MOC 1 Scoring Guidelines

MOC 1: Description of SNP Population (General Population)

 

Identification and a comprehensive description of the SNP-specific population are integral components of the model of care (MOC). All elements in this standard depend on a complete population description that addresses the full continuum of care of current and potential SNP beneficiaries, including end-of-life needs and considerations (if relevant).

SNPs must include a complete description of specially tailored services for beneficiaries considered especially vulnerable (refer to Element 1B), using specific terms and details (e.g., members with multiple hospital admissions within three months, “medication spending above $4,000”).

Element A: Description of Overall SNP Population

The organization’s MOC description of its target SNP population must:

  1. Describe how the health plan staff will determine, verify and track eligibility of SNP beneficiaries.
  2. Describe the social, cognitive and environmental factors, living conditions and co-morbidities associated with the SNP population.
  3. Identify and describe the medical and health conditions impacting SNP beneficiaries.
  4. Define the unique characteristics of the SNP population served.

Scoring

100%: The organization meets all 4 factors
80%: The organization meets 3 factors
50%: The organization meets 2 factors
20%: The organization meets 1 factors
0%: The organization meets no factors

Explanation

Element stem: Target population characteristics

The organization’s description of its target population is an integral component of the MOC narrative that provides a fundamental foundation on which the other elements build to develop a comprehensive program that fully addresses the continuum of care for its beneficiaries.

The organization’s MOC must show how it identifies its members and must describe the target population that includes specific information on the characteristics of the population it intends to serve. This information must include specific components that characterize its beneficiaries, such as average age, gender and ethnicity profiles, the incidence and prevalence of major diseases, chronic conditions and other significant barriers faced by the target population.

The organization may use beneficiary information from other product lines (e.g., Medicare Advantage or Medicaid plans) as an example of the intended target population if the plan does not have members, or it must provide details compiled from the intended plan service area.

Factor 1: Determine, verify and track eligibility

The organization must have a process for identifying, verifying and tracking SNP beneficiaries to ensure eligibility for appropriate care coordination services. The MOC description must include information on the relevant resources (systems or data collection methodology) used to perform these tasks.

Factors 2 & 3: Identify health conditions

The MOC description includes specific information on the current health status of its SNP beneficiaries and characteristics that may impact their status. Factor 2 should include descriptions of the demographic, social and environmental factors, and living conditions associated with the SNP population such as average age, gender, ethnicity and potential health disparities associated with certain groups, such as language barriers, deficits in health literacy, poor socioeconomic status, cultural beliefs or barriers that may interfere with conventional provision of health care or services, caregiver considerations or other concerns. Factor 3 should identify and describe the medical and cognitive factors, co-morbidities and other health conditions that affect SNP beneficiaries.

Factor 4: Define unique characteristics of the SNP population (plan type)

Each SNP type (Chronic [C-SNP], Dual-Eligible [D-SNP] or Institutional [I-SNP]) description must include the unique health needs of beneficiaries enrolled in each plan as well as limitations and barriers that may pose challenges affecting their overall health:

  • C-SNPs:
    • Describe chronic conditions, incidence and prevalence as related to the target population covered by this SNP.
      • The description must include information on limitations and barriers that pose potential challenges for beneficiaries (e.g., multiple co-morbidities, lack of care coordination between multiple providers)
  • D-SNPs:
    • Describe dual-eligible members, such as full duals or partial duals.
      • The description must include information on limitations and barriers that pose potential challenges for beneficiaries (e.g., gaps in coordination of benefits between Medicare and Medicaid, poor health literacy).
  • I-SNPs:
    • Specify the facility type and provide information about facilities where SNP beneficiaries reside (e.g., long term care facility, home or community-based services).
    • Include information about the types of services, as well as about the providers of specialized services.
      • The description must include information on limitations and barriers that pose potential challenges for beneficiaries (e.g., dementia, frailty, lack of family/caregiver resources or support).

Element B: Subpopulation—Most Vulnerable Beneficiaries

The organization must have a complete description of the specially tailored services it provides to its most vulnerable members that:

  1. Defines and identifies the most vulnerable beneficiaries within the SNP population and provides a complete description of specially tailored services for such beneficiaries.
  2. Explains how the average age, gender, ethnicity, language barriers, deficits in health literacy, poor socioeconomic status, as well as other factors, affect the health outcomes of the most vulnerable beneficiaries.
  3. Illustrates a correlation between the demographic characteristics of the most vulnerable beneficiaries and their unique clinical requirements.
  4. Identifies and describes established relationships with partners in the community to provide needed resources.

Scoring

100%: The organization meets all 4 factors
80%: The organization meets 3 factors
50%: The organization meets 2 factors
20%: The organization meets 1 factors
0%: The organization meets no factors

Explanation

Factor 1: Define most vulnerable beneficiaries

Although the definition of “SNP beneficiary” typically implies members requiring additional care and services, the description focuses on the sickest or most vulnerable SNP members.

The organization’s MOC must include a robust and comprehensive definition that describes who these members are (i.e., what sets them apart from the overall SNP population), the methodology used to identify them (e.g., data collected on multiple hospital admissions within a specified time frame; high pharmacy utilization; high risk and resultant costs; specific diagnoses and subsequent treatment; medical, psychosocial, cognitive or functional challenges) and specially tailored services for which these beneficiaries are eligible.

The organization may use beneficiary information from other product lines (e.g., Medicare Advantage or Medicaid plans) as an example of the intended target population if the plan does not have members, or it must provide details compiled from the intended plan service area.

Factors 2 & 3: Correlation between demographic characteristics and clinical requirements

The organization’s MOC definition of its most vulnerable beneficiaries must describe the demographic characteristics of this population (i.e., average age, gender, ethnicity, language barriers, deficits in health literacy, poor socioeconomic status and other factors) and specify how these characteristics combine to adversely affect health status and outcomes and affect the need for unique clinical interventions.

The definition must include a description of special services and resources the organization anticipates for provision of care to this vulnerable population.

Factor 4: Establish relationships with community partners

The organization’s MOC must describe its process for partnering with providers within the community to deliver needed services to its most vulnerable members, including the type of specialized resources and services provided and how the organization works with its partners to facilitate member or caregiver access and maintain continuity of services.