Form CMS-10565 Model of Care Matrix Upload Document for Initial Applica

ATTACHMENT A
Model of Care Matrix Upload Document for Initial Application and Renewal
Please complete and upload this document into HPMS.
Table 1: Contract Information
Contract Information
SNP Contract Name (as provided in HPMS)
SNP CMS Contract Number

Applicant’s Information Field
Enter Contract Name here
Enter Contract Number here (Also list other contracts
where this MOC is applicable)

Care Management Plan Outlining the Model of Care
In the following tables, list the document, page number, and section of the corresponding description in your
care management plan for each model of care element:

1. Description of the SNP Population:
Model of Care Elements
Element A: Description of the Overall SNP Population
The identification and comprehensive description of the SNP-specific population is an
integral component of the MOC because all of the other elements depend on the firm
foundation of a comprehensive population description. The organization must provide
information about its local target population in the service areas covered under the
contract. Information about national population statistics is insufficient. It must provide an
overview that fully addresses the full continuum of care of current and potential SNP
beneficiaries, including end-of-life needs and considerations, if relevant to the target
population served by the SNP. The description of the SNP population must include, but not
be limited to, the following:
 Clear documentation of how the health plan staff determines or will determine,
verify, and track eligibility of SNP beneficiaries.
 A detailed profile of the medical, social, cognitive, environmental, living conditions,
and co-morbidities associated with the SNP population in the plan’s geographic
service area.
 Identification and description of the health conditions impacting SNP beneficiaries,
including specific information about other characteristics that affect health such as,
population demographics (e.g. average age, gender, ethnicity, and potential health
disparities associated with specific groups such as: language barriers, deficits in
health literacy, poor socioeconomic status, cultural beliefs/barriers, caregiver
considerations, other).
 Define unique characteristics for the SNP population served:
 C-SNP: What are the unique chronic care needs for beneficiaries enrolled
in a C-SNP? Include limitations and barriers that pose potential challenges
for these C-SNP beneficiaries.
 D-SNP: What are the unique health needs for beneficiaries enrolled in a
D-SNP? Include limitations and barriers that pose potential challenges for
these D-SNP beneficiaries.
 I-SNP: What are the unique health needs for beneficiaries enrolled in an ISNP? Include limitations and barriers that pose potential challenges for
these I-SNP beneficiaries as well as information about the facilities and/or
home and community-based services in which your beneficiaries reside.
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Model of Care Elements
Element B: Sub-Population: Most Vulnerable Beneficiaries
As a SNP, you must include a complete description of the specially-tailored services for
beneficiaries considered especially vulnerable using specific terms and details (e.g.,
members with multiple hospital admissions within three months, “medication spending
above $4,000”). The description must differentiate between the general SNP population
and that of the most vulnerable members, as well as detail additional benefits above and
beyond those available to general SNP members. Other information specific to the
description of the most vulnerable beneficiaries must include, but not be limited to, the
following:
 A description of the internal health plan procedures for identifying the most
vulnerable beneficiaries within the SNP.
 A description of the relationship between the demographic characteristics of the
most vulnerable beneficiaries with their unique clinical requirements. Explain in
detail how the average age, gender, ethnicity, language barriers, deficits in health
literacy, poor socioeconomic status and other factor(s) affect the health
outcomes of the most vulnerable beneficiaries.
 The identification and description of the established partnerships with
community organizations that assist in identifying resources for the most
vulnerable beneficiaries, including the process that is used to support continuity
of community partnerships and facilitate access to community services by the
most vulnerable beneficiaries and/or their caregiver(s).

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2. Care Coordination:
Care coordination helps ensure that SNP beneficiaries’ healthcare needs, preferences for health services and
information sharing across healthcare staff and facilities are met over time. Care coordination maximizes the use of
effective, efficient, safe, and high-quality patient services that ultimately lead to improved healthcare outcomes,
including services furnished outside the SNP’s provider network as well as the care coordination roles and
responsibilities overseen by the beneficiaries’ caregiver(s). The following MOC sub-elements are essential components
to consider in the development of a comprehensive care coordination program; no sub-element must be interpreted
as being of greater importance than any other. All five sub-elements below, taken together, must comprehensively
address the SNPs’ care coordination activities.
Model of Care Elements
Element A: SNP Staff Structure
Fully define the SNP staff roles and responsibilities across all health plan functions
that directly or indirectly affect the care coordination of beneficiaries enrolled in
the SNP. This includes, but is not limited to, identification and detailed explanation
of:
 Specific employed and/or contracted staff responsible for performing
administrative functions, such as: enrollment and eligibility verification,
claims verification and processing, other.
 Employed and/or contracted staff that perform clinical functions, such as:
direct beneficiary care and education on self-management techniques,
care coordination, pharmacy consultation, behavioral health counseling,
other.
 Employed and/or contracted staff that performs administrative and
clinical oversight functions, such as: license and competency verification,
data analyses to ensure appropriate and timely healthcare services,
utilization review, ensuring that providers use appropriate clinical
practice guidelines and integrate care transitions protocols.
 Provide a copy of the SNP’s organizational chart that shows how staff
responsibilities identified in the MOC are coordinated with job titles. If
applicable, include a description of any instances when a change to staff
title/position or level of accountability was required to accommodate operational
changes in the SNP.
 Identify the SNP contingency plan(s) used to ensure ongoing continuity of critical
staff functions.
 Describe how the SNP conducts initial and annual MOC training for its employed
and contracted staff, which may include, but not be limited to, printed
instructional materials, face-to-face training, web-based instruction, and
audio/video-conferencing.
 Describe how the SNP documents and maintains training records as evidence to
ensure MOC training provided to its employed and contracted staff was
completed. For example, documentation may include, but is not limited to:
copies of dated attendee lists, results of MOC competency testing, web-based
attendance confirmation, and electronic training records.
 Explain any challenges associated with the completion of MOC training for SNP
employed and contracted staff and describe what specific actions the SNP will
take when the required MOC training has not been completed or has been found
to be deficient in some way.

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Model of Care Elements
Element B: Health Risk Assessment Tool (HRAT)
The quality and content of the HRAT should identify the medical, functional, cognitive,
psychosocial and mental health needs of each SNP beneficiary. The content of, and
methods used to conduct the HRAT have a direct effect on the development of the
Individualized Care Plan and ongoing coordination of Interdisciplinary Care Team
activities; therefore, it is imperative that the MOC include the following:
 A clear and detailed description of the policies and procedures for completing
the HRAT including:
 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
and used by the Interdisciplinary Care Team (MOC Element 2D).
 Detailed explanation for how the initial HRAT and annual
reassessment are conducted for each beneficiary.
 A description of how the SNP ensures that the results from the initial
HRAT and the annual reassessment HRAT conducted for each
individual are addressed in the individual’s care plan.
 Detailed plan and rationale for reviewing, analyzing, and stratifying (if
applicable) the results of the HRAT, including the mechanisms to
ensure communication of that information to the Interdisciplinary Care
Team, provider network, beneficiaries and/or their caregiver(s), as well
as other SNP personnel that may be involved with overseeing the SNP
beneficiary’s plan of care. If stratified results are used, include a
detailed description of how the SNP uses the stratified results to
improve the care coordination process.

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Element C: Face-to-Face Encounter
A face-to face encounter must be conducted between the SNP and each consenting enrollee Document Page
no less than on an annual basis. Face-to-face encounters can be conducted in-person or
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through remote technology, such as telehealth, and must occur within the first 12 months of
enrollment. The face-to face encounter is part of the overall care management strategy, and
as a result, the MOC must include the following:
 A clear and detailed description of the policies, procedures, purpose and
intended outcomes of the face-to-face encounter, including:
 A description of who will conduct the face-to-face encounter, employed and/or
contracted staff.
 A description of the types of clinical functions, assessments and/or services that
may be provided during the face-to-face encounter.
 A description of how health concerns and/or active or potential health issues
will be addressed during the face-to-face encounter, and,
 A description of how the SNP will conduct care coordination activities through
appropriate follow-up, referrals and scheduling as necessary.

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Element D: Individualized Care Plan (ICP)
 The ICP components must include, but are not limited to: beneficiary selfmanagement goals and objectives; the beneficiary’s personal healthcare
preferences; description of services specifically tailored to the beneficiary’s needs;
roles of the beneficiaries’ caregiver(s); and identification of goals met or not met.
 When the beneficiary’s goals are not met, provide a detailed description
of the process employed to reassess the current ICP and determine
appropriate alternative actions.
 Explain the process and which SNP personnel are responsible for the development
of the ICP, how the beneficiary and/or his/her caregiver(s) or representative(s) is
involved in its development and how often the ICP is reviewed and modified as the
beneficiary’s healthcare needs change. If a stratification model is used for
determining SNP beneficiaries’ health care needs, then each SNP must provide a
detailed explanation of how the stratification results are incorporated into each
beneficiary’s ICP.
 Describe how the ICP is documented and updated, including updates based on
more recent HRAT information, as well as, where the documentation is
maintained to ensure accessibility to the ICT, provider network, beneficiary and/or
caregiver(s).
 Explain how updates and/or modifications to the ICP are communicated to the
beneficiary and/or their caregiver(s), the ICT, applicable network providers, other
SNP personnel and other stakeholders as necessary.

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Model of Care Elements
Element E: Interdisciplinary Care Team (ICT)
 Provide a detailed and comprehensive description of the composition of the ICT;
include how the SNP determines ICT membership and a description of the roles
and responsibilities of each member. Specify how the expertise, training, and
capabilities of the ICT members align with the identified clinical and social needs
of the SNP beneficiaries, and how the ICT members contribute to improving the
health status of SNP beneficiaries. If a stratification model is used for determining
SNP beneficiaries’ health care needs, then each SNP must provide a detailed
explanation of how the stratification results are used to determine the
composition of the ICT.
 Explain how the SNP facilitates the participation of beneficiaries and their
caregivers as members of the ICT.
 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.
 Explain how the ICT uses healthcare outcomes to evaluate established
processes to manage changes and/or adjustments to the beneficiary’s
health care needs on a continuous basis.
 Identify and explain the use of clinical managers, case managers or others who play
critical roles in ensuring an effective interdisciplinary care process is being
conducted.
 Provide a clear and comprehensive description of the SNP’s communication plan
that ensures exchanges of beneficiary information is occurring regularly within the
ICT, including not be limited to, the following:
 Clear evidence of an established communication plan that is overseen by
SNP personnel who are knowledgeable and connected to multiple facets
of the SNP MOC. Explain how the SNP maintains effective and ongoing
communication between SNP personnel, the ICT, beneficiaries,
caregiver(s), community organizations and other stakeholders.
 The types of evidence used to verify that communications have taken
place, e.g., written ICT meeting minutes, documentation in the ICP, other.
 How communication is conducted with beneficiaries who have hearing
impairments, language barriers and/or cognitive deficiencies.

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Model of Care Elements
Element F: Care Transitions Protocols
 Explain how care transitions protocols are used to maintain continuity of care for
SNP beneficiaries. Provide details and specify the process and rationale for
connecting the beneficiary to the appropriate provider(s).
 Describe which personnel (e.g., case manager) are responsible for coordinating thecare
transition process and ensuring that follow-up services and appointments are
scheduled and performed as defined in MOC Element 2A.
 Explain how the SNP ensures elements of the beneficiary’s ICP are transferred
between healthcare settings when the beneficiary experiences an applicable
transition in care. This must include the steps that need to take place before, during
and after a transition in care has occurred.
 Describe, in detail, the process for ensuring the SNP beneficiary and/or caregiver(s)
have access to and can adequately utilize the beneficiaries’ personal health
information to facilitate communication between the SNP beneficiary and/or their
caregiver(s) with healthcare providers in other healthcare settings and/or health
specialists outside their primary care network.
 Describe how the beneficiary and/or caregiver(s) will be educated about indicators
that his/her condition has improved or worsened and how they will demonstrate
their understanding of those indicators and appropriate self-management
activities.
 Describe how the beneficiary and/or caregiver(s) are informed about who their
point of contact is throughout the transition process.

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3. SNP Provider Network:
The SNP Provider Network is a network of healthcare providers who are contracted to provide health care services to
SNP beneficiaries. The SNP is responsible for a network description that must include relevant facilities and
practitioners necessary to address the unique or specialized health care needs of the target population as identified in
MOC 1, and provide oversight information for all of its network types. Each SNP is responsible for ensuring their MOC
identifies, fully describes, and implements the following for its SNP Provider Network:

Model of Care Elements
Element A: Specialized Expertise
 Provide a complete and detailed description of the specialized expertise available
to SNP beneficiaries in the SNP provider network that corresponds to the SNP
population identified in MOC Element 1.
 The description must include evidence that the SNP provides each enrollee with
an interdisciplinary team that includes providers with demonstrated experience
and training in the applicable specialty, or area of expertise, in treating
individuals that are similar to the target population.
 Explain how the SNP oversees its provider network facilities and ensures its
providers are actively licensed and competent (e.g., confirmation of applicable
board certification) to provide specialized healthcare services to SNP beneficiaries.
Specialized expertise may include, but is not limited to: internal medicine,
endocrinologists, cardiologists, oncologists, mental health specialists, other.
 Describe how providers collaborate with the ICT (MOC Element 2D) and the
beneficiary, contribute to the ICP (MOC Element 2C) and ensure the delivery of
necessary specialized services. For example, describe: how providers communicate
SNP beneficiaries’ care needs to the ICT and other stakeholders; how specialized
services are delivered to the SNP beneficiary in a timely and effective way; and how
reports regarding services rendered are shared with the ICT and how relevant
information is incorporated into the ICP.

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Model of Care Elements
Element B: Use of Clinical Practice Guidelines & Care Transitions Protocols
 Explain the processes for ensuring that network providers utilize appropriate
clinical practice guidelines and nationally-recognized protocols. This may include,
but is not limited to: use of electronic databases, web technology, and manual
medical record review to ensure appropriate documentation.
 Define any challenges encountered with overseeing patients with complex
healthcare needs where clinical practice guidelines and nationally-recognized
protocols may need to be modified to fit the unique needs of vulnerable SNP
beneficiaries. Provide details regarding how these decisions are made,
incorporated into the ICP (MOC Element 2C), communicated with the ICT (MOC
Element 2D) and acted upon.
 Explain how SNP providers ensure care transitions protocols are being used to
maintain continuity of care for the SNP beneficiary as outlined in MOC Element 2E.
Element C: MOC Training for the Provider Network
 Explain, in detail, how the SNP conducts initial and annual MOC training for network
providers and out-of-network providers seen by beneficiaries on a routine basis.
This could include, but not be limited to: printed instructional materials, face- toface training, web-based instruction, audio/video-conferencing, and availability of
instructional materials via the SNP plans’ website.
 Describe how the SNP documents and maintains training records as evidence of
MOC training for their network providers. Documentation may include, but is not
limited to: copies of dated attendee lists, results of MOC competency testing, webbased attendance confirmation, electronic training records, and physician
attestation of MOC training.
 Explain any challenges associated with the completion of MOC training for network
providers and describe what specific actions the SNP Plan will take when the
required MOC training has not been completed or is found to be deficient in some
way.

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4. MOC Quality Measurement & Performance Improvement:
The goals of performance improvement and quality measurement are to improve the SNP’s ability to deliver
healthcare services and benefits to its SNP beneficiaries in a high-quality manner. Achievement of those goals may
result from increased organizational effectiveness and efficiency by incorporating quality measurement and
performance improvement concepts used to drive organizational change. The leadership, managers and governing
body of a SNP organization must have a comprehensive quality improvement program in place to measure its current
level of performance and determine if organizational systems and processes must be modified based on performance
results.

Model of Care Elements
Element A: MOC Quality Performance Improvement Plan
 Explain, in detail, the quality performance improvement plan and how it ensures
that appropriate services are being delivered to SNP beneficiaries. The quality
performance improvement plan must be designed to detect whether the overall
MOC structure effectively accommodates beneficiaries’ unique healthcare needs.
The description must include, but is not limited to, the following:
 The complete process, by which the SNP continuously collects, analyzes,
evaluates and reports on quality performance based on the MOC by using
specified data sources, performance and outcome measures. The MOC
must also describe the frequency of these activities.
 Details regarding how the SNP leadership, management groups and other
SNP personnel and stakeholders are involved with the internal quality
performance process.
 Details regarding how the SNP-specific measurable goals and health
outcomes objectives are integrated in the overall performance
improvement plan (MOC Element 4B).
 Process it uses or intends to use to determine if goals/outcomes are met,
there must be specific benchmarks and timeframes, and must specify the
re-measurement plan for goals not achieved.

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Model of Care Elements
Element B: Measurable Goals & Health Outcomes for the MOC
 Identify and clearly define the SNP’s measurable goals and health outcomes
and describe how identified measurable goals and health outcomes are
communicated throughout the SNP organization. Responses must include but
not be limited to, the following:
 Specific goals for improving access and affordability of the
healthcare needs outlined for the SNP population described in
MOC Element 1.
 Improvements made in coordination of care and appropriate delivery
of services through the direct alignment of the HRAT, ICP, and ICT.
 Enhancing care transitions across all healthcare settings and providers
for SNP beneficiaries.
 Ensuring appropriate utilization of services for preventive health
and chronic conditions.
 Identify the specific beneficiary health outcomes measures that will be used
to measure overall SNP population health outcomes, including the specific
data source(s) that will be used.
 Describe, in detail, how the SNP establishes methods to assess and track
the MOC’s impact on the SNP beneficiaries’ health outcomes.
 Describe, in detail, the processes and procedures the SNP will use to
determine if the health outcomes goals are met or not met.
 For MOC renewals: Include appropriate data pertaining to the fulfillment or
achievement of the previous MOC’s goals.
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If the MOC did not fulfill the previous MOC goals, the plan must describe how it
will achieve or revise the goals for the plan’s next MOC implementation.

Element C: Measuring Patient Experience of Care (SNP Member Satisfaction)
 Describe the specific SNP survey(s) used and the rationale for selection of that
particular tool(s) to measure SNP beneficiary satisfaction.
 Explain how the results of SNP member satisfaction surveys are integrated into
the overall MOC performance improvement plan, including specific steps to be
taken by the SNP to address issues identified in response to survey results.

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Element D: Ongoing Performance Improvement Evaluation of the MOC
 Explain, in detail, how the SNP will use the results of the quality performance
indicators and measures to support ongoing improvement of the MOC, including
how quality will be continuously assessed and evaluated.
 Describe the SNP’s ability to improve, on a timely basis, mechanisms for
interpreting and responding to lessons learned through the MOC performance
evaluation process.
 Describe how the performance improvement evaluation of the MOC will be
documented and shared with key stakeholders.

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Model of Care Elements
Element E: Dissemination of SNP Quality Performance related to the MOC
 Explain, in detail, how the SNP communicates its quality improvement
performance results and other pertinent information to its multiple stakeholders,
which may include, but not be limited to: SNP leadership, SNP management
groups, SNP boards of directors, SNP personnel & staff, SNP provider networks,
SNP beneficiaries and caregivers, the general public, and regulatory agencies on a
routine basis.
 This description must include, but is not limited to, the scheduled frequency of
communications and the methods for ad hoc communication with the various
stakeholders, such as: a webpage for announcements; printed newsletters;
bulletins; and other announcement mechanisms.
 Identify the individual(s) responsible for communicating performance updates in a
timely manner as described in MOC Element 2A.

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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 09381296 (CMS-10565). The current expiration date is June 30, 2022. The time required to complete this information
collection is estimated to average 6 hours per response, including the time to review instructions, search existing data
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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.

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