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Summary of, and response to, public comments

ICR 201310-0938-014 · OMB 0938-0935 · Object 43009101.

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File Type	application/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Title	Summary of, and response to, public comments
Author	CMS
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File Modified	2013-09-19
File Created	2026-09-15
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Extracted Text

2015 Consolidated 60-day comments for Part C Application
Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

Some recruitment efforts struggle with
meeting both of CMS' time and distance
requirements.

Will CMS reconsider health plans as
meeting criteria if at least one (time OR
distance) is met? Example geographical
terrain in rural areas impedes meeting
criteria requirements.

Revision

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

Because of contracting issues (providers not Will CMS reconsider Diagnostic
willing to accept MA rates), we typically do Radiology/Mammography as a required
not recruit free standing radiology centers to Facility specialty type?
provide Diagnostic Radiology or
Mammography. Instead these services are
directed to Acute Inpatient Hospitals or
received at PCP or Specialist.

Revision

United
Healthcare

60day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

Medicare.gov is our main source of truth in Will there ever be an opportunity to review
terms of comparison of our networks.
providers based on specialty type in excess
of a 25 mile range? Will CMS update their
web site to offer searching criteria beyond
25 mile range?

Revision

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Reject: Recruitment is a plan
issue as to timing, effort, flexibility on payment
arrangements, use of commercially-contracted
network, leverage, etc. If terrain in a rural area is
a barrier to transportation and access for health
care and other services, the particular
circumstances should be explained during the
application process for the county in question via
the exception process after the initial deficiency
letter is received.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Clarify: This needs to be
clarified. A PCP or Specialist who operates his or
her own state and federally approved radiology
and/or mammography equipment in the office
could be used as could a hospital's OP radiology
department.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Accept: CMS is looking into
expanding the search radius early next year. It has
not been implemented due to technical database
issues.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

United
Healthcare

60 dau

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

Medicare.gov lists services available at an How do we address a service or provider
Acute Inpatient Hospital, yet the hospital
that is posted to Medicare.gov as being
operating certificate is not approved by
Medicare participating and those providers
DOH to provide those services, or the
are used to judge our network
hospital confirms they do not provide those adequacy/accessibility, but we find out
services.
through provider verification that they do
not perform the services or are not
participating? (ie outpatient cardiac
catherization v. cardiac surgery)

Revision

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

CMS requires information that is not readily We believe that CMS's requirements for this
or easily available for use in an automated data is administratively burdensome.
fashion. For instance, the number of
Therefore, we request that CMS provide
Medicare certified beds for hospitals, SNFs, certain information downloadable in excel
ICUs and IP Psych facilities is not readily or other data files that will assist plans in
available to MCOs. This is also true of
their automated production of HSD tables
Medicare certification numbers.
and population of these fields with accurate
CMS information. For example, CMS
should provide a resource from which
MCOs can obtain Medicare Certification #s,
bed counts, etc so that this information is
consistent across all health plans.

Insertion

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

Release of HSD Tables Prior to Final
Release of Application in Early January.

Revision

Comments & Recommendation(s) from
Source

Release of HSD Tables Prior to Final
Release of Application in Early January:
While it is recognized and appreciated that
CMS provides draft applications earlier iin
the year, we request that the final HSD
Tables be made available by November or
December rather than with the release of the
Final Application in early January. This
would allow organizations with a high
volume of submissions additional time to
train network personnel and sufficient time
to upgrade HSD tools, excel formulas, etc.
on any changes made to the tables.

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Clarify: Medicare.gov
information should not be the sole source of
information about the Medicare status of
individual services or components operated by a
hospital. Due dilligence with regard to this issues
is the responsibility of the plan bulding a
Medicare Advantage network and the specifics of
what the facility says about these services needs to
be confirmed by documents and written
assurances, not taken over the phone from one
individual.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Reject: This type of information
is well known in multiple departments aand
offices of these facilities and often maintained on
their website or in other public relations and
business documents for external users to request.
No government data base is going to be as current
and up to date as the facility's own official record
in the CEO or CFO's office.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Accept with Modification: We
will look into the possibility of an earlier release
of the final format of the HSD Tables prior to the
release of the final version of the application in
January.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

Not all document revisions are dated in the
naming convention to know that those
downloaded from HPMS are the same as
those posted on CMS website.

All documents posted to this site should be
dated in the naming convention:
http://www.cms.gov/MedicareAdvantageAp
ps/

Revision

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

For Large Metro and Metro counties that in We recommend CMS consider adjusting the
addition to one or more urban centers also criteria either by using a lower level county
contain large rural areas where physicians classification or by lengthening the distance
are not available (forests, reservations,
standards for certain specialists in those
military bases, etc) and the number of
geographically challenged counties to better
Medicare beneficiaires is low or noncompensate for these geographical
existent in these areas.
differences within a county? How do we
approach this with CMS?

Revision

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

Medicare.gov does not provide
How does CMS determine availability of
downloadable files of providers performing services? What are CMS' definitions of
these services: Cardiac Surgery, Cardiac
these services?
Catheterization, Outpatient Infusion Chemo,
Mammography, and Outpatient Dialysis.

N/A

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

CMS Exception form required for 2014 DISTANCE FROM BENEFICIARIES IN
THE COUNTY field.

We recommend that CMS provide clarity &
direction on how they want health plans to
use the Sample Beneficiary file, HSD
Beneficiary Coverage by Zip Code Report,
and the Part D Eligibility File, and more
detailed instructions on how CMS is
calculating distances.

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Revision

This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Accept with Modification: We
will look into this with HPMS and our contractors
for possible improvement.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Reject: This example is one of
the reasons why we offer the applicant the
exception process. We are aware of differences
across single counties, especially large counties,
and have looked very carefully at how competing
applicants and existing applicants have been able
to structure their delivery networks in these
counties or in more rural or other unique
characteristics of parts of these counties.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Reject: Definitions of these
services are available from Medicare. We
determine availiabilty of these services from
private and public data and FFS claims file
information as well as the provider networks of
other managed care organizations operating in the
same area.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014
Response: Accept with Modification: We will
share this with the staff working to improve
guidance and instructions and the automated fields
for active consideration.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

Certification number: The lists of certified We need clarification from CMS if not all
providers that we receive from CMS'
locations are certified or if we are to assume
(downloadable files from their website)
our national and multi-location contracts are
does not always show all locations of a
covered under the main provider's
contracted provider. Ex: Walgreens certification number.
CMS's lists show some Walgreens'
locations, but not all of the locations that we
have contracted.

Revision

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

It is redundant/duplicative to require health It is suggested that the exception form only
plans to repeat listing the contracted
require the health plan to identify the
providers/facilities "that will ensure access" "closest contracted provider".
on the Exception form when they are
already listed on the HSD table.

N/A

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

With the suggested change in requiring
complete copies of executed Medicare
contracts and any applicable downstream
agreements, the standard previous
turnaround time may be too short.

We would like CMS to consider
lengthening the time frame in which health
plans have to provide complete executed
Medicare agreements (including any
applicable downstream agreements). The
suggested timeframe would be 15 days.

Revision

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

CY 2014 HSD Application Instructions
Will CMS be adding a column Q to the
reference column Q (Model Contract
Provider Table? Column Q appears in CY
Amendment - Indicate if contract uses CMS 2014 Instructions but not in Provider Table
Model MA Contract Amendment by
sample or the CMS summary of changes.
entering Yes or No) in the MA Provider
Our HSD table needs to be built to include
Table section.
this or be subject to HPMS upload fail. We
would also need a copy of the Model
Contract Amendment to know what CMS is
referencing. Where is it available?

Revision

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Accept with Modfication: We
will research this topic in CMS and clarify in
instructions whether or not an application can
assume national and multi-location contracted
provider sites are covered under a "main provider"
certification number.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Reject: The exception template
information is reviewed on its own merits with
reference to HSD Tables by an exception team
reviewer and others on the national team. These
staff need to understand and the plan needs to
affirmatively state the choices that will be
available to Medicare enrollees to get the service
in the most timely manner, not just one choice.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014
Response: Clarify: We will refer this suggestion
to the workgroup revising the entire contract
review approach.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Accept: CMS will add column Q
to the Provider Table and plans to release the
CMS Medicare Advantage Contract Amendments
for both provider and administrative contracts in
the early fall of 2012.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

The CMS downloadable certified
Request that CMS produce certified
Transplant facilities list is in PDF format
transplant list in a .txt or Excel/Access,
requiring considerable manual manipulation similar to the other website posted
to convert to Excel or Access so that it can downloadable files of CMS certified
be used in an automated reporting
providers (Hospital, Home Health, DME,
etc)

Revision

United
Healthcare

60 day

Instructions

2.9 Health Services
Delivery (HSD) Tables
Instructions

Certain Orthotic & Prosthetic providers can Could CMS reconsider Orthotics &
serve a county without necessarily being
Prosthetics differently, for example, similar
located in the county, e.g. a mail order
to home health?
vendor supplying directly to the home. In
addition, we’ve noticed that CMS is
including retail vendors such as Walmart,
CVS, etc. in the O&P category when MA
plans may focus on more typical orthotic
suppliers who can customize the
orthotics/prosthetics, etc. or provide them
through hospitals or physician offices.

Revision

United
Healthcare

60 day

Attestations

3.7 Fiscal Soundness

3.7(A)(2) is duplicative of 3.3(A)(1); that is United suggests that Section 3.7(A)(2) be
we attest to state licensing twice.
deleted as it appears it is duplicative of
3.3(A)(1).

Deletion

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Application Page Description of the Issue or Question
Number

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

60 day

30
3.9 CMS Provider
Participation Contracts &
Agreements (Section B)

United
Healthcare

Attestations

Comments & Recommendation(s) from
Source

As part of the application review process, The new requirement requires more
Applicants will need to provide fully
uploading since entire contracts are
executed contracts for physicians/providers requested rather than just signature pages.
that CMS reviewers select based upon the It also requires provider matrices produced
CMS Provider and Facility tables that are for each selected sample during the shorter
part of the initial application submission.
deficiency period rather than with the initial
CMS reviewers will list the
application filing. Can CMS provide the
providers/facilities and specific instructions sample size per application they expect to
in CMS’ first deficiency notice. 4.3 CMS request, expected length of the window for
Provider Contract Matrix
uploading requested contracts and matrices,
Instructions for CMS Provider Contract
and the zip file size maximum that HPMS
Matrix
will accept?
This matrix must be completed by MA
Applicants and should be used to indicate
the location of the Medicare requirements in
each contract / agreement for the
Applicant’s first tier, downstream and
related entity providers that CMS has
identified in the contract sample.

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Revision

Application Page Description of the Issue or Question
Number

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

United
Healthcare

60 day

Attestations

3.13 Marketing (Section 37
A.4.)

United
Healthcare

60 day

Attestations

3.16 Claims (Section
A.4.)

42-43

Applicant agrees to provide general
coverage information, as well as
information concerning utilization,
grievances, appeals, exceptions, quality
assurance, and financial information to any
beneficiary upon request.

Comments & Recommendation(s) from
Source

We request clarification of specifically
which materials are to be made available
"upon request" as this language is not
reflected in 42 CFR 422.2260 through 42
CFR 422.2276, referenced in the first
paragraph of Section 3.13 of the Part C Medicare Advantage and 1876 Cost Plan
Expansion Application.

We think that the addition of the word
We believe that the addition of the word
“complete” in this attestation will more
“complete” in this attestation will more
closely align with the CMS requirements
closely align with CMS requirements to
and with United’s claims processing
process complete claims promptly. We
policies. For example, United does not
recommend that the attestation be revised
“develop” all claims that are incomplete,
by inserting the word “complete,” as
such as certain claims that are missing
follows:
information or have invalid coding. These
claims typically involve only provider
"Applicant will comply with all applicable
liability, so they would not affect the
standards, requirements and establish
member. This slight change in the
meaningful procedures for the development
attestation wording would allow United to and processing of all complete claims
answer this attestation with a “yes” without including having an effective system for
having to qualify our response.
receiving, controlling, and processing
claims actions promptly and correctly."

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

N/A

Revision

This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Clarify: Per 42 CFR 422.111 (c),
an MA organization must disclose specific
information upon request. This information
includes, but is not limited to, the following: the
procedures the organization uses to control
utilization of services and expenditures; grievance
information according to 422.564; and appeals
information according to 422.578. CMS clarifies
that the applicant could fulfill a request for the
aforementioned information by providing the
Evidence of Coverage document. Additionally, 42
CFR 422.111 (c) (5) requires the MA
organization to fulfill requests for the financial
condition of the MA organization, including the
most recently audited information regarding, at
least, a description of the financial condition of the
MA organization offering the plan. MA
organizations have flexibility in creating materials
to fulfill a request for information on their
financial condition. At a minimum, the material
would need to include the elements noted in 42
CFR 422.111 (c) (5).
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Disagree: The requirement in
42 CFR 422.520 is that “clean” claims be paid
promptly (within 30 days) and that all other claims
be paid or denied within 60 days.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

United
Healthcare

60 day

Attestations

3.16 Claims (Section
A.3.)

Applicant agrees to give beneficiary prompt CMS rules do not require that plans provide
notice of acceptance or denial of a claim's notice of claim acceptance when there is no
payment in a format consistent with the
cost share involved (except for PFFS
appeals and notice requirements stated in 42 claims). There is also no requirement to
CFR Part 422 Subpart M.
notify beneficiaries of claim denials when
the claim only involves provider
reimbursement (such notices would be
confusing to beneficiaries). Rather, the
requirement is that when a claim is denied
resulting in member liability, plans must
provide the member with his or her appeals
rights. We suggest an addition to the
attestation that explains that the notice is
required in all cases where there is costsharing or member liability. We request that
the attestation be revised as follows:
Applicant agrees to give beneficiary prompt
notice of acceptance or denial of a claim's
payment in a format consistent with the
appeals and notice requirements stated in 42
CFR Part 422 Subpart M, in all cases
where there is a member cost-sharing or
member liability.

Insertion

United
Healthcare

60 day

Attestations

3.28 Tiering of Medical
Benefits (Section A.1.)

All beneficiaries have equal access to the
We request clarification of "various tiers" as
various tiers proposed. Note: this is new for this term is not reflected in 42 CFR
2014
422.112.

Revision

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Application Page Description of the Issue or Question
Number

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

United
Healthcare

60 day

Document
Upload
Templates

67
4.3 CMS Provider
Contract Matrix (Number
3)

United
Healthcare

60 day

89
APPENDIX I: Specific Requirements
Solicitations for Dual-Eligible SNPs
for Special
(State Medicaid Agency
Needs Plan
Contracts)
(SNP)
Proposals

We encourage CMS to provide flexibility We recommend removal of the reference to
with the deadlines for completing State
a July 1 deadline for submitting State
Medicaid Agency contracts. There may be Medicaid Agency contracts.
cases where state legislative activity or the
start of Financial Alignment Demonstration
plans may make it difficult to complete the
contract by July 1st.

United
Healthcare

60 day

APPENDIX I: Definitions
Solicitations
for Special
Needs Plan
(SNP)
Proposals

Can clarification be provided on when the
"Dual Eligible Subset - Zero Dollar Cost
Share" designation or the "Dual Eligible
Subset" designation should be used?

92-93

Designate if the contract uses the CMS
Model Medicare Advantage contract
amendment with a "(M)" next to the
provider/facility name.

Comments & Recommendation(s) from
Source

We believe the "CMS Model Medicare
Advantage contract amendment" document
has not been released and we would like to
know when it will be released.

We request an example of when these
designations should be used.

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

N/A

Deletion

N/A

This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Clarify: CMS plans to release
Medicare Advantage Contract Amendments for
both provider and administrative contracts in the
fall of 2012.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Reject: We believe the July 1
deadline for submitting State Medicaid Agency
contracts is flexible, and has been in place over the
past 2 years.
This comment was received for the CY2014
package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Clarify: The Dual eligible subset
type allows for enrollment of - any (or all)
categories of eligibility provided there is State
agreement. It is the most flexible classification of
D-SNP. The DE Subset D-SNP type can be further
designated as a zero dollar cost share when the
Subset enrolled includes the Medicaid categories
with 0 dollar Medicare cost share, that is, QMB
and QMB + , and/or any other Medicaid category,
e.g., FBDE, when the State has agreed to cover the
Medicare cost share for that Medicaid eligibility
group in its State plan.

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

APPENDIX I: 4. D-SNP Proposal
Solicitations Application
for Special
Needs Plan
(SNP)
Proposals

Not provided

Please clarify what material needs to be
submitted for an existing D-SNP that is
changing its subtype. Is the entire SNP
proposal needed when changing D-SNP
subtypes?

APPENDIX I: 11. Model of Care
Solicitations Attestations (Provider
for Special
Network and Use of
Needs Plan
Clinical Practice
(SNP)
Guidelines)
Proposals

104

Under the "Provider Network and Use of
We recommend that this section be
Clinical Practice Guidelines" category, item modified so that a sampling can be used in
#59 states, "Applicant conducts periodic
monitoring surveillance.
surveillance of employed and contracted
providers to assure that nationally
recognized clinical protocols and guidelines
are used when available and maintains
monitoring data for review during CMS
monitoring visits), the term "contracted
providers". This statement implies that the
Applicant will need to conduct surveillance
of all providers, Therefore, this raises
concerns about this applicability to the
broader provider network that can be
several thousand providers.

Revision

APPENDIX I: 14. D-SNP Upload
Solicitations Document (Number 3)
for Special
Needs Plan
(SNP)
Proposals

115

Under the 2011 D-SNP State Medicaid
Agency Contract Upload Document, item
#3, bullet #3 states, "Third party liability
and coordination of benefits". We believe
that clarify is needed with regard to the
meaning of "third party liability."

Deletion

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

United
Healthcare

60 day

United
Healthcare

60 day

United
Healthcare

60 day

Application Section
(Number/ Header)

We recommend that reference to "third
party liability" be removed because CMS
has not provided clear direction as to what
is meant be this. As an alternative, CMS
needs to clarify or provide background on
"third party liability" in this context.

package which was already approved by OMB
12/2012. A response is not applicable since the
comment does not apply to this CY2015 package.
CMS has already responded to the comment and
that your response can be found in the CY 2014
PRA package.
2014 Response: Reject: We do not believe this
modification is necessary because sampling is an
acceptable method of surveillance.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

60 day

United
Healthcare

60 day

UnitedHealthcare 60 day

Application Section
(Number/ Header)

APPENDIX I: 14. D-SNP Upload
Solicitations Document (Number 5)
for Special
Needs Plan
(SNP)
Proposals

APPENDIX I: 15. D-SNP State Medic
Solicitations aid Agency Contract
for Special
Matrix (Element #3)
Needs Plan
(SNP)
Proposals

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

115

We are assuming that this section would
only be included if the State Medicaid
Agency contract requires the D-SNP to
provide Medicaid services. Broadly, if
State Medicaid Agencies and MAOs
determine that increased coordination will
best serve dually-eligible members, the
requirements should be clarified to allow
this. Specifically, in item #5 and elsewhere
that references providing Medicaid benefits,
clarify in these areas that agreed-upon
coordination is acceptable.

117

135
APPENDIX 6.4 Attestations ; 2
II:
Certification (Number 9)
Employer/Uni
on-Only
Group Waiver
Plans
(EGWPs)
MAO "800
Series"

a. There is a significant amount of
confusion for both D-SNPs and State
Medicaid Agencies as to whether the State
Medicaid Agency contract requires the DSNP to provide Medicaid services. Please
clarify that the provision of Medicaid
benefits is not always required and that
increased levels of agreed-upon
coordination of Medicaid benefits is also
acceptable.

b. Specifically, the NOTE comment only
makes reference to Medicaid services "that
the organization is obligated to provide
under its State contract," which is confusing
without a reference to coordination of
services as another alternative.
The third element of the Dual SNP contract Flexibility should be provided to allow the
matrix provides that:
Medicaid benefits to be documented in a
variety of ways that will accommodate each
Medicaid benefits covered under the SNP state's unique negotiated approach. For
These are the Medicaid medical services
example, due to the overlap of benefits
that the organization is obligated to provide covered by both Medicare (primary) and
under its State contract, not the nonMedicaid (secondary), if a state wants a
Medicare mandatory Part C services
combined list of Medicaid and Medicare
covered under the MA contract.
benefits outlining each program's
responsibility for a category of service, that
There is confusion about what should be
should be sufficient to meet this element
documented for this element. Further the and will help MAO's create a better Section
above description makes it sound like the IV of the Summary of Benefits.
D-SNP is required to provide Medicaid
benefits, when in fact most D-SNPs do not
provide/cover Medicaid benefits, but rather
help members to coordinate the services
available through Medicare and Medicaid.
Applicant understands that
We believes that the correct citations are 42
dissemination/disclosure materials for its
CFR 422.2262 and 42 CFR 423.2262,
EGWPs are not subject to the requirements respectively.
contained in 42 CFR 422.80 or 42 CFR
423.50 to be submitted for review and
approval by CMS prior to use.

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Revision

N/A

Revision

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Association for
Community
Affliated Plans
(ACAP)

60 day

UCare Minnesota 60 day

Cigna
HealthSpring

60 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Special Needs 13
Plans
Application
Section
Apendix I /
Quality
Improvement
Program
Requirements

109 - 110

Special Needs 13 and 20
Plans
Application
Section
Apendix I /
Quality
Improvement
Program
Requirements

109 - 110

Special Needs 13
Plans
Application
Section
Apendix I /
Quality
Improvement
Program
Requirements

109-110

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

ACAP comments that the Quality
Improvement Program Attestation section
be streamlined similar to the newly revised
MOC attestation section.

ACAP asks that the Quality section be
Streamline this
REJECT: The Quality Improvement Program Plan
streamlined to reflect an attestation of
section by omitting outlines the elements of the Medicare Advantage
compliance with the various requirements attestations in the
Organizations SNP QI program and provides a
rather than providing detailed information SNP Quality section frameworkfor how the SNP is to execute quality
on the application and uploading documents and have an
improvement requirements at 42 CFR Section
that are otherwise submitted to CMS, the
attestation of
422.152. The Quality Improvement Program Plan
states or their contractors.
compliance.
attestations and narrative are to encompass all
aspects a SNP's quality projects, as well as all
quality data collected by the SNP. Therefore,
many of these attestations are appropriate.
However, CMS will examine the Quality
Improvement Program Requirements Attestations
in the SNP application section for the next
application cycle (i.e., CY 2016) to determine
whether any attestations are duplicative, can be
streamlined, or removed.
How does this new Domain synchronize
Duplication with the MOC and the Section with Section 20, Quality Improvement
Synchronize the
REJECT: The Quality Improvement Program Plan
20, Quality Improvement Program Matrix, Program Matrix? It appears there is
MOC with Section outlines the elements of the Medicare Advantage
Synchronize these sections.
duplication and recommend this section be 20 and remove the Organizations SNP QI program and provides a
section and reduce or frameworkfor how the SNP is to execute quality
eliminated. If there are elements that are
remove the number improvement requirements at 42 CFR Section
unique, recommend they should be
of attestations for the 422.152. The Quality Improvement Program Plan
incorporated into Section 20 rather than
have a new set of requirements. The SNP Quality Improvement attestations and narrative are to encompass all
Program
aspects of a SNP's quality projects, as well as all
leadership and management discussed in
Requirements
quality data collected by the SNP. Therefore,
Element A is covered in the Staff
many of these attestations are appropriate.
Structure section. This appears to be
However, CMS will examine the Quality
duplicative of 2A. Similar to the removal of
Improvement Program Requirements Attestations
attestations for the SNP Model of Care, we
in the SNP application section for the next
recommend that the attestations for the #13,
application cycle (i.e., CY 2016) to determine
Quality Improvement Program
whether any attestations are duplicative, can be
Requirements be removed or reduced, as the
streamlined, or removed.
detailed information is included in section
#20 Quality Improvement Program Matrix
Upload Document.
Clarification on the attestations especially
#21 and #27 in the Quality Improvement
Program Attestations is needed.

#21 – Since supplemental benefit flexibility States that benefit
is not permitted for SNPs other than
flexibility should be
FIDESNPs, we request clarification as to
for all SNPs not just
how standard D-SNPs, C-SNPs and I-SNPs FIDE-SNPs.
can meet this requirement. We support
benefit flexibility for all SNPs – not just
FIDESNPs.

Reject: Attestation #21 does not refer to benefit
flexibility supplemental benefits as described in
Chapter 16b. The add-on services and
supplemental benefits referred to in the attestation
are those noted in the Medicare Managed Care
Manual Chapter 4, Section 30.

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Special Needs 13
Plans
Application
Section
Apendix I /
Quality
Improvement
Program
Requirements

109 - 110

Clarification on the attestations especially
#21 and #27 in the Quality Improvement
Program Attestations is needed.

Special Needs 13
Plans
Application
Section
Apendix I /
Quality
Improvement
Program
Requirements
Attestations 3.12 Quality
Improvement Program

109 - 110

Clarification on the attestations especially
#21 and #27 in the Quality Improvement
Program Attestations is needed.

#27 – We do not think that this attestation Suggest to remove
attesation #27.
question adds value, and requiring the
sharing of this analysis with ICT
members/providers may detract from other
critical priorities as determined by the QI
program. Furthermore, a QIP derived from
the Care Transitions analysis would
necessitate the sharing of information and
results with all applicable stakeholders. In
some cases, these stakeholders will be ICT
members but in other cases, they may not be
– considering that all plans define ICTs
differently. If this question continues to be
included, we suggest changing the term
“interdisciplinary care team” to “applicable
stakeholders.”
All attestations begin with “For each special Requests

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Cigna
HealthSpring

60 day

Cigna
HealthSpring

60 day

HealthPartners

60 day

Application Section
(Number/ Header)

needs plan,” however, some data such as
CAHPS and HOS is collected at the
contract level and therefore could include
SNPs as well as regular MA plans, would
you please clarify if all data is to be
collected at the SNP PBP -level?

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Reject: suggestion to remove attestation #27. The
purpose of the SNP is to provide high quality care
coordination for special needs beneficiaries as
well as communicate critical information, such as
a transition of care anaylsis to those on the
interdiscplinary care team. However, CMS will
examine the Quality Improvement Program
Requirments Attestations in the SNP application
section for the next application cycle (i.e., CY
2016) to determine which attestations are
duplicative, can be streamlined, or removed to
reduce burden.

Clarification: Only MAOs with SNPs having 500
clarification on
or more enrolled members are required to submit
whether all data is to HOS data. Only MAOs with SNPs having 600 or
be collected at the
more enrolled members are required to report
SNP PBP level.
CAHPS information. CAHPS and HOS are
collected by CMS at the contract level, not the
SNP PBP level.

Needs clarification on what the attestation is Are the CMS attestations and instructions Revision
referring to. Is the attestation referring to related to the Quality Improvement Project
(QIP) Plan or the Quality Improvement (QI)
Quality Improvement Program or the
Quality Improvement Project. Acronyms Program? The references and acronyms in
section
are confusing.
3.12 (see below) and crosswalk are different
than CMS regulations and guidance. For
example,
CMS references the Quality Improvement
Program as “QI Program” and the Quality
Improvement Project Plan as the “QIP
Plan”. The crosswalk has several references,
including the
title to “Quality Improvement Project (QIP)
Plan.” However, the elements to be cross
walked are
broader than the QIP Plan and follow the
regulations applicable to the QI Program.

Accept: Clarifying the acronyms used for Quality
Improvmenet Program and Quality Improvement
Project. CMS is revising the attestation in section
3.12 to indicate that this is the Quality
Improvement Program or QI Program.

Application Page Description of the Issue or Question
Number

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

HealthPartners

60 day

Instructions

4.11 Crosswalk for Part C 90
Quality Improvement
(QI) Program Project
(QIP) Plan

Association for
Community
Affiliated Plans

60-day

Instructions

Appendix 1: DSNP State 127
Medicaid Agency
Contract Negotiations
Status Document

Florida Blue
Cross and Blue
Shield

60-day

HSD
Instructions

HSD Instructions

Florida Blue
Cross and Blue
Shield
Florida Blue
Cross and Blue
Shield

60-day

HSD
Instructions

HSD Instructions

5-6

60-day

HSD Tables

HSD Table

N/A

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Are the CMS attestations and instructions Revision
related to the Quality Improvement Project
(QIP) Plan or the Quality Improvement (QI)
Program? The references and acronyms in
section
3.12 (see below) and crosswalk are different
than CMS regulations and guidance. For
example,
CMS references the Quality Improvement
Program as “QI Program” and the Quality
Improvement Project Plan as the “QIP
Plan”. The crosswalk has several references,
including the
title to “Quality Improvement Project (QIP)
Plan.” However, the elements to be cross
walked are
broader than the QIP Plan and follow the
to the
QI Program.
Clarification
Removal of DSNP State Medicaid Agency regulations
Commenterapplicable
supports the
deletion
of the
Contract Negotiations Status Document
requirement to upload the an actual copy of
the state contract for coordination of the
SNP with the Medicaid Program.
Needs clarification on acronyms in the
crosswalk section 4.11.

Accept: Clarifying the acronyms used for Quality
Improvmenet Program and Quality Improvement
Project. CMS is revising section 4.11 to indicate
that this is the Quality Improvement Program or
QI Program.

Clarify: CMS is not deleting the requirement to
upload an actual copy of the state contract for
coordination of the SNP with the Medicaid
Program. We have deleted the requirement to
upload the DSNP State Medicaid Agency Contract
Negotiation Status Document.
Accept: CY2015 HSD instruction were not up to
date and therefore CMS has revised the specialty
codes on page two to reflect the deletion of 009
and 032 and added 035 Cardiothoracic surgery.

Commenter stated that Cardiac and thoracic
Speciality Codes were eliminated in
CY2014 but are showing up on the CY2015 specialty codes were eliminated in 2014
HSD Instructions. Organizations wants to (009 and 032) and a new code was
confirm this change or point out this error. created (035). The application is now
proposing to reverse this change for 2015.
Florida Blue
would like to confirm that this is an
intended change and not an error.
Define IPA
Commenter suggested that CMS define
"IPA."

Revision

Accept: Independent Practice Association (IPA)
has been defined in HSD Instructions.

Clarification needed on how the owner of a Commenter would like clarification on how
group practice is designated.
the owner of a group practice is designated would employee designation be correct?

Clarification

Clarify: If the physician listed in the HSD Table is
an employee, the president, medical director, or
other officer of the practice has the authority to
bind the physician to see patients from a particular
MAO. If the physician listed in the HSD table is
an owner, partner or other, only the physician can
bind him or herself by contracting on his or her
own.

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Appendix 1: N/A
Model of Care

N/A

General Comments: Most Vulnerable
Beneficiaries

60-day

Appendix 1: N/A
Model of Care

N/A

General Comments

Medica Health
Plan

60-day

Appendix 1: N/A
Model of Care

N/A

General Comments

A few commenters supported a number of
the modified MOC requirements. However,
they believed that requirements related to
documentation of community partnerships
in each service area and the requirement
that plans repeat the exercise of describing
the demographic characteristics of the target
population and of the most vulnerable
subset of the population is excessive. They
suggested that it is not clear that the added
reporting burden will be rewarded with
significant improvements in health
outcomes. These commenters supported the
merger of the care of vulnerable population
element in this description since the most
vulnerable subsets are a part of the overall
population,
but believe
it is ita would
more efficient
One
commenter
stated that
be
helpful to know what type of evidence, if
any, would be required, for example
policies, standard operating procedures,
reports to better understand if the plan’s
narrative
is on target.
One commenter
suggested that the use of

Medica Health
Plan

Appendix 1: N/A
Model of Care

N/A

General Comments

Association for 60-day
Community
Affiliated Plans;
Medica Health
Plan

Appendix 1: N/A
Model of Care

N/A

MOC Multi-Year Approval

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

SNP Alliance

60-day

Medica Health
Plan

Application Section
(Number/ Header)

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Clarification

Revision

Reject: CMS uses the term 'detailed' to emphasize
that the MOC narrative should be thorough and
complete in its description. CMS' does not require
examples be submitted with the MOC; however,
all components of the MOC should be
comprehensively addressed using the modified
MOC Element Criteria. CMS' expectation is that
the MOC be uploaded in narrative format only.
No supporting documents are necessary.

Clarification

Clarify: CMS understands the constraints
associated with obtaining a beneficiaries' medical
records. These unique situations need to be
thoroughly and clearly addressed in the MOC.
CMS does not necessarily expect to see that
enrollee medical information is 100%
unobtainable. However, the SNP should be
outlining current approaches & methods for
collecting medical information as well as barriers
to obtaining medical information for SNP
beneficiaries (should that be the case).

Clarification

Clarify: Currently the 3-year approval for the
MOC remains intact. CMS will inform the SNPs
of any changes made to the 3-year approval for the
MOC. SNPs will be required to submit a MOC in
its revised, finalized form, only as required, based
on the MOC's current approval period.

the term “detailed” is not helpful. A more
concise, clear term or phrase should be
used. The use of 4 examples of how any
requirement will be performed, as requested
in the last submission, seemed excessive
and not helpful to those plans with many
years of experience. A SNP can provide
policies, procedures, and/or examples
instead of narrative.
A few commenters suggested that there
appears to be an underlying assumption that
medical groups and plans have direct access
to one another’s data. This is not true for
some SNPs and although they are working
on agreements to access information
directly from contracted medical providers
[they do receive claims] they are 4 years
into this process and have not made enough
progress to reduce manual data collection
for many, many items. Furthermore, State
privacy laws are often more stringent than
A few commenters were in support of the
MOC 3-year approval and requested that
plans could wait until their next scheduled
review to resubmit using the modified MOC
Element Criteria. They also commented
that NCQA has an excellent model to
follow with its accreditation process.

Clarify: CMS is not changing the intent of the
MOC nor the expectations regarding the
components of the MOC, as reflected in the MOC
Element criteria. Although the number of
elements have been reduced, we simply
consolidated inter-related elements that previously
were to be addressed as separate and distinct
components. The modified structure continues to
capture all relevant information previously
required via those distinct elements. That said,
CMS believes it has provided high-level and nonprescriptive MOC Element criteria, thereby
providing SNPs with the necessary flexibility to
describe a thorough and comprehensive MOC
designed to meet the healthcare needs of their
unique beneficiaries.
Reject: CMS' expectation is the MOC be
uploaded in narrative format only. No supporting
documents are necessary.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

60-day
SNP Alliance:
Medica Health
Plan, Health
Partners, Inc., &
CignaHealthSpring

Appendix 1: N/A
Model of Care

N/A

Most Vulnerable Beneficiaries; End-of-Life Some commenters suggest that the End-ofRequirement
life requirement should be qualified; e.g.,
“if relevant to the target population served
by the SNP”. The commenters suggested
modifying the end-of-life requirement with
the caveat “if relevant to the target
population served by the SNP.”

Clarification &
Revision

Medica Health 60-day
Plan, SNP
Alliance,
America's Health
Insurance Plan,
Health Partners,
Inc., & Cigna
HealthSpring

Appendix 1: N/A
Model of Care

N/A

Care Coordination: Request to use risk
Many commenters were concerned that
stratification for HRA, ICP, ICT, and Care CMS did not allow the use of a risk
Transitions
stratification method to identify relevant
beneficiary diagnosis collected on the
Health Risk Assessment tool. They also
recommended that they be allowed to use a
risk stratification approach for developing
the Individualized Care Plan and the
Interdisciplinary Care Team. The
commenters also requested they be allowed
to use a risk stratification approach to
determine appropriate care transitions to
improve their service delivery strategies.
The commenters thought this was necessary

Clarification

Clarify: The description of the sub-population is a
specific congressional requirement in 42 CFR
Section 422.101(f)(2)(iv), which requires all
MAOs that offer SNP products to implement a
MOC component that specifically addresses the
coordination and delivery of specialized benefits
and services that meet the needs of the SNP's
most vulnerable beneficiaries, including
frail/disabled beneficiaries and beneficiaries near
the end of life. SNPs should be in a position to
decipher the specific differences that make these
beneficiaries more vulnerable than the SNP's
general target population. The SNP's MOC
policies and procedures should appropriately
reflect any unique approaches that address the
unique needs of sub-population(s) and explain the
distinct differences between the most vulnerable
beneficiaries and those in the overall SNP
Clarify: CMS does not object to SNP's using risk
stratification processes to meet the needs of its
SNP beneficiaries. The MOC Element Criteria 2B currently supports the use of 'stratification' for
the Health Risk Assessment component of the
MOC. If a SNP chooses to use a risk stratification
model to support elements of its MOC, CMS
expects these processes to be thoroughly and
completely described in the MOC narrative.
Moreover, CMS also recognizes that not all SNPs
use a risk stratification approach to determine
member healthcare needs; therefore, this level of
detail is based solely on the SNP organization's
capabilities and is not considered a requirement

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

PACE-like Model: Some commenters are
concerned that the new MOC requirements
are moving in the direction of a PACE
model which is not an appropriate model for
SNPs. There are concerns about the level of
detail and overall "prescriptiveness" the
new requirements propose. Further, the
requirements for the ICT communication
processes would work in a PACE model but
do not work for virtual teams. The
commenters highlight that in a state wide
model; member, providers, and care
coordinators are not co-located. Face to
face meetings are rarely possible for the
purpose of care coordination only. Plans do
not pay clinicians for office time for this
service. Clinicians’ are willing to consult
and advice via phone and communication is
carried out but not in face to face or web
meetings. Clinical notes, which are
separate from the ICP, should provide the
record
of ICT discussions.
Therefore
Some commenters
stated that
trainingthe
and
competency testing of all providers is
unrealistic, especially for health plans that
have extensive provider networks. This
requirement is both repetitive and time
consuming. The commentors relay that the
extensive recordkeeping is burdensome and
challenging. The commenters request
clarification on expectations related to
tracking of completed training and whether
SNPs must "mandate" that all providers
participate in this training. The number and
variety of providers for a health plan makes
this very challenging. The commenters
support the need for having information on
the MOC available to providers and
recommend that documentation focus on
notification of providers of training
opportunities, not 100% compliance. The
commenters also suggest receiving
attestations from providers or their
contracted organization that all ongoing
required trainings are completed could be
an acceptable alternative. It is also

HealthPartners, 60-day
Inc., SNP
Alliance, Medica
Health Plan, &
Health Partners,
Inc.

Appendix 1: N/A
Model of Care

N/A

PACE-like Model associated with ICT,
Care Coordination, & Virtual
Communication

60-day
CignaHealthSpring,
Medica Health
Plan, Health
Partner's Inc.,
America's Health
Insurance Plan,
Ucare, & SNP
Alliance,

Appendix 1: N/A
Model of Care

N/A

MOC-Provider Network Training
Requirements

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Clarification

Clarify: CMS is not promoting a PACE-like
Model to meet the MOC requirements. CMS is not
changing the intent of the MOC nor the
expectations regarding the components of the
MOC, as reflected in the MOC Element criteria.
CMS has provided high-level and non-prescriptive
MOC Element criteria, thereby providing SNPs
with the necessary flexibility to describe a
thorough and comprehensive MOC designed to
meet the healthcare needs of their unique
beneficiaries. This includes the communications
processes of the ICT, which are critical to
successful care coordination processes.

Clarification &
Revision

Clarify: The expectations regarding MOC training
for network providers has not changed. CMS does
not expect SNP's to necessarily achieve 100%
compliance for training and competency of the
MOC, especialy those with extensive provider
networks. However, CMS does expect and
requires SNPs to use innovative methods to
address this issue of provider network training.
SNPs have the flexibility to thoroughly describe
how they meet this element requirement based on
the unique structure of their organization. The
examples provided by these commenters speaks to
the level of uniqueness and complexity associated
with MOC training requirements for providers and
should be thoroughly described as such in the
MOC. CMS also recognizes the strategies
provided in the comments aide in the justification
and rationale of adhering to the MOC Training for
the Provider Network element that is unique to
your organization; we cannot emphasize enough
the importance of providing this level of detail in
the MOC narrative. However, this does not
eliminate the requirement that the SNP Provider
Network needs to be informed/trained on the

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

America's Health 60-day
Insurance Plan &
Health Partners,
Inc.

Appendix 1: N/A
Model of Care

N/A

60-day
CignaHealthSpring,
SNP Alliance,
Health Partners,
Inc. & UCare

Appendix 1: N/A
Model of Care

HealthPartners,
Inc., SNP
Allicance,
Medica Health
Plan, & Cigna
HealthSpring

60-day

Appendix 1: N/A
Model of Care

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

A few commenters were concerned that
CMS does not allow or promote the use of
‘member risk methods’ to tailor
beneficiaries risk level and associated
healthcare needs. They are concerned that
CMS is requiring SNPs to provide the same
intensity of services to high and low risk
members who require minimal intervention
or who do not wish to participate in care
management programs. They believe more
SNP resources should be used to care for
the highest risk most vulnerable members.
MOC Requirements in the MA Application Some commenters requested that the release
and Medicare Managed Care Manual
of SNP Model of Care updates be released
in the SNP-specific Chapter 16b instead of
the MA Application process. Furthermore,
they urged CMS to rely upon this process
for updating the Manual chapter as the
means for issuing for comment and
finalizing substantive revisions to the MOC
rather than initially proposing such changes
in the draft MA application.

Clarification

N/A

Quality Measurement & Performance
Improvement: MOC Quality Performance
Improvement Plan and clarification on
expectations of SNP leadership &
management roles.

A few commenters requested CMS to
clarify the requirement to describe how
SNP leadership, management groups, other
personnel, and stakeholders are involved
with the quality performance process. They
specifically asked ‘what is CMS’ goal and
what problem is this new requirement
intending to address’?

Clarification

N/A

Care Transitions Protocols

Some commenters were concerned that
CMS is requiring ‘all’ SNP providers to
ensure care transition protocols are being
used to maintain care continuity.
Furthermore, they stated that “Any
transition of care” is too broad and implies
an MCO is aware of everything that is
happening to the enrollee. It would be
impossible for the MCO to manage every
transition. MCOs should focus on where
there is risk for readmission and/or adverse
outcomes.

Clarification &
Revision

Care Coordination: Use of 'member risk
methods' for HRA, ICP, ICT and Care
Transition Protocols.

Clarification

Clarify: CMS encourages use of 'member risk'
methods to achieve appropriate care coordination
efforts for their SNP beneficiaries; however, it is
not a requirement that all SNPs use these type of
'member risk methods'. SNPs have the flexibility
and autonomy to describe how they meet these
MOC element requirements based on the unique
and relevant structure of their organization. The
example this commenter has provided speaks to
the level of uniqueness and complexity associated
with SNP beneficiaries' healthcare needs and
should be thoroughly described as such in the
Clarify: CMS' Chapter 16b will be updated to
reflect the current modifications for the MOC
Element Criteria once finalized. CMS is mandated
to include the MOC Element Criteria with the MA
Application through the Office of Management &
Budget - Paper Reduction Act process every year
which allows for the appropriate public comment
period; therefore, Chapter 16b of the Medicare
Managed Care Manual is not the proper vehicle
through which to seek comment and effectuate
modification to the MOC elements. We would
note that the PRA process also includes a 30-day
Clarify: CMS believes quality healthcare
reasonates from the leadership of an organization
down to its front-line staff. CMS seeks to identify
those individuals in leadership/management
postions involved with the quality performance of
the MOC outcomes and how the results of the
MOC outcomes inform administrative decisions
for improving quality of care for SNP
beneficiaries. CMS believes this level of
Clarify: The term "care transitions" refers to the
movement patients make between health care
practitioners and settings as their condition and
care needs change during the course of a chronic
or acute illness. SNPs have the flexibility to
describe how they meet this element requirement
based on the unique and relevant structure of their
organization. Therefore, it is each SNP's
responsibility to identify its specific care
transitions they monitor routinely as well as the
rationale and justification for doing so. CMS does
not expect SNP's to be accountable for every care
transition; therefore, we have changed 'any'
transition in care to 'applicable' transitions in care.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Some commenters recommended that the
NCQA review for purposes of the 3-year
approval focus on performance monitoring
and outcomes rather than structure and
process. They also thought a tighter
alignment with the SNP Structure &
Process Measures related to goals and
improvement activities would be helpful to
SNPs. Furthermore, they were concerned
that
thecommenters
MOC Element
Criteria
was a
Some
requested
clarification
on what it means by ‘continuous evaluation’
by the ICT. They requested that the term
‘continuous’ be changed to ‘periodic’.
Furthermore, they requested that the
requirement regarding the use of outcomes
for “continuous” evaluation of processes to
manage changes in beneficiaries’ health be
modified to “periodic” evaluation. They
further requested that the meaning of
“periodic” be defined by plans in relation to
the needs of the specific population they
serve since Some needs will vary
significantly by SNP subset.

60-day
Kaiser
Foundation
Health Plan, Inc.,
Medica Health
Plan, Health
Partners, &
America's Health
Plan

Appendix 1: N/A
Model of Care

N/A

MOC Quality Measurement and
Performance Improvement Plan

HealthPartners,
Inc., SNP
Alliance, &
CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

Clarification of 'continuous evaluation' by
ICT members

60-day
CignaHealthSpring &
Medica Health
Plan

Appendix 1: N/A
Model of Care

N/A

Care Coordination: SNP Staff Structure

60-day
SNP Alliance,
Cigna
HealthSpring,
Health Partners,
Inc., & Medica
Health Plan

Appendix 1: N/A
Model of Care

N/A

SNP Provider Network; Specialized
Expertise & Credentialing

60-day
SNP Alliance,
Health Partners,
Inc., & Cigna
HealthSpring

Appendix 1: N/A
Model of Care

N/A

SNP Staff Structure

Some commenters requested clarification
about how the organizational chart should
look. They recommended changing the
requirement to “an organizational chart that
also shows staff responsibilities identified in
the MOC.” They also suggested removing
the reference to job descriptions as it is
redundant with staff responsibilities.
Furthermore, SNP Structure: The focus on
job titles should be eliminated. Focusing on
job functions and job responsibilities is
Some commenters were concerned that
CMS was requiring a duplicative
requirement for provider credentialing in
the SNP MOC. They cited that
documentation requirements associated with
provider credentialing should be limited to
the competency of specialized healthcare
providers that are not accounted for under
the standard credentialing rules. They
Some commenters are seeking clarification
on CMS’ expectations regarding
“contingency planning for staff continuity.”
They suggested that this requirement be
reframed in the context of human resource
workforce policies consistent with the
general MA requirements and not structured
as a unique SNP requirement.

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Revision

Reject: The SNP Structure & Process Measures
are not directly linked to the MOC narrative or the
MOC implementation. This comment is outside
the scope of the current information collection
process; however, should CMS consider
alignment of the MOC and S & P Measures in the
future, we will solicit appropriate comment.

Clarification/
Revision

Clarify: CMS expects SNPs to evaluate if the
structure/processes developed by the ICT are
working and effective for the beneficiary. It is up
to the SNP to determine how often an evaluation
is needed, which CMS assumes would be
dependent on the structure of the ICT, beneficiary
need/s and other applicable care coordination
structures of the SNP. The example/s provided
speaks to the level of uniqueness and complexity
associated with SNP beneficiaries' healthcare
needs and should be thoroughly described as such
in the MOC, and not simply on an "as-needed"
basis."

Clarification &
Revision

Accept: CMS has modified MOC Element 2D to
Clarify:
CMS
does not'explain
recommend
a 'standard'
reflect the
following:
how the
ICT used
organizational
chart
for
the
MOC.
SNPs
have the
healthcare outcomes to evaluate established
flexibility
autonomy
to make
this
processes, and
. . . on
a continuous
basis'.
determination based on the structure of their
unique organization. CMS has changed the
language used in MOC Element 2A - Bullet 2 to
reflect 'job title' versus 'job description'. We
continue to capture job functions in Element 2A.

Revision

Accept: CMS has deleted MOC Element 3A bullet 3 'provide evidence that appropriate
provider credentialing information in accurately
documented, updated, and maintained'. This will
eliminate redundancy of this MOC requirement.
However, MOC Element 3A - Bullet 2 has been
retained.

Clarification &
Revision

Clarify: CMS expects SNPs to identify the
processes associated with filling critical staff
functions when staff turnover occur; this will
ensure that the SNP has a plan in place to maintain
continuity of care for SNP beneficiaries.
Accept with Modification: CMS has changed
MOC Element 2A to reflect 'Identify the SNP
contingency plan(s) used to ensure ongoing
continuity of "critical" staff functions.

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Appendix 1: N/A
Model of Care

N/A

Care Coordination: Individualized Care
Plan

Some commenters are concerned that CMS’
did not acknowledge and address how
MOCs should approach the development of
an ICP for members that refuse to
participate in the care management process.

Clarification

SNP Alliance & 60-day
America's Health
Insurance Plan

Appendix 1: N/A
Model of Care

N/A

Quality Measurement & Performance
Improvement:

Some commenters requested clarification
on CMS’ expectations that the SNP
requirements will be related to or integrated
with MA contract level quality
improvement program requirements, and
they recommended that CMS revise the
draft to address this issue. Furthermore, the
commenters recommended that this domain
be streamlined.

Revision

Medica Health
Plan

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination

Revision

Medica Health
Plan

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination

Individualized Care Plan: One commenter
stated that CMS assumes all plans share
medical records. Further, for plans without
a common electronic record, access to
documents is not easy. A requirement to
identify the processes that are used to keep
ICT members informed, such as telephonic
outreach or faxed documents, is preferred if
an integrated medical electronic records is
not available. Many
ofTeam:
us are Astill
Interdisciplinary
Care
fewstriving
commenters requested clarificaiton of what
is meant by “continuously evaluate
established processes.” Further, they
requested that the word “continuous”
change to the word "periodic or as needed
for the target population.” If the ICT is
working with an individual, they would
evaluate the plan of care more than the ICT
processes for an individual member. The
health plan should evaluate ICT processes
with input from all the ICT teams.

Medica Health
Plan

60-day

Appendix 1: N/A
Model of Care

N/A

Care Transitions Protocol

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

HealthPartners,
Inc. & SNP
Alliance

60-day

Application Section
(Number/ Header)

One commenter suggested that the Eric
Coleman model works well but not for
cognitively impaired individuals. How does
self-management apply to those with
cognitive and severe mental health issues?

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Clarification/
Revision

Clarify: SNPs have the flexibility and autonomy
to develop an appropriate approach for members
that refuse to participate in their healthcare
processes; this process should be thoroughly and
completely described in the MOC narrative.
Therefore, it is the plan's responsibility to address
Reject: The Quality Performance Improvement
Plan is specific to the MOC. CMS acknowledges
that the quality improvment program requirements
could be streamlined and the revision of the MOC
Element Criteria is the first step in that direction.
We believe we have structured a high-level MOC
Element criteria that provides SNPs with the
flexibility to describe a thorough and
comprehensive MOC designed to meet the
healthcare needs of their unique beneficiaries.
SNPs have the flexibility and authority to describe
how they meet this element requirement based on
the unique and relevant structure of their
organization; this includes those areas that address
Reject: CMS understands the constraints
associated with obtaining beneficiaries' medical
records. Some unique situations need to be
thoroughly and clearly addressed in the MOC and
the SNP has the flexibility to identify what their
specific processes are for meeting this ICT
element. The example provided (telephonic
outreach and/or faxed documents) should be
addressed in the MOC (if this is appliable).
Clarify: CMS expects SNPs to evaluate if the
structure/processes developed by the ICT are
working and effective for the beneficiary. It is up
to the SNP to determine how often an evaluation
is needed, which CMS assumes would be
dependent on the structure of the ICT, beneficiary
need/s and other applicable care coordination
structures of the SNP. The example/s provided
speaks to the level of uniqueness and complexity
associated with SNP beneficiaries' healthcare
needs and should be thoroughly described as such
in the MOC, and not simply on an "as-needed"
basis."
Clarify: CMS' relies on the SNP to address this in
their MOC narrative (if applicable). We recognize
that Self-Management Support would not be
feasible for certain beneficiaries. The SNP would
be expected to discuss its Self-Mangement
Support activities that are taking place for those
SNP beneficiaries where it is feasible and any
modified approaches, as applicable, specific to

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Appendix 1: N/A
Model of Care

N/A

SNP Provider Network

Appendix 1: N/A
Model of Care

N/A

ICT Expectations

Clinical Practice Guidelines: A few
commenters stated that most guidelines do
not address those over 70 nor do they
address how to adapt when multiple chronic
conditions are present. Clinicians do not
document why they adapt a guideline, they
simply document their orders and their plan
of care. The ICP should identify problems,
goals, and interventions not rationales for
the interventions. Discussions among the
ICT often clarify the rationale, but
documentation is rarely available. The
A few commenters stated that the
expectation that there are regular, face-toface interactions with the ICT is neither
realistic nor appropriate for an entire
population of SNP members. A virtual
model through telephonic and/or electronic
means is appropriate as this model provides
very effective team-based care. They
encouraged CMS to allow plans to develop
innovative and flexible methods in which to
communicate within the ICT. In an
environment where electronic health
records are used as a means for
communicating patient updates to multiple
provider types, we encourage CMS to
support MCOs in the development of ICT
meetings in a “virtual” world. Althoug they
do support face-to-face team-based care
when appropriate but we request the ability

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

Medica Health
Plan

60-day

HealthPartners,
Inc.

60-day

Application Section
(Number/ Header)

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Clarification

Clarify: The focus on clinical practice guidelines
has not changed as part of the proposed elements;
the previous structure also promoted the use of
accepted clinical practice guidelines. If the SNP
uses a modified approach for meeting this element
(Use of Clinical Practice Guidelines) then this
should be thoroughly described in its MOC, with
the applicable justifications for making the
modificaitons and beneficiaries for whom the
modified approach applies. CMS has provided
high-level and non-prescriptive MOC Element
criteria, thereby providing SNPs with the
Clarify: CMS does allow and encourages SNPs to
develop innovative and flexible methods to
communicate with the ICT; it is the SNP's
responsibility to thoroughly and completely
describe these processess in the MOC.

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Appendix 1: N/A
Model of Care

N/A

Care Coordination

Health Risk Assessment: A few
commenters recommended that CMS
change the verbiage as follows: Description
of how the HRAT is used to develop and
update, in a timely manner, the
Individualized Care Plan (MOC Element
2C) for each beneficiary and how the
HRAT information is disseminated to the
Interdisciplinary Care Team (MOC Element
2D).

Revision

Reject: CMS expects to know how the ICT uses
the HRAT to meet SNP beneficiaries' healthcare
needs. SNPs have the flexibility to determine
when a beneficiary's ICP needs to be updated;
however, CMS expects this update process to be
'timely'. Since the HRAT is completed on an
annual basis, it would be expected that SNPs
update their beneficiaries' ICP on an annual basis
at the very minimum.

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination

Interdisciplinary Care Team: A few
commenters stated that the requirement to
explain the role of personnel responsible for
developing the ICP seems duplicative of the
requirements under staff structure which
requires plans to “fully define SNP staff
roles across all health plan functions, . . .”

Clarification

HealthPartners,
Inc.

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination

Individualized Care Plan: One commenter
stated - MCOs should be able to develop an
ICP that is individualized and centric to the
member.

Clarification

Clarify: If the staff structure descriptions in the
MOC include those staff that oversee the ICP;
then, this must be comprehensively addressed in
the MOC. CMS believes the individuals
responsible for developing the ICP play a critical
role and this needs to be described thoroughly and
completely in the MOC. Moreover, the MOC
Staff Structure likely includes staff that are not
Clarify: CMS agrees with this statement and
encourages SNPs to develop an ICT that meets the
member's specific health care needs.

HealthPartners,
Inc.

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination

Clarification

Clarify: SNPs have the flexibility to succinctly
and comprehensively describe how they meet this
element requirement based on the unique and
relevant structure of their organization.

HealthPartners,
Inc.

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination

Interdisciplinary Care Team: Some
commenters stated that the description of
the roles and responsibilities of each ICT
member is excessive & exhaustive as it
applies to specifying how their expertise
aligns with the clinical and social needs
listed on the care plan and how these
Interdiciplinary Care Team: One
commenter stated that the ICT composition
should be determined primarily at the plan
level based on the Medicare subset the SNP
was approved to serve.

Clarification

Clarify: CMS agrees with this statement and
believes SNPs have the necessary flexibility and
autonomy to make these determinations.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

HealthPartners,
Inc.

60-day

HealthPartners,
Inc.

Application Section
(Number/ Header)

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Appendix 1: N/A
Model of Care

N/A

Care Coordination

Interdisciplinary Care Team: One
commenter requested clarification about the
requirement to have “regular” exchange of
information within the ICT. Communication
with the ICT may vary widely from SNP to
SNP type and depending on the level of
care requirements of the member.

Clarification

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination

Revision

60-day

Appendix 1: N/A
Model of Care

N/A

SNP Provider Network

America's Health 60-day
Insurance Plan

Appendix 1: N/A
Model of Care

N/A

Individualized Care Plan

Ucare & SNP
Alliance

60-day

Appendix 1: N/A
Model of Care

N/A

Interdisciplinary Care Team: Composition

Interdisciplinary Care Team: One
commenter recommended that the ICT
should be composed of care team members
that directly have a major role with the
members’ care and not all care givers need
to be included. They also recommended that
the following language changes: “Explain
how the beneficiary’s HRAT and ICP are
used to identify ICT composition in cases
where additional team members are needed
to meet the unique needs of an individual
Use of Clinical Practice Guidelines & Care
Transition Protocols: One commenter stated
that the need to modify CPGs or protocols
should not be limited to vulnerable subset.
It is relevant to all SNP enrollees with
One commenter suggested that the first
bullet and first sub-bullet in the description
of the elements of the Individualized Care
Plan (ICP) require that ICP components
must include beneficiary self-management
goals and objectives and if the beneficiary’s
goals are not met, a description of the
process employed to reassess the ICP. This
commenter recommended that the language
in the first sub-bullet of the MOC Element
for the ICP be revised to also refer to the
role of the caregiver(s).
Some commenters felt that they should be
able to determine the composition of the
ICT, and to determine the frequency with
which the ICT meets. The composition
should be tailored to the individual needs of
each member, and should be acceptable that
the ICT consist of, at minimum, CC,
member, and PCC, with other providers
added on a short term basis as the CC
deems appropriate. The CC should be able
to determine the frequency of ICT
communication, and plans should not be
required to guarantee regular and ongoing

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

HealthPartners,
Inc.

60-day

HealthPartners,
Inc.

Application Section
(Number/ Header)

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Clarification

Revision

Clarification

Clarify: CMS believes exchanges in
communication among the ICT members is a
critical function in order for the ICT to meet the
healthcare needs of the beneficiary. CMS
understands that ICT communication will differ
in the types and levels of communication that
takes place and will be dependent on the needs of
the individual beneficiary. SNPs have the
flexiblity and autonomy to decide how this
Accept with modification: CMS has changed the
language in MOC Element 2D - Bullet 1; subbullet 2 which now reads ' Describe how the
beneficiary's HRAT (MOC Element 2B) and ICP
(MOC Element 2C) are used to determine the
composition of the ICT, including those cases
where additional team members are needed to
meet the unique needs of the individual
beneficiary'.
Clarify: CMS agrees with this statement. SNPs
have the flexibility to describe how they meet this
element requirement based on the unique and
relevant structure of their organization.
Accept: CMS has added the 'role of the
caregiver(s) to Element 2C - Bullet 1.

Clarify: CMS supports this comment and the
examples provided by the commenters speaks to
the level of uniqueness and complexity associated
with the composition of the ICT. SNPs have the
flexibility and authority to describe how they meet
this element requirement based on the unique and
relevant structure of their organization. CMS
recognizes the innovative strategies provided in
your comment also identifies the justification and
rationale of adhering to the MOC ICT element that
is unique to your organization; we cannot
emphasize enough the importance of providing
this level of detail in the MOC narrative.

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Appendix 1: N/A
Model of Care

N/A

Description of the SNP Population

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination

SNP Alliance

60-day

Appendix 1: N/A
Model of Care

N/A

Staff Structure

SNP Alliance

60-day

Appendix 1: N/A
Model of Care

N/A

Staff Structure

One commenter stated that the detailed
profile of the medical, social, cognitive, and
other health factors should be described at
the product level. Even environmental
factors, such as for duals, may not differ
substantially across many service areas. We
recommend modifying this requirement
such that plans describe the characteristics
of the population served at the product level
– dual, institutional, C-SNPs, based on
national and plan specific data related to the
target population, and that the service area
requirement be limited to situations where
there is a notable difference from the usual
One commenter stated they serve a wide
range of Medicare beneficiaries, all with
special needs, but with a diverse set of
needs. If SNPs are required to offer an
intensive level of care management for
every beneficiary enrolled, we are
concerned that more resources than
necessary will be expended on some
beneficiaries, resulting in resource shortages
for the ones who need the most intensive
One commenter requested a revision for the
MOC training requirements for staff;
specifically the staff training methods for
employed and contracted staff “may”
include, but not be limited to, printed
instructional
materials,
etc.an explanation
One commenter
requested
for the need to maintain MOC training
records; specifically, how long is a plan
required to maintain such records and for
what purpose?

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

SNP Alliance

60-day

SNP Alliance

Application Section
(Number/ Header)

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Revision

Reject: The example provided speaks to the
uniqueness and complexity associated with the
SNP Population. CMS believes SNPs have the
flexibility and autonomy to describe how they
meet this requirement based on the structure of
their organization. SNPs should determine how
they identify and describe their SNP population.

Clarification

Clarify: CMS understands there are a wide variety
of differences associated with the healthcare needs
of SNP beneficiaries. SNPs have the flexiblity and
autonomy to determine how they manage their
beneficiaries using the appropriate care
management procedures; differences in care
management approaches should be thoroughly and
completely described in the SNP MOC narrative.

Revision

Accept: CMS will change Element 2A to indicate
that staff training methods for employed and
contracted staff 'may' include, but not be limited
to, printed materials, etc.

Clarification

Clarify: SNPs should be able to provide evidence
to meet CMS expectation that the MOC training
requirement has been accomplished; this becomes
especially important during a CMS audit. Each
SNP has the flexibility and autonomy to make the
determination of how they maintain and record
such information based on the structure of their
organization. This process needs to be thoroughly

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Appendix 1: N/A
Model of Care

N/A

Staff Structure

Appendix 1: N/A
Model of Care

N/A

Individualized Care Plan

One commenter requested clarification
about CMS’ expectations regarding MOC
training for employed or contracted staff.
They believe that staff involved in the
implementation of the model of care should
be required to participate in the MOC
training, but that staff who are not involved
in the MOC implementation, such as mail
room clerks or certain administrative staff
should be exempted from the training.
Further, they stated that it would be helpful
for CMS to identify the type of staff that
would not be expected to participate in
MOC training, but SNPs also should be able
to exempt staff for which the training would
not be relevant. The resources for training
and record-keeping are significant for large
and should only be expended if it makes a
difference for beneficiary care and
outcomes. This commenter also urged
CMS not to adopt a one-size-fits-all
approach to the ICP and to give plans the
One commenter requested clarification
about the requirement to identify which
goals have been met and not met. How does
CMS anticipate plans will meet this goal?
This requirement seems more appropriate
for a PACE model where the ICT meets
routinely to discuss the various care plans
and treatment goals of PACE center
beneficiaries. We believe this requirement
would be more appropriate in Domain 4B
under Measureable Goals and Health
Outcomes

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

SNP Alliance

60-day

SNP Alliance

60-day

Application Section
(Number/ Header)

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Clarification

Clarify: SNPs have the flexiblity and autonomy to
determine which providers and staff need to be
informed and trained on the contents of the MOC.

Clarification

Clarify: The issue raised by the commenter is not
related to the SNP's overall goals and health
outcomes, which is what is addressed in Element
4B. The comment relates specifically to
beneficiary-level goals based on the beneficiary's
unique ICP. If a SNP beneficiary has current and
active risk factors with identified goals to maintain
his/her health status, progress should be noted in
the beneficiary's ICP. Re-assessment of a
beneficiary's health goals should be routinely
assessed and documented in the ICP as necessary.

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Appendix 1: N/A
Model of Care

N/A

Interdisciplinary Care Team

60-day

Appendix 1: N/A
Model of Care

N/A

Interdisciplinary Care Team

60-day

Appendix 1: N/A
Model of Care

N/A

Care Transitions Protocols

Some commenters requested clarification of
the requirement that the exchange of
beneficiary information occurs “regularly”
within the ICT. The commenters have
similar concers about the requirement for
“continuous” evaluation of changes in
health care needs. In some cases, the
exchange of information about beneficiaries
may occur weekly while in other cases it
may occur only quarterly or less often if the
beneficiaries’ health condition is stable and
they do not have an encounter with the
health care system. Further, in some cases,
the exchange of information may occur
between selected members of the ICT and
the provider network, not only within the
ICT. They requested that this requirement
be focused on the concept of “timeliness”
which will vary in relation to the needs of
One commenter requested clarification on
what is meant by the requirement that
communications are overseen by personnel
who are “knowledgeable and connected to
multiple facts of MOC.” Does this mean the
medical director, the primary care manager,
etc.?
One commenter supported the requirement

Appendix 1: N/A
Model of Care

N/A

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

SNP Alliance

60-day

SNP Alliance

60-day

Application Section
(Number/ Header)

SNP Provider Network

that beneficiaries and their family
caregivers be provided information on selfmanagement and indicators of whether the
patient’s condition has improved or
worsened. However, plans should not be
held accountable for ensuring that the
patients and/or caregivers understand the
information provided. Despite plans’ best
efforts, an older person and/or their older
spouse or someone with cognitive
limitations may have a limited or no ability
to manage their own care. In fact, SNP
plans serving persons with behavioral
health, mental health and cognitive
Use of Clinical Practice Guidelines & Care
Transition Protocols: One commenter stated
that the need to modify CPGs or protocols
should not be limited to vulnerable subsets.
It is relevant to all SNP enrollees with
comorbidities.

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Clarification

Clarify: The example provided speaks to the
uniqueness and complexity associated with SNP
beneficiaries' healthcare needs and should be
thoroughly described in the MOC. The SNP
should determine how often the ICT
communicates with the beneficiary; CMS
understands that communication will vary from
beneficiary to beneficairy and is dependent of
other factors. SNPs have the flexibility and
autonomy to describe how they meet this element
requirement based on the structure of their
organization as well as the beneficiaries'
healthcare needs.

Clarification

Clarify: SNPs are responsible for ensuring the
staff involved with beneficiaries' healthcare needs
are fully capable of interpreting such needs. Each
SNP has the flexiblity and autonomy to determine
which staff meet this criteria and provide a
thorough description of this in its MOC narrative.

Clarification

Clarify: CMS relies on the SNP to address this in
their MOC narrative (if applicable). If there are
instances where 'ensuring beneficiaries and/or
caregivers understand the contents of their ICP'
are not feasible, the SNP should describe these in
its MOC. Moreover, the SNP should discuss their
Self-Mangement Support activities for those
beneficiaries where it is feasible and
identify/discuss any modified approaches, as
applicable, for cognitively-impaired individuals.

Clarification

Clarify: CMS agrees with this statement; the use
of Clinical Practice Guidelines and Care
Transition Protocols is not limited to vulnerable
subsets in the SNP population; Clinical Practice
Guidelines and Care Transition Protocols apply to
ALL SNP enrollees.

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Appendix 1: N/A
Model of Care

N/A

Quality Measurement & Performance
Improvement:

One commenter indicated they believe that
“less can be more,” that the ongoing
expectation for SNPs to provide excessive
documentation of every aspect of their
model of care diminishes SNPs’ and CMS’
ability to focus on the elements and issues
that are most important.

Clarification

Clarify: CMS expects SNPs to provide a thorough
and complete MOC narrative based on the
specified criteria. CMS does not require
additional supporting documents to be included
with the MOC Narratives. All elements should be
addressed comprehensively in a single document.

60-day

Appendix 1: N/A
Model of Care

N/A

Description of the SNP Target Population

One commenter was concerned that the
requirement regarding community-based
services seems a little excessive since it is
not a Medicare service and we are not paid
for this function. They suggested limiting it
to fully integrated DSNPs and IE-SNPs.
They supported expanded flexibility on
supplemental benefits that would make this
question more relevant to non-FIDE SNPs.

Clarification

Clarify: CMS does not believe this is excessive
and expects SNPs to identify and thoroughly
describe what is applicable to their specific SNPtype in their MOC. SNPs have the flexibility to
describe how they meet this element requirement
based on the structure of their organization as well
as the beneficiaries' healthcare needs.

CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination: SNP Staff Structure

Revision

Clarify: CMS has changed the language used in
MOC Element 2A - Bullet 4 to reflect 'may' versus
'must'.

CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

Clarification

Clarify: CMS believes that pertinent information
discovered on a beneficiary's HRA needs to be
identified in the ICP even though it may not be an
active problem it could be an associated risk
factor(s) for future reference. SNPs may determine
how they meet this requirement based on the
healtcare needs of their beneficaires and should
describe this in the MOC.

CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination: Individualized Care
Plan

One commenter requetsed clarification on
how they should address the comprehensive
ICP requirements (e.g. self-management
goals and objectives and goal progress
tracking) for members whom they are
unable to reach (did not provide current
address, will not answer phone calls or
letters, etc.).

Clarification

Clarify: CMS does not expect that a large
proportion of the SNP's population will be
unreachable and/or unwilling to participate in
health care management processes. We expect the
SNP to thoroughly account for such situations in
its MOC.

CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination : Individualized Care
Plan

One commenter was concerned that the
hard copies of ICPs need to be provided to
all members? Are web-based or telephonic
communications of ICPs acceptable?

Clarification

Clarify: CMS does not expect each beneficiary be
handed a 'hard copy' of their ICP. CMS does
allow web-based and telephonic communications
between ICP members; however, evidence to
support these types of communication exchanges
needs to be available should the SNP be audited.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

SNP Alliance

60-day

CignaHealthSpring

Application Section
(Number/ Header)

One commenter requested revising the staff
MOC training element, specifically,
whether the training documentation MAY
include or MUST include all of the formats
listed: printed instructional materials, faceto-face training, web-based instruction, etc.
Care Coordination:Health Risk Assessment One commenter requested clarification of
Tool
the requirements regarding HRA and ICP
linkage. Is the expectation that every issue
(clinical or functional) identified on the
HRA be included in the ICP?

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Appendix 1: N/A
Model of Care

N/A

Care Coordination: Interdisciplinary Care
Team

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination: Interdisciplinary Care
Team

CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination: Interdisciplinary Care
Team

CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination: Care Transition
Protocols

CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

Care Coordination: Care Transition
Protocols

CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

Quality Measurement & Performance
Improvement: MOC Quality Performance
Improvement Plan

100

CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

Quality Measurement & Performance
Improvement: Measuring Patient
Experience of Care

101

CignaHealthSpring

60-day

Appendix 1: N/A
Model of Care

N/A

Quality Measurement & Performance
Improvement: Ongoing Performance
Improvement Evaluation

One commenter is concerned that the
requirement to explain the roles and
responsibilities of each ICT member and the
requirement to explain the use of case
managers in the ICT process are redundant.
They recommended only including one of
One commenter had concerns about MOC
Element 2D - Bullet 3: Regarding the
communication plan, could you please
clarify the use of the term “regularly”
regarding the exchange of information, as
the frequency can and should vary widely
One commenter requested clarification
regarding proposed MOC Element 2D Bullet 3, Sub-bullet 1. Specifically, the
commenter asked CMS to clarify what is
meant by “knowledgeable and connected to
multiple facets of the MOC?” Is it
acceptable for those with oversight
responsibilities to be knowledgeable (but
not always directly involved) in multiple
One commenter requested that 3B - Bullet 2
be deleted to avoid redundancy; the
commenter suggested moving the reference
to element 2A.
One commenter requested that MOC
Element 3B - Bullet 5 be modified because
some members will not be able to selfmanage their condition; therefore, this
requirement would be most relevant to low
and medium risk members.
One commenter requested clarification of
MOC Element 4A-Bullet 1: Are plans
required to detail the specific data and
performance measures if they are described
in 4B?
One commenter requested CMS to define
what is meant by a “Patient Experience of
Care” survey. Does the survey need to be
SNP-member specific or are we able to use
the same survey for our regular MA
One commenter suggested that MOC
Element 4B could be consolidated into
element 4.A and 4.E since the content is
very similar.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

CignaHealthSpring

60-day

CignaHealthSpring

Application Section
(Number/ Header)

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Clarification

Clarify: It is the SNPs responsibility to determine
the composition of the ICT; if case managers are
utilized by the SNP and are members of the ICT;
this can be documented succinctly in the MOC.

Clarification

Clarify: CMS believes communication should be
conducted on a 'regular' basis between the ICT
members depending on the SNP beneficiary's
healthcare needs. SNPs should determine the
appropriate intervals and describe this in their
MOC.
Clarify: SNPs are responsible for ensuring that the
appropriate staff involved with beneficiaries'
healthcare needs are fully capable of interpreting
such needs. The SNP should describe how this is
determined in their MOC.

Clarification

Revision

Clarification

Reject: The language in MOC Element 2A is
directly linked to MOC Element 2E. Therefore,
the MOC narrative addresses both components
comprehensively, and without redundancy.
Clarify: CMS' relies on the SNP to address this is
in the MOC narrative (if applicable). SelfManagement Support would not be feasible for
certain beneficiaries. The SNP would want to
discuss its Self-Mangement Support activities that
are taking place for those SNP beneficiaries where
Clarify: SNP should only describe their specific
data and performance measures in MOC Element
4B.

Clarification

Clarify: Patient Experience of Care is another term
used to address patient satisfaction. SNPs have the
flexibility to design this survey in the manner they
choose.

Revision

Reject: These particular elements are separate and
distinct. MOC Element 4B relates specifically to
the identified measurable goals and health
outcomes; MOC Element 4A speaks to what the
MOC performance plan entails; and, MOC
Element 4E speaks to how the outcomes of the
MOC performance measures are communicated

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

102

60-day

103

CignaHealthSpring

Application Section
(Number/ Header)

Appendix 1: N/A
Model of Care

GENERAL COMMENTS
60-day
America's
Model of Care N/A
Health Insurance
Attestations
Plans

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

N/A

One commenter requested CMS to define
'routine' in MOC Element 4E They also
suggested changing the wording of this
bullet to indicate that the list of stakeholders
MAY include SNP leadership, boards of
directors, etc. since the groups listed are
communicated with under specific
circumstances and some only on an “asneeded” basis.

Quality Measurement & Performance
Improvement: Dissemination of SNP
Quality Performance

108

Removal of Attestations

104

Association for
Community
Affiliated Plans

60-day

Model of Care N/A
Attestations

108

Removal of Attestations

105

SNP Alliance

60-day

Model of Care N/A
Criteria
Modifications

N/A

Description of the SNP Population

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

Clarification &
Revision

Clarify: CMS expects SNPs to inform plan
management/leadership and other stakeholders of
the MOC performance based on the MOC specific
outcomes/goals identified for their MOC. It is up
to the SNP to determine how often this level of
reporting is needed and to whom it needs to be
communicated based on the organizational
structure of the SNP. This type/level of
communication should be occurring on a routine
and/or regular basis.

One commenter stated: the “CMS Summary
of Substantive and Technical Changes...”
for the draft Medicare Advantage Part C
Application indicates on page 6 that CMS
has removed 240 Model of Care attestation
questions from the application and retained
2 uploads. They appreciate CMS’ effort to
streamline the application process and
support the reduction in the number of
attestations.
One commenter supports the agency
proposals which eliminate numerous
duplicative attestations regarding the MOC.

N/A

Accept: CMS has changed the language of MOC
Element 4E - Bullet 1 to reflect 'communication of
its quality improvement performance results and
other pertinent information to its multiple
N/A - supportive of CMS approach.

N/A

N/A - supportive of CMS approach.

One commenter supports the requirement to
identify limitations and barriers that pose
potential challenges for beneficiaries. This
information will allow SNPs to further
document the challenges plans face in
meeting the needs of high-risk/high-need
populations, including barriers or challenges
originating in statute or standard MA
regulations that are inconsistent with the
needs of the population. For example, while
IE- beneficiaries require a range of home
and community-based services to avoid
nursing home care, these benefits are not
covered by Medicaid and supplemental
benefit requirements only allow FIDESNPs
meeting certain criteria to offer such
benefits.

N/A

N/A - supportive of CMS approach.

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

106

SNP Alliance

60-day

Model of Care N/A
Criteria
Modifications

N/A

107

SNP Alliance

60-day

Model of Care N/A
Criteria
Modifications

N/A

108

SNP Alliance

60-day

Model of Care N/A
Criteria
Modifications

N/A

109

SNP Alliance

60-day

Model of Care N/A
Criteria
Modifications

N/A

Streamlined MOC Elements

Comments & Recommendation(s) from
Source

One commenter supports the reorganization
of the MOC domains and elements. They
support the logic of having all of the care
management related functions under a
single domain, addressing the
communications issues within the domain
or element, instead of having a separate
communications domain, moving the
provider training requirements into the staff
structure and SNP provider network
requirements and moving care of the most
vulnerable into the description of the target
population. They believe that these types of
One commenter supports and appreciates
Purpose Elements
the purpose statements included at the
beginning of the domains and a number of
the elements. It helps provide direction and
a sense of CMS’ expectations for the
domains and elements.
New Care Transition & Member Experience One commenter supports the concept of
of Care Elements
including care transition and patient
experience of care elements as they are
appropriate to the MOC and it is well
known that “breakdowns” in care most
often occur during transitions. Inclusion of
these elements also is consistent with other
SNP stakeholder recommendations to better
Social Determinants of Health
One commenter supports the focus on
health disparities and social determinants of
health and believe this focus will help
clarify and document the how social
determinants affect beneficiares’ health and
how plans need to respond to effectively
meet their health care needs. Social
determinants have significant implications
for cost and quality that need to be

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

N/A

N/A - supportive of CMS approach.

N/A

N/A - supportive of CMS approach.

N/A

N/A - supportive of CMS approach.

N/A

N/A - supportive of CMS approach.

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

110

SNP Alliance

60-day

Model of Care N/A
Criteria
Modifications

N/A

111

SNP Alliance

60-day

Model of Care N/A
Criteria
Modifications

N/A

Comments & Recommendation(s) from
Source

Policy of MOC Approval status under New One commenter requested that the new
MOC Requirements
MOC requirements apply to plans moving
forward and that SNPs that have received
NCQA approved for a 2-3 year period not
be required to resubmit models of care until
their approval period has expired; i.e., that
approved MOCs be “grandfathered” for the
current approval period. We also request
that any changes to the MOC be provided to
plans no later than December 1, 2013 and
that NCQA conduct a training on MOC
changes during the first week of December
so that plans understand CMS’ expectations
before they begin developing new MOCs or
making changes to current MOCs for the
February 2014 submission. Many plans
begin working on their MOCs as soon as
they file their NOIAs. Early access to
documentation
MOC changes
will
Description of the SNP Population
One commenterofsupports
the focus
on
health disparities and related
social/economic determinants of health.
This focus is consistent with existing SNP
requirements such as cultural competence,
having translators available, having
marketing materials printed in different
languages, etc. The relationship between
social determinants and health care practice
and outcomes has gained increasing
prominence in the health community over
the past decade. They believe that the
requirements to address social determinants
in SNP models of care will help document
the impact of these determinants on the
health of the population, the type of atypical
interventions plans must employ to address
beneficiary needs and obtain positive
outcomes, the additional costs of effective
care delivery for enrollees affected by social
determinants and the need to adjust
performance measurement in relation to
social determinants. Documentation of
health disparities and the relationship to the
SNP model of care will help illustrate over
time the need for changes to our current
payment and performance evaluation
systems for special needs beneficiaries,
most of whom are dually eligible and at
higher risk of social determinant impacts.

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

N/A

Currently the 3-year approval for the MOC
remains intact. CMS will inform the SNPs of any
changes made to the 3-year approval for the MOC.
SNPs will be required to submit a MOC in its
revised, finalized form, only as required, based on
the MOC's current approval period. Additionally,
CMS will take the proposed training timeline into
consideration; however, other agency constraints
may prevent us from offering MOC training prior
to the end of 2013.

N/A

N/A - supportive of CMS approach.

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Model of Care N/A
Criteria
Modifications

N/A

Staff Structure

60-day

Model of Care N/A
Criteria
Modifications

N/A

Care Coordination

SNP Alliance

60-day

Model of Care N/A
Criteria
Modifications

N/A

SNP Provider Network

SNP Alliance

60-day

Model of Care N/A
Criteria
Modifications

N/A

SNP Provider Network

One commenter supports and appreciates
the opportunity to explain challenges related
to the MOC training requirements as we
believe it can help improve the MOC
training process in the future.
One commenter supports the reorganization
of the Model of Care to include key care
coordination or care management functions
from health risk assessment to care
transitions under the single umbrella
domain of “care coordination.” They
believe it provides an opportunity to
Use of Clinical Practice Guidelines & Care
Transition Protocols: One commenter
supports the requirement to define the
challenges of overseeing patients with
complex healthcare needs where CPGs need
to be modified to fit unique needs of
vulnerable beneficiaries. This will provide
SNPs an opportunity to document longstanding concerns that there are very few
evidence-based protocols for beneficiaries
over 70 years old with special needs and
few if any CPGs that modify individual
disease state protocols to accommodate the
health care needs of individuals with
One commenter supports the requirement to
explain challenges as a way of helping CMS
recognize the standard is unrealistic for
most network model plans.

Comment Source of
Number Comment:
(Company
Name)

2013 MA Application
Applicatio Part
n 60 day or
30 day

112

SNP Alliance

60-day

113

SNP Alliance

114

115

Application Section
(Number/ Header)

Type of Suggestion CMS Decision (Accept, Accept with Modification,
(Insertion Deletion, Reject, Clarify)
or Revision)

N/A

N/A - supportive of CMS approach.

N/A

N/A - supportive of CMS approach.

N/A

N/A - supportive of CMS approach.

N/A

N/A - supportive of CMS approach.