CMS-10191 SNP-MOC Questionnaire

OMB Control Number 0938-1000 (Expires: TBD)

ATTACHMENT V-A
MEDICARE ADVANTAGE AND PRESCRIPTION DRUG
SPECIAL NEEDS PLANS - MODEL OF CARE (SNP-MOC)
QUESTIONNAIRE (SNP-Q)
Name of Sponsoring Organization:
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Contract Numbers:
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Name and Title of Person Completing Questionnaire:
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Date Completed:
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This questionnaire is designed to assist CMS in understanding the unique qualities of your
organization’s SNP program operations.
Please upload the completed form to HPMS within 5 business days of receiving your audit
engagement letter. Separate questionnaires may be provided for each entity/operating system
showing the CMS contracts that are applicable to each completed questionnaire (if multiple
questionnaires are completed, they must be zipped together and uploaded to HPMS as a single
file).
We recognize that your time is valuable and appreciate your availability to provide responses to
our questions regarding the SNP program operations. The responses to these questions may be
discussed during the SNP audit.
1. Has your organization experienced any seamless enrollments, PBP mergers, acquisitions, or
plan consolidations within the 12 months preceding the date of the engagement letter? If so,
please describe the circumstance.
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2. Confirm your organization’s SNP plan type offerings (C-SNP, D-SNP or I-SNP) at time of
audit engagement letter and provide enrollment statistics for the three largest PBPs of each SNP
type offered as of the date of the audit engagement letter. If only 1 or 2 SNP types offered,
provide enrollment statistics for those SNP types.
Enter your response here
PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-1000 (Expires: TBD). The time required to complete this information collection is estimated to average 701 hours per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection
burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you
have questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE.

ATTACHMENT V-A
MEDICARE ADVANTAGE AND PRESCRIPTION DRUG
SPECIAL NEEDS PLANS - MODEL OF CARE (SNP-MOC)
QUESTIONNAIRE (SNP-Q)

3. Describe your organization’s internal system utilized for tracking HRAs, ICPs, and ICT
decisions and activities.
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4. Does your organization use an acuity scoring system to assess enrollee severity of
illness/intensity of service? If yes, please describe your organization’s enrollee risk stratification
levels and your process for assigning enrollees to a risk stratification level.
Enter your response here
5. Describe the processes when transition of care is documented for a new enrollee or an enrollee
who has experienced hospitalization. How do you define transition of care?
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6. Describe the process for tracking MOC training for ICT-implicated staff and FDRs.
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7. Describe the outreach policy pertaining to HRA administration and ICP development.
Describe the process for enrollees that cannot or do not want to be contacted.
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8. Please identify FDRs that you contract with that conduct SNP related care coordination
activities, such as administering HRAs or outreach.
Enter your response here

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