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U.S. Dept. of Health & Human Services
Model of Care (MOC)
Guidance for Special Needs Plans Model of Care.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: November 15, 2019
As provided under section 1859(f)(7) of the Social Security Act, every SNP must have a Model of Care (MOC) approved by the National Committee for Quality Assurance (NCQA). The MOC provides the basic framework under which the SNP will meet the needs of each of its enrollees. The MOC is a vital quality improvement tool and integral component for ensuring that the unique needs of each enrollee are identified by the SNP and addressed through the plan's care management practices. The MOC provides the foundation for promoting SNP quality, care management, and care coordination processes. Please note that detailed information regarding the SNP MOC elements and scoring criteria are located in chapter 5 of the Medicare Managed Care Manual, which can be found at the link below.
The statute gives the Secretary the authority to establish standards for the MOC approval process. The NCQA MOC approval process scores each of the clinical and non-clinical elements of the MOC. SNPs are approved for one, two, or three year periods.
SNPs that have a failing score (less than 70 percent) for their initial MOC submission will have one cure opportunity to achieve a passing score (greater than 70 percent). Regardless of the score following that cure opportunity (provided the score is at least 70 percent), those SNPs will receive a one-year approval. The table below summarizes the MOC review and cure process.
| Score for Initial MOC Submission (%) | Cure Options | Post 1st Cure | Final Approval Status |
|---|---|---|---|
| 85% to 100% | No cure options | N/A | 3-year approval |
| 75% to 84% | No cure options | N/A | 2-year approval |
| 70% to 74% | No cure options | N/A | 1-year approval |
| 69% or below | One cure option | 70% or higher | 1-year approval |
| 69% or below | One cure option | 69% or below | No approval |
This policy provides added incentive for SNPs to develop and submit comprehensive and carefully considered MOCs for initial NCQA approval and rewards those SNPs that have demonstrated ability to develop quality MOCs.
An MAO must submit a MOC if one of the following scenarios applies:
NOTE: Beginning for CY 2017, MAOs are not required to submit a new MOC when requesting a service area expansion (SAE) for a SNP (see the below link to the January 14, 2016, HPMS memo "Changes to Special Needs Plan and Medicare-Medicaid Plan Model of Care Submissions and Updates in the Health Plan Management System").
SNPs may now submit their MOC matrix upload document and narrative in the new MOC Module in HPMS. MOC matrix upload documents and narratives should not be submitted in the SNP application module as was done in previous years.
Any MAO seeking to offer a new SNP must submit its MOC matrix upload document and narrative in the SNP application module.
MAOs offering SNPs that need to revise their MOC mid-cycle during their MOC approval period may submit the summary of changes to the MOC and the red-lined revised MOC to the new MOC Module in the Off-Cycle Submission of Summaries section.
For more information about these changes, please see the below link to the January 14, 2016, HPMS memo.
Please visit the new NCQA SNP Approval Website. The CY 2016 SNP MOCs are posted for the public on this website. In addition, in order to increase transparency, promote SNP accountability, and provide information on how the SNP MOC narrative met, or failed to meet, the full intent of the MOC element standard, the website includes:
The website also provides general information and resources regarding MOC training and technical assistance. All NCQA training slides are located on this website in the Training Archive.
HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.
Date Published: 12/31/2020
