Form CMS-10565 Revised Model of Care Matrix Upload Document

ATTACHMENT B
Model of Care Matrix Document: Off-Cycle Submission
Table 1: Special Needs Plan (SNP) Contract Information
SNP Contract Information
Contract Name (as provided in HPMS)
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 page number and section of the corresponding description in
your Care Management Plan for each Model of Care (MOC) element. Once you have completed
this document, upload it into HPMS along with a summary of changes and a redlined version of
the revised MOC.
1. Description of the 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. The organization must provide an overview that
fully addresses the full continuum of care of current and potential SNP enrollees, including
end-of-life needs and considerations, if relevant to the target population served by the SNP.

Model of Care Elements

Element A: Description of the Overall SNP Population
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 enrollees.
 Detailed profile of the medical, social, cognitive, and environmental
aspects, the living conditions, and the co-morbidities associated with the
SNP population in the plan’s geographic service area.
 Identification and description of the health conditions impacting SNP
enrollees, 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 (e.g., language barriers, deficits in health literacy, poor
socioeconomic status, cultural beliefs/barriers, caregiver considerations,
other).
 Definition of unique characteristics for the SNP population served:
 C-SNP: What are the unique chronic care needs for C-SNP
enrollees? Include limitations and barriers that pose potential

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challenges for these C-SNP enrollees.
D-SNP: What are the unique health needs for D-SNP enrollees?
Include limitations and barriers that pose potential challenges
for these D-SNP enrollees.

I-SNP: What are the unique health needs for I- SNP
enrollees? Include limitations and barriers that pose
potential challenges for these I-SNP enrollees as well
as information about the facilities and/or home and
community-based services settings in which your
enrollees reside.
Element B: Sub-Population: Most Vulnerable Enrollees
As a SNP, you must include a complete description of the specially-tailored
services for enrollees considered especially vulnerable using specific terms and
details (e.g., enrollees 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 enrollees,
as well as detail additional benefits above and beyond those available to general
SNP enrollees. Other information specific to the description of the most
vulnerable enrollees must include, but not be limited to, the following:
 Description of the internal health plan procedures for identifying
the most vulnerable enrollees within the SNP.
 Description of the relationship between the demographic
characteristics of the most vulnerable enrollees and 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 enrollees.
 Identification and description of the established partnerships with
community organizations that assist in identifying resources for the
most vulnerable enrollees, including the process that is used to
support continuity of community partnerships and facilitate access to
community services by the most vulnerable enrollees and/or their
caregiver(s).

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2. Care Coordination
Care coordination helps ensure that SNP enrollees’ 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 enrollees’ 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 SNP’s care
coordination activities.
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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
SNP enrollees. This includes, but is not limited to, identification and
detailed explanation of:
 Employed and/or contracted staff who perform
administrative functions, such as: enrollment and eligibility
verification, claims verification and processing, etc.
 Employed and/or contracted staff who perform clinical
functions, such as: direct enrollee care and education on selfmanagement techniques, care coordination, pharmacy
consultation, behavioral health counseling, etc.
 Employed and/or contracted staff who perform
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.
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 enrollee. The
content of, and methods used to conduct the HRAT have a direct effect on the
development of the Individualized Care Plan (ICP) and ongoing coordination of
Interdisciplinary Care Team (ICT) activities; therefore, it is imperative that the
MOC include the following:

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Model of Care Elements
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 ICP (MOC Element
2D) for each enrollee, and how the HRAT information
is disseminated to and used by the ICT (MOC Element
2E).
 Detailed explanation for how the initial
HRAT and annual reassessment are
conducted for each enrollee.
 Description of how the SNP ensures that the results
from theinitial HRAT and the annual reassessment
HRAT conducted for each individual are addressed in
the ICP.
 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 ICT, provider network, enrollees
and/or their caregiver(s), as well as other SNP
personnel that may be involved with overseeing the
SNP enrollee’s ICP. If stratified results are used, include
a detailed description of how the SNP uses the
stratified results to improve the care coordination
process.
Element C: Face-to-Face Encounter
Regulations at 42 CFR §422.101(f)(1)(iv) require that all SNPs must provide, on at
least an annual basis, beginning within the first 12 months of enrollment, as
feasible and with the individual’s consent, for face-to-face encounters for the
delivery of health care or care management or care coordination services and be
between each enrollee and a member of the enrollee’s ICT or the plan’s case
management and coordination staff, or contracted plan healthcare providers. A
face-to-face encounter must be either in-person or through a visual, real-time,
interactive telehealth encounter. 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.
 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.
 A description of how the SNP will conduct care coordination activities
through appropriate follow-up, referrals, and scheduling as
necessary.
Element D: Individualized Care Plan (ICP)

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Model of Care Elements
 The ICP components must include, but are not limited to: enrollee
self- management goals and objectives; the enrollee’s personal
healthcare preferences; description of services specifically tailored to
the enrollee’s needs; roles of the enrollees’ caregiver(s); and
identification of goals met or not met.
 When the enrollee’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 enrollee and/or his/her caregiver(s)
or representative(s) are involved in its development, and how often
the ICP is reviewed and modified as the enrollee’s healthcare needs
change. If a stratification model is used for determining SNP
enrollees’ healthcare needs, then each SNP must provide a detailed
explanation of how the stratification results are incorporated into
each enrollee’s ICP.
 Describe how the ICP is documented and updated, including updates
based on more recent HRAT information and where the
documentation is maintained to ensure accessibility to the ICT,
provider network, enrollee, and/or caregiver(s).
 Explain how updates and/or modifications to the ICP are
communicated to the enrollee and/or their caregiver(s), the ICT,
applicable network providers, other SNP personnel, and other
stakeholders as necessary.
Element E: Interdisciplinary Care Team (ICT)
 In the management of care, the SNP must use an ICT that includes a
team of providers with demonstrated expertise and training, and, as
applicable, training in a defined role appropriate to their licensure in
treating individuals similar to the targeted population of the SNP.
 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 enrollees, and
how the ICT members contribute to improving the health status of
SNP enrollees. If a stratification model is used for determining SNP
enrollees’ 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 enrollees
and their caregivers as members of the ICT.
 Describe how the enrollee’s HRAT (MOC Element 2B) and
ICP (MOC Element 2D) 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 enrollee.
 Explain how theICT uses healthcare outcomes to evaluate

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established processes to manage changes and/or
adjustments to the enrollee’s healthcare 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 enrollee information is
occurring regularly within the ICT, including but not 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, enrollees, 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 enrollees who have
hearing impairments, language barriers, and/or cognitive
deficiencies.

Element F: Care Transition Protocols
 Explain how care transition protocols are used to maintain continuity of
care for SNP enrollees. Provide details and specify the process and
rationale for connecting the enrollee to the appropriate provider(s).
 Describe which personnel (e.g., case manager) are responsible for
coordinating the care 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 enrollee’s ICP are
transferred between healthcare settings when the enrollee 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 enrollee and/or
caregiver(s) have access to and can adequately utilize the enrollees’
personal health information to facilitate communication between the
SNP enrollee and/or their caregiver(s) with healthcare providers in other
healthcare settings and/or health specialists outside their primary care
network.
 Describe how the enrollee 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 enrollee 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 enrollees. The SNP is responsible for a network description that
must include relevant facilities and practitioners necessary to address the unique or specialized
healthcare needs of the target population as identified in MOC Element 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 sub-elements for its SNP Provider
Network.

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Model of Care Elements
Element A: Specialized Expertise
 Provide a complete and detailed description of the specialized expertise
available to SNP enrollees 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 ICT that includes providers with demonstrated
experience and training in the applicable specialty or area of
expertise, or, as applicable, training in a defined role appropriate to
their licensure 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 enrollees. Specialized expertise may include,
but is not limited to: internal medicine physicians, endocrinologists,
cardiologists, oncologists, mental health specialists, other.
 Describe how providers collaborate with the ICT (MOC Element 2E) and
the enrollee, contribute to the ICP (MOC Element 2D), and ensure the
delivery of necessary specialized services. For example, describe: how
providers communicate SNP enrollees’ care needs to the ICT and other
stakeholders; how specialized services are delivered to the SNP enrollee
in a timely and effective way; how reports regarding services rendered
are shared with the ICT; and how relevant information is incorporated
into the ICP.
Element B: Use of Clinical Practice Guidelines & Care Transition 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 enrollees. Provide details regarding
how these decisions are made, incorporated into the ICP (MOC
Element 2D), communicated with the ICT (MOC Element 2E), and
acted upon.
 Explain how SNP providers ensure care transition protocols are
being used to maintain continuity of care for the SNP enrollee as
outlined in MOC Element 2F.
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 enrollees on a
routine basis. This could include but is not limited to: printed
instructional materials, face-to-face training, web-based instruction,
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Model of Care Elements
the SNP’s 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, web- based 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 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 enrollees 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
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
enrollees. The quality performance improvement plan must be
designed to detect whether the overall MOC structure effectively
accommodates enrollees’ 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 byusing 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).

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Model of Care Elements
Process the SNP uses or intends to use to determine if
goals/outcomes are met. There must be specific
benchmarks and timeframes, and the SNP must specify
the re-measurement plan for goals not achieved.
Element B: Measurable Goals & Health Outcomes for the MOC
 Identify and clearly define the SNP’s measurable goals and health
outcomes; describe how identified measurable goals and health
outcomes are communicated throughout the SNP; and evaluate
whether goals were fulfilled from the previous MOC. 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 enrollees.
 Ensuring appropriate utilization of services for
preventive health and chronic conditions.
 Identify the specific enrollee 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 enrollees’ 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.
 Provide relevant information pertaining to the MOC’s goals as well as
appropriate data pertaining to the fulfillment the previous MOC’s goals.
 For SNPs submitting an initial MOC, provide relevant information
pertaining to the MOC’s goals for review and approval.
 If the MOC did not fulfill the previous MOC’s goals, indicate in the MOC
submission how the SNP will achieve or revise the goals for the next
MOC.
Element C: Measuring Patient Experience of Care (SNP Enrollee Satisfaction)
 Describe the specific SNP survey(s) used and the rationale for selection of
that particular tool(s) to measure SNP enrollee satisfaction.
 Explain how the results of SNP enrollee 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.
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,

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Model of Care Elements
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.
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 on a routine
basis to its multiple stakeholders, which may include but not be
limited to: SNP leadership, SNP management groups, SNP boards of
directors, SNP personnel and staff, SNP provider networks, SNP
enrollees and caregivers, the general public, and regulatory agencies.
 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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