SNP & MMP Model of Care Off-cycle Revisions FAQs and Clarifications

1. Background

CMS developed a module where SNPs and MMPs can submit necessary revisions to their most recently approved MOCs. The new module and the process for submitting is outlined in the “Announcement of Calendar Year (CY) 2016 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter.”

SNPs and MMPs must notify CMS of certain changes, and electronically submit a summary of those changes to their MOCs via CMS’ HPMS system in the format described later in this document.

The following content includes clarification about which MOC revisions are to be submitted to CMS using the new module as well as some Q & As which are intended to describe previously identified circumstances that would warrant SNPs or MMPs to make changes to their MOCs and submit to CMS.

2. Submission Requirements

2.1 What Constitutes a Change–Reportable Changes

The following identifies circumstances in which SNPs and MMPs must report changes to their MOC:

Substantial organizational changes:

  • Changes that affect the SNP’s processes that are essential to successfully implementing the approved MOC
  • Changes in legal entity, parent organization, and oversight (novations, mergers, changes to corporate structure);
  • Target population changes;
  • New benefit inclusion or benefit exclusions (especially for a SNP’s most vulnerable members);
  • Changes in level of authority or oversight (medical provider to non-medical provider, clinical vs. non-clinical personnel conducting care coordination activities);
  • Inclusions or deletions or exclusions of services that can considerably impact critical functions necessary to maintain member well-being and related SNP operations;
  • Changes to delegated providers and agreements; and
  • Changes in policies or procedures pertinent to:
      1. The health risk assessment process.
      2. Revising processes to develop and update the individualized care plan.
      3. Risk stratification methodology.
      4. Care Transitions Protocols.
      5. Communication and frequency of meetings with ICT members, beneficiaries, and caregivers

FAQs for 2.1

Q1: Our SNP was recently purchased by another legal entity. For business and marketing purposes, we changed our name. Is this reportable to CMS?

A1: Yes, novation and mergers or changes to corporate structure require changes to the MOC and affect the processes to successfully implement the MOC, such revisions are to be submitted to CMS.

Q2: For our most vulnerable population, members with mental health or substance abuse conditions, we added supplemental services to include: increased the number of days for inpatient stays that are now covered services that were previously limited such as treatments and outpatient visits per coverage period. Does this require a submission for revisions review?

A2: Yes, this falls under benefit inclusions and exclusions (included in above list of fundamental organization changes) and are considered substantive because the changes have a direct effect on maintaining member well-being and subsequent SNP operations.

Q3: After annual review, we made some changes to our delegated provider agreements to specifically delineate notification of certain treatments and services formerly approved by the Medical Director. Should we consider this a substantive change?

A3: Yes, as it is considered a change in level of authority or oversight.

Q4: Upon review of our risk stratification process and identification of challenges and limitations, we are implementing a new methodology for data collection to better select members falling into a new category; will we need to revise our MOC and highlight the changes for any audits?

A4: Yes, this sounds like a change to your risk stratification methodology and is reportable.

Q5: Review of our SNP utilization data indicates that the SNP has a larger diabetic population than anticipated. Can our SNP revise the MOC to address the specific needs of this population?

A5: Yes, the SNP can revise the MOC to address the specific needs of these enrollees.

2.2 Non-Reportable Changes–What Not to Report

The bullets below identify changes that do not require CMS notification:

  • Changes in administrative staff, types/level of staff (adding steps or levels to administrative staff positions);
  • Updates to demographic data about the target population (e.g., revising to address increases or decreases in target population data);
  • Updates to quality improvement metric results (e.g., revising HEDIS or other outcome goals as a result of meeting/not meeting benchmarks);
  • Additions/deletions of specifically named providers (e.g., Dr. Smith is replacing Dr. Jones as a Neurology provider); and
  • Grammatical and/or non-substantive language changes (e.g., correcting misspelled words or sentence structure).

FAQs for 2.2

Q1: Our SNP noticed several language errors and misspellings in our MOC as submitted by a former staff member. Can we submit a revised MOC?

A1: No, grammatical and language changes do not impact operational processes and therefore are not reportable for submission as a revision.

Q2: We experienced a change in our QI Director and added an Assistant Director to the team, do we have to report these changes to CMS?

A2: No, changes in administrative staff, types or levels are not a reportable change.

Q3: We revised our health risk assessment (HRA) tool recently and plan to submit our revised MOC highlighting this change. Is this an appropriate revision?

A3: Changes to the HRA tool are not reportable; however, changes to the evaluation processes and procedures are reportable.

Q4: We have implemented a step level for our administrative staff (e.g. Admin Levels 1-3). We highlighted staff responsibility in our previously submitted and approved MOC. Does this require a revision of our MOC?

A4: No, changes in administrative staff, types and levels are not considered reportable as substantive changes.

Q5: Our SNP’s target population make-up has shifted; however, this demographic data does not impact any changes in our services or operations. Should we report this change?

A5: No, updates to demographic data regarding your target population do not require revisions to your current MOC unless the changes create demands on organizational processes requiring modifications to policies, procedures or operations.

3. Submission Process FAQS — MOC Revisions

SNPs cannot submit MOC revisions to achieve higher scores or address deficiencies in the HPMS notification letter. MOC revisions will not be scored, rather, NCQA will review the revised MOC and designate the changes as “Acceptable” or “Non-Acceptable.” Your MOC’s original approval period (e.g., 1 year or multi-year) will not change. This process allows for one opportunity to correct identified deficiencies.

FAQs

Q1: We reviewed our MOC final scores and revised our narrative to address the deficiencies noted in   the notification letter. Should we submit a revised MOC highlighting these revisions?

A1: No, it is not necessary to submit a revised MOC as a result of edits to your MOC. If the changes highlighted do not impact current operating processes, you may hold these changes until the next required submission at the end of your approval period.

Q2: We received an adequate score on our MOC; however, my CEO and Medical Director want us to revise the MOC in order to achieve a higher score. Is this considered an acceptable revision?

A2: No, NCQA staff will not review and score submissions based on deficiencies in previously approved MOCs. The original score and the approval timeframe stands.

Q3Our SNP reviewed our MOC report and noticed weak areas in the MOC narrative that can be improved.  Can we revise and resubmit our MOC?

A3: No, NCQA staff will not review submissions based on deficiencies in previously approved MOC. A new MOC with improvements should be submitted into HPMS at time of renewal.

4. How to Submit

Once you determine that your organization’s MOC requires revisions that are reportable (as defined above), the MMP or SNP will:

  • Access HPMS via the internet at https://hpms.cms.gov and follow the instructions.
  • Click on the MOC module in HPMS.
  • Download and complete Attachment B Revised Model of Care Matrix. The completed matrix will include a rationale for making the reportable change(s) and a summary of the modifications.
  • Upload the MOC Off-cycle Submission Matrix document with the summary of changes, the modifications must include a redlined version of the current approved MOC with the revisions in red font.

FAQs

Q: How does a SNP submit the revised MOC to CMS?

A: Complete Attachment B: Revised Model of Care Matrix document and submit the document along with the revised red-lined MOC to https://hpms.cms.gov.  Under Contract Management, click on the MOC module and follow the instructions.

5. How will CMS and NCQA Evaluate My Revisions?

NCQA reviews the revisions to verify that they are consistent with the standards in the currently approved MOC. Findings are assigned as “Acceptable” or “Non-Acceptable” and are entered into HPMS. A system-generated email will be sent to the SNP or MMP Application contact, the MA Quality contact and the individual who submitted the revised MOC.

5.1 Acceptable Results

FAQs

Q: If our revised MOC is designated as “Acceptable,” will we qualify for an additional approval timeframe?

A: No, your MOC’s original approval timeframe stands; and you will operate under your revised MOC for the rest of the original approval period.

5.2 Non-Acceptable Results

FAQs

Q: If our revised MOC is designated as “Non-Acceptable,” will we qualify for additional opportunities to correct any deficiencies?

A: If the MOC revisions are designated as “Non-Acceptable,” you have one opportunity to address the issues identified as non-acceptable in the revisions.

5.3 Cure Opportunities

The off-cycle revision process allows for one opportunity to address any issues with the revised MOC. If the SNP or MMP contact receives notification that your MOC revisions are designated as “Non-Acceptable,” make the appropriate edits, and follow the instructions (above) to upload your second submission.

FAQs

Q: Our second submission was determined to be “Non-Acceptable.” What should we do? Can we operate under our revised MOC?

A: No, you may not operate under the revised MOC because the revised MOC is not considered consistent with the quality standards included in the originally approved MOC. If the revisions you proposed made to your MOC are determined to be “Non-Acceptable,” you must continue to operate under your originally approved MOC.

6. General Questions — Off Cycle Submissions

6.1 Submitting against previously approved 11 Elements vs. the current 4 Elements

FAQs

Q: Our MMP plan received MOC approval in 2013 using the 11 Required Element format (three-year approval through 2017 based on delayed California MMP implementation).  For off cycle submission changes, please confirm that plans are not required to submit in the new 4 Required Element format. 

A: MMPs submitting their previously approved MOC with 11 elements should submit a redlined version of their approved MOC (using the 11 elements for which it was approved). Please keep in mind that you are required to submit for renewal next year (2017 or upon expiration of your approval period) under the new MOC requirements.

6.2 Target Population

FAQs

Q1: In reviewing our target population’s demographic data, we notice that we have more than the anticipated number enrollees in our Diabetes C-SNP. Do we need to revise the description of our target population?

A1: Although you may need to add to your provider network in order to maintain adequate enrollee/provider ratios, a larger than expected target population does not require revisions to your MOC.

Q2: We noticed a trending increase in congestive heart failure (CHF) and myocardial infarctions (MI) in our diabetic C-SNP and have decided to add a new disease management benefit to better address these health conditions. Should we revise our previously approved MOC and submit to CMS?

A2: Yes, benefit inclusions as well as exclusions usually affect current operations. It is appropriate to submit the revised, redlined MOC to CMS for evaluation.

6.3 Care Coordination

FAQs

Q: Upon annual review, we determined a decrease in our ability to capture members transitioning directly into skilled nursing facilities for short term admissions. Subsequently, our Case Management VP, in collaboration with the Medical Director initiated changes to our care transitions protocol and notification processes. The SNP issued multifaceted notifications to inform the provider community as well as internal staff, members and stakeholders. Should we report this change to CMS?

A: The SNP must formally submit its revised MOC for approval as this does change overall functions and processes and procedures

6.4 Provider Network

FAQs

Q1:  Our SNP is known for its ability to provide a specialized network for its unique target population. These providers are very much involved in the Interdisciplinary Care Team (ICT) in order to maintain the health of members. Their services are utilized on an as needed basis. Recently, we changed our system and now require all medical providers to document their assessment in the new system to allow the ICT to review as time permits. Should this change be reported?

A1:  As long as the frequency and process of the ICT meetings does not change, this change does not need to be reported. Having a system change and requiring providers to document and note assessments of members for the ICT to review is not considered substantive.

Q2:  Our organization requires out-of-network providers (who see beneficiaries on a routine basis) to receive MOC training. We enhanced our training content to address the challenges and limitations identified. Do updates to the training need to be approved?

A2:  No, the content added to the MOC training is not considered substantive and does not need to be incorporated as a revision to the MOC.

6.5 Quality Measurement & Performance Improvement

FAQs

Q1:  Do Quality Improvement goals need to be redlined in a previously approved MOC and submitted in an off cycle submission? Example: HEDIS goals change each year.

A1:  No, goals pertaining to HEDIS and other outcome measures that change from year to year do not need to be submitted via an off-cycle MOC submission.

Q2:  I understand that metric results do not need to be reported. What about if there are updates to the SNP-specific measurable goals and health outcome objectives because specific thresholds were met regarding the MOC quality?

A2:  No, updates of goals and health outcome objectives that met the planned thresholds do not need to be reported. Organizations who do not change the overall performance improvement plan process for meeting the new goals do not need to submit revisions.

Q3:  As an organization, we have not revised any of our measureable goals or health outcomes. We have, however, changed how these goals are communicated throughout the SNP organization. Are we required to report this change in communication?

A3:  Yes. Since the process for communicating the specific goals for improving access and affordability of the healthcare needs has changed, a revised MOC must be submitted. Because the changes in the overall communication process effects improvements made in coordination of care and appropriate delivery of services based upon the HRAT results, ICP and ICT development and structure, care transitions and utilization of services, this is considered substantive.

7. Contacting CMS

For technical inquiries related to the MOC requirements, or other issues related to the SNP and MMP MOC, please contact CMS at:

SNPs:

CMS DPAP mailbox

https://dpap.lmi.org

Subject line:  SNP MOC Inquiry

 

MMPs:

CMS MMP mailbox

mmcocapsmodel@cms.hhs.gov

Subject line:  MMP MOC Inquiry