ATTACHMENT IX
Special Needs Plans – Model of Care Implementation
Audit Process and Universe Request
o
o

Documentation showing sponsor’s verification of SNP eligibility prior to submission of
the enrollment to CMS;
Documentation showing sponsor’s ongoing verification of SNP eligibility.

2. Apply Compliance Standards: Apply the following test to each of the 30 cases. For a case to receive a
score of “pass,” the case must present evidence to favorably address both of the following questions:
x Was the appropriate eligibility verification completed? (Applies to all SNP plans)
x Is there evidence of re-verification of eligibility, when required? (Applies to D-SNPs and ISNPs)
3. Sample Case Results: CMS will test each of the 30 cases. If CMS requirements are not met, a sample
case fails and a condition (finding) is documented. If CMS requirements are met, a sample case
passes and no conditions (findings) are documented.
II. Appropriateness of Health Risk Appraisal (HRA), Interdisciplinary Care Team (ICT) and
Individualized Care Plan (ICP), Use of Evidence-Based Clinical Guidelines.
1. Obtain Evidence: CMS will review for proper administration of the Health Risk Assessment, as well
as the appropriateness and implementation of the individual care plans of the same 30 members
selected for the Enrollment Verification element. The appropriateness of the Interdisciplinary Care
Team and the use of evidence-based clinical guidelines in the development and implementation of the
enrollees’ ICPs will also be assessed. For each case, the plan must produce all relevant documentation
including, but not limited to:
x The completed beneficiary Health Risk Assessment(s).
x A copy of the beneficiary’s Individualized Care Plan (ICP).
x Care and case management documentation associated with the ICP (including claims, encounters
and Prescription Drug Events) submitted for the beneficiary since the last HRA was completed.
Specific documentation will be selected by the audit team based on the content of the ICP.
2. Apply Applicable Compliance Standards: Apply the applicable test to the relevant 30 sampled
cases. For these cases to receive a score of “pass,” the case must present evidence to favorably
address all of the questions below.
3.1. Health Risk Assessment:
x
Did the sponsor conduct an HRA?
x
Did the sponsor conduct the HRA timely?
x
Did the completed HRA include a comprehensive initial assessment and/or reassessment of
the physical/medical, psychosocial, cognitive and functional areas of need and medical and
mental health history?
x
Did the personnel who reviewed, analyzed and stratified the HRA possess appropriate
professional knowledge and credentials?
3.2 Individual Care Plan and use of Evidence-Based Clinical Practice Guidelines:
x
Did the ICP include specific interventions designed to meet all the needs identified in the
HRA?
x
Did the ICP documentation show evidence of using clinical guidelines and protocols?
x
Did the personnel who reviewed the ICP possess professional knowledge and credentials?
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ATTACHMENT IX
Special Needs Plans – Model of Care Implementation
Audit Process and Universe Request
x
x

Was the ICP reviewed/revised with appropriate frequency?
Did the sponsor provide sufficient documentation to verify the implementation of the ICP
(through examination of claims, encounters and Prescription Drug Events for items outlined
in the ICP)?

3.3 Interdisciplinary Care Team
x Does documentation demonstrate that the ICP was managed by an interdisciplinary team
comprised of appropriate clinical disciplines?
4. Sample Case Results: CMS will test each of the 30 cases. If CMS requirements are not met, a sample
case fails and a condition (finding) is documented. If CMS requirements are met, a sample case
passes and no conditions (findings) are documented.
III. Monitoring and Evaluation of the Model of Care
x

Obtain Evidence: CMS will review for appropriateness of the plan’s Model of Care and the
monitoring thereof. For each case, the plan must produce all relevant documentation including, but
not limited to:
x The plan’s methodology for collecting, analyzing, reporting and evaluating their MOC’s
performance
x Information regarding the personnel having responsibility for overseeing the MOC’s monitoring
and evaluation
x Evidence of data collection/results of internal analysis/evaluation, including reports generated
based on findings from internal analysis (i.e. progress toward goals/objectives, areas for
improvement, etc.)
x Any Corrective Action Plans developed and implemented as a result of internal analysis and the
results of the CAPs, if applicable
x A copy of the most recent evaluation of the MOC
x Communication to stakeholders regarding results of monitoring or improvements to the MOC
Note: This evidence will vary by plan based on the provisions of the plan’s approved MOC. The
evidence to be obtained will be more specific after CMS has completed the desk review of the
background information that was submitted with the universe.

x

Apply Compliance Standard to MOC monitoring and evaluation: CMS will review all documentation
to determine if compliance standards were met. CMS will evaluate the documentation and apply the
following tests to the MOC. For the MOC monitoring and evaluation, there should be a favorable
response to all of the following elements:
x Did the plan collect, analyze, and evaluate the MOC (e.g., specific data sources, specific
performance and outcome measures, etc.)?
x Did the plan use the analyzed results of performance measures to improve the MOC (e.g., internal
committee and other structured mechanism)?
x When necessary, did the plan develop and implement corrective actions?
x Did the plan communicate results and improvements in the MOC to stakeholders?
x Are the appropriate personnel responsible for oversight of the MOC’s evaluation and monitoring
process?
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ATTACHMENT IX
Special Needs Plans – Model of Care Implementation
Audit Process and Universe Request
x

Sample Case Results: CMS will review documentation for the MOC. If CMS requirements are not
met, a sample case fails and a condition (finding) is documented. If CMS requirements are met, a
sample case passes and no conditions (findings) are documented.

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