PRA CMS-10565 -MOC Supporting Statement 30 day V2

Supporting Statement – Part A

Initial and Renewal Model of Care Submissions Off-cycle Submission of Model of Care Changes CMS-10565, OMB 0938-1296

Background

The Affordable Care Act (ACA) PL 111-148 Section 3205(e) and Section 1859(f)(7) and (b)(6)(B)(iii) of the Social Security Act requires that all Medicare Advantage (MA) Special Needs Plans (SNPs) be approved by the National Committee for Quality Assurance (NCQA). SNPs are a specific type of Medicare Advantage coordinated care plan that provide targeted care to individuals with unique special needs. Special needs individuals are defined as: 1) institutional beneficiaries (I- SNPs); 2) dual eligible beneficiaries who are eligible for both Medicare and Medicaid (D-SNPs); and 3) beneficiaries who have one or more co-morbid and medically complex chronic conditions that are substantially disabling or life threatening (C- SNPs). SNPs are required to submit Models of Care (MOC) as a component of the Medicare Advantage application process through the Health Plan Management System (HPMS) and subsequently through the MOC renewal process through HPMS. A MOC is a narrative submitted to CMS by the SNP that describes the:

• Basic quality framework the plan will use to meet the individual needs of SNP enrollees; and

• SNP’s infrastructure to promote care management and carecoordination.

SNP MOCs are considered a vital quality improvement tool and integral component for ensuring that the unique needs of each beneficiary enrolled in a SNP are identified and addressed.

MOC approval is based on NCQA’s evaluation using scoring guidelines developed by NCQA and the Centers for Medicare & Medicaid Services (CMS) for the Secretary of the Department of Health and Human Services. The MOC elements cover the following areas: MOC 1- Description of the SNP Population; MOC 2 - Care Coordination; MOC 3 - Provider Network; and MOC 4 - Quality Measurement & Performance Improvement. Based on their SNP type and MOC scores, SNPs receive an approval for a period of 1, 2 or 3 years.

There are two types of MOC collections:

Initial and Renewal Collection

At the time SNP applications are due, a Medicare Advantage organizations (MAO) wishing to offer a new SNP will submit a MOC with their SNP application in the Application module in HPMS for NCQA review and approval. MAOs wishing to renew their current SNP, will submit

a MOC in the Model of Care module in HPMS for NCQA review and approval. Based on their MOC scores, I-SNPs and D-SNPs receive an approval for a period of 1, 2 or 3 years. C-SNPs must renew their MOCs annually per section 1859(b)(6)(B)(iii) of the Act.

Off-cycle Submission

A D-SNP or I-SNP that decides to make substantive revisions to their existing approved MOC will submit a summary of their off-cycle MOC changes, along with the red-lined MOC, in the Model of Care module in HPMS for NCQA/CMS review and approval. MOC changes are at the discretion of SNPs and it is the responsibility of SNPs to notify CMS of significant changes and electronically submit their summary of changes to their MOC in HPMS. Furthermore, SNPs may not implement any changes until NCQA/CMS has approved the changes.

In 2015, CMS created a Model of Care module in HPMS so that renewal MOC narrative submissions and reports are now located in one place and outside of the HPMS Application module. CMS also developed a MOC off-cycle revision process so that SNPs can enter revisions to the MOC in HPMS during their MOC approval periods. The Model of Care module includes the following sections:

• Renewal MOC submission,

• Off-cycle Submission, and

• Reports

Note that this collection has surpassed the expiration data and is now in violation of the Paperwork Reduction Act. Therefore, CMS is requesting reinstatement approval from OMB.

1. Justification

1. Need and Legal Basis

The ACA, Section 3205(e), requires that all SNPs be approved by NCQA. This approval is based on NCQA’s evaluation of SNPs’ MOC narratives using MOC scoring guidelines. The Bipartisan Budget Act (BBA) of 2018, Section 50311, modified the MOC requirements for C- SNPs in section 1859 (b)(6)(B)(iii) of the Act. Specifically, section (B)(iv) requires that beginning in 2020 and subsequent years, C-SNPs will submit MOCs annually for evaluation and approval.

• 42 CFR – 422.4(a)(1)(iv) – Types of MA plans

• 42 CFR – 422.101(f) – Requirements relating to basic benefits

• 42 CFR – 422.152(g) – Quality improvement program

1. Information Users

NCQA and CMS will use information collected in the SNP Application HPMS module to review and approve MOC narratives in order for an MA plan to operate as a new SNP in the upcoming calendar year(s). This information is used by CMS as part of the Medicare Advantage

SNP application process. NCQA and CMS will use information collected in the Renewal Submission section of the HPMS MOC module to review and approve the MOC narrative in order for the SNP to receive a new approval period and operate in the upcoming calendar year(s).

Results of the Initial and Renewal MOC review will be made publically available. NCQA and CMS will use information in the Off-Cycle Submission section of the HPMS

MOC module to review changes SNPs wish to make to an approved MOC during their approval period. It is the responsibility of SNPs to notify CMS of significant changes to their MOC in HPMS. NCQA will conduct a review for CMS to determine if the changes made to a MOC are consistent with the overall approved MOC before SNPs may implement the changes.

3. Use of Information Technology

SNPs will submit initial and renewal MOCs as well as summaries of any substantive off-cycle MOC changes to CMS through HPMS. This is the platform that CMS uses to coordinate communication and the collection of information from MA organizations. All submissions will occur electronically on the CMS web-based HPMS system.

No signatures are required for these submissions.

4. Duplication of Efforts

This information collection does not duplicate any other effort and the information cannot be obtained from any other source.

5. Small Businesses

The collection of information will have a minimal impact on small businesses because applicants must possess an insurance license and be able to accept substantial financial risk. Generally, state statutory licensure requirements effectively preclude small businesses from being licensed to bear risk needed to serve Medicare enrollees.

6. Less Frequent Collection

Initial and Renewal Collections

Given the importance of the activities covered in the MOC at safeguarding and improving the health of vulnerable Medicare beneficiaries enrolled in SNPs, CMS feels it is appropriate that SNPs be required to submit new MOCs at least every three years (and every year for C-SNPs as mandated by the BBA of 2018). Requiring SNPs to provide MOCs less frequently would mean that CMS would not be requiring SNPs to reconsider their care approaches in light of innovations and changes in the delivery of health services.

Off-cycle Submission of Model of Care Changes

The consequences of not collecting this information are: 1) SNPs would not be able to change policies or strategies in their MOCs to take advantage of new technology or insight; or 2) CMS would not be aware and NCQA would not have reviewed MOC changes the SNPs are performing. NCQA and CMS must review substantive MOC changes because the statutory authority requires all SNPs to have a current NCQA approved MOC during plan operation.

7. Special Circumstances

No special circumstances apply to this information collection request.

8. Federal Register/Outside Consultation

The 60-day Federal Register notice published 11/08/2018 (83 FR 55891).

During the comment period, we received several comments from SNPs and industry advocates. CMS’ responses to the comments can be found in Appendix A.

The 30-day Federal Register notice published 03/28/2019 (84 FR 11799)

During the comment period, we once again received several comments from SNPs and industry advocates. CMS’ responses to the comments can be found in Appendix A.

9. Payments/Gifts to Respondents

This data collection will not include respondent incentive payments or gifts. However, note that in order for an MA plan to become a SNP or renew a current SNP, they must develop and submit a MOC that is deemed acceptable by NCQA as described above in the background section.

10. Confidentiality

Consistent with federal government and CMS policies, CMS will protect the confidentiality of the requested proprietary information. Specifically, only information within a submitted MOC summary (or attachments thereto) that constitutes a trade secret, privileged or confidential information, (as such terms are interpreted under the Freedom of Information Act (FOIA) and applicable case law), and is clearly labeled as such by the SNP, and which includes an explanation of how it meets one of the expectations specified n 45 CFR Part 5, will be protected from release by CMS under 5 U.S.C. §552(b)(4). Information not labeled as trade secret, privileged, or confidential or not including an explanation of why it meets one or more of the FOIA exceptions in 45 CFR Part 5 will not be withheld from release under 5 U.S. C. § 552(b)(4).

11. Sensitive Questions

There are no questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.

12. Burden Estimates (Hours & Wages)

Wage Estimates

To derive average costs, we used data from the U.S. Bureau of Labor Statistics’ May 2017 National Occupational Employment and Wage Estimates for all salary estimates (www.bls.gov/oes/current/oes_nat.htm). We selected the position of registered nurse because the SNP nurse usually develops and submits the MOC. CMS typically interacts with the health plan quality registered nurse in matters related to the Model of Care after it is submitted to CMS. In this regard, the following table presents the mean hourly wage, the cost of fringe benefits (calculated at 100 percent of salary), and the adjusted hourly wage.

National Occupational Mean Hourly Wage and Adjusted Hourly Wage

Occupation Title	Occupation Code	Mean Hourly Wage ($/hr.)	Fringe Benefit ($/hr.)	Adjusted Hourly Wage ($/hr.)
Registered nurse	29-1141	35.36	35.36	70.72

*Under the Insurance Carrier industry.

As indicated, we are adjusting our employee hourly wage estimates by a factor of 100 percent. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly from employer to employer, and because methods of estimating these costs vary widely from study to study. Nonetheless, there is no practical alternative, and we believe that doubling the hourly wage to estimate total cost is a reasonably accurate estimation method.

Burden Estimates

Initial and Renewal Collection

The SNP will access HPMS via the internet at https://hpms.cms.gov/ and follow the appropriate instructions in HPMS. The MAO/SNP will click on the Application or MOC module in HPMS and download the SNP MOC Matrix document (see Attachment A, Model of Care Matrix Upload Document for Initial Application and Renewal). The SNP will complete the document, and then upload their MOC matrix document with the MOC narrative. The SNP MOC Matrix upload document outlines the CMS SNP MOC standards and elements that must be addressed in the MOC narrative. The document also serves as a table of contents for the MOC narrative. Training to use the Model of Care module will be minimal, and at no cost to the SNPs.

Using HPMS data, we estimate that approximately 220 SNPs will submit MOCs annually. For each SNP submitting a MOC, we assume 6 hrs of work by SNP personnel at a cost of $424.32 (6 hrs x $70.72/hr). In aggregate we estimate 1320 hrs (220 SNPs x 6 hrs) at a cost of $93,350 (1320 hrs x $70.72/hrs).

Off-cycle Submission of Model of Care Changes

SNPs must submit a summary of their MOC changes in HPMS if they choose to make significant changes to their MOCs during the approval period. This allows SNPs to make off- cycle revisions to their MOCs. It is important to note that off-cycle MOC changes are at the discretion of SNPs. It is the responsibility of SNPs to notify CMS of significant changes to their MOC. NCQA will conduct a review for CMS to determine if the changes made to a MOC are consistent with the overall approved MOC.

The SNP will access HPMS via the internet at https://hpms.cms.gov/ and follow the appropriate instructions in HPMS. The SNP will click on the MOC module in HPMS, download the SNP MOC Off-Cycle Submission Matrix document (see Attachment B, Revised Model of Care Matrix Upload Document) and complete the document. The SNP will then upload their MOC Off-Cycle Submission Matrix document with a summary of changes, and a redlined version of the revised MOC. Training to use the Model of Care Off- Cycle Submission module will be minimal and at no cost to the SNPs.

Using HPMS data, we estimate that approximately 103 SNPs (D-SNPs/I-SNPs) will submit off- cycle MOC changes. For each SNP submitting off-cycle MOC changes, we assume 4 hrs of work by SNP personnel at a cost of $282.88 (4 hrs x $70.72/hr). This translates to 412 hrs for the 103 SNPs that we estimate may submit an off-cycle MOC in a given year. In aggregate we estimate 412 hrs (103 SNPs x 4 hrs) at a cost of $29,137 (412 hrs x $70.72/hr).

Burden Summary

Information Collection	Respondents		Responses (per Respondent)	Total Responses	Burden per Response (hours)	Total Annual Burden (hours)	Labor Cost of Reporting ($/hr)	Total Cost ($)
Annual MOC submissions	220		1	220	6	1320	70.72	93,350
Off-cycle Submission (MOC	103		1	103	4	412	70.72	29,137
Total	323		--	323	--	1,732	--	122,487

13. Capital Cost (Maintenance of Capital Costs)

We do not anticipate additional capital costs. CMS requirements do not require the acquisition of new systems or the development of new technology to complete the application.

System requirements for submitting HPMS applicant information are minimal and should already be met by MA organizations as they already use HPMS. MA organizations will need the following access to HPMS: (1) Internet or Medicare Data Communications Network (MDCN) connectivity,

(2) use of Microsoft Internet Explorer web browser (version 5.1 or higher) with 128-bits encryption and (3) a CMS-issued user ID and password with access rights to HPMS for each user within the MA organization who will require such access. CMS anticipates that all qualified applicants meet

these system requirements and will not incur additional capital costs.

14. Cost to Federal Government

The annualized cost to the Federal government for NCQA to review the MOC summary for initial and renewal submissions is included in a contract with CMS. Further, the annual cost to the Federal government to maintain HPMS is included in a separate contract between Softrams LLC and CMS.

NCQA’s salary information listed below derives from the business proposal under the CMS contract with NCQA to train the SNP staff and review the MOC. Softrams LLC salary information listed below derives from the business proposal under the CMS contract to maintain the MOC module in HPMS.

Initial and Renewal submissions

NCQA, under a contract with CMS, trains the health plan on how to develop the MOC for the information collection using CMS guidelines, complete the CMS MOC matrix upload document, upload the MOC narrative, and submit the documents into HPMS. The collection will be entered into HPMS, an existing agency platform which is developed and maintained by Softrams LLC, under a separate contract with CMS.

Train Health Plans and Review MOC	12 hrs x $187.97/hr* x 220	$496,241
Develop and maintain module	5 hrs x $131.62/hr* x 100	$65,810

*includes fringe, indirect rates

Off-cycle Submissions

The annualized cost to the Federal government for the MOC summary review is included in a contract with CMS and NCQA for the MOC review. The collection will be entered into HPMS, an existing agency platform which is developed and maintained by Softrams LLC, under a separate contract with CMS.

Review MOC Summary	4 hrs x $187.97/hr* x 103	$ 77,444
Develop and maintain module	5 hrs x $131.62 /hr* x 63	$41,460

*includes fringe, indirect rates

Total

The total cost is $ 680,955

15. Changes to Burden

There are no changes in the level of burden for D-SNPs and/or I-SNPs. There is a minimal increase

in burden for C-SNPs because they are now required to submit a MOC annually. For example, in 2018, there were 28 C-SNPs that submitted a MOC. There are currently 84 C-SNPs in operation. With the requirement for C-SNPs to submit a MOC annually in 2020 and subsequent years, there is an increase of 56 expected annual C-SNP MOC submissions for review and approval by NCQA. In addition, there has been a change in the number of respondents for both collection instruments.

More specifically, a decrease in the overall annual MOC submissions and total hourly burden, which is likely the result of high quality MOCs receiving a three year approval period versus a one year approval period, and, an increase in off-cycle submissions due to SNPs making material changes to their MOCs during the approval period.

As a result of the BBA mandate for annual C-SNP MOC submissions and based on comments from SNPs and industry advocates to reduce burden on C-SNPs, CMS is eliminating the off-cycle MOC submission process for C-SNPs. We believe that the annual C-SNP MOC submissions will eliminate the need for C-SNPs to submit off-cycle MOCs.

16. Publication/Tabulation Dates

Results of the Initial and Renewal MOC review will be made publically available on the NCQA website, located at: https://snpmoc.ncqa.org/. Visitors have access to the overall score for each SNP as well as the number of points the SNP scored on each element, and, which requirements were met or not met.

17. Expiration Date

OMB’s assigned expiration date will be displayed within the PRA Disclosure Statement in the Model of Care Matrix Upload Document for Initial Application and Renewal and in the Revised Model of Care Matrix Upload Document.

18. Certification Statement

There are no exceptions to the certification statement identified in item 19 of OMB Form 83-1 associated with this data collection effort.

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