Model of Care (MOC) Development — What You Need to Know

Model of Care (MOC) approvals expiring December 31, 2022, must submit a new MOC by February 2023.

CODY® can help you gain a 2- or 3-year approval on your Dual-Eligible SNPs (D-SNP) or Institutional SNPs (I-SNP) Model of Care (MOC). For Chronic SNPs (C-SNP), we can provide a review of requirements prior to the annual submission.

Special Needs Plans (SNPs) Model of Care (MOC) are considered a vital quality improvement tool and an integral component for ensuring that the unique needs of each beneficiary enrolled in a SNP are identified and addressed. The Patient Protection and Affordable Care Act (ACA) stresses the importance of the MOC as a fundamental component of SNP quality improvement and requires the National Committee for Quality Assurance (NCQA) to review and approve each SNPs MOC based on standards and scoring criteria established by CMS.

NCQA assesses Model of Care (MOC) according to detailed CMS scoring guidelines. The MOC requirements include clinical and non-clinical standards:

  • MOC 1: Description of the SNP Population
  • MOC 2: Care Coordination
  • MOC 3: SNP Provider Network
  • MOC 4: MOC Quality Measurement & Performance Improvement

Scoring is based on the percentage of points assessed out of the total possible points for each element. To relieve the burden of annual reporting, CMS implemented a multi-year approval process granted to those CMS that receive higher MOC scores. The approval categories are as follows:

  • 3-Year Approval – score of 85% or higher
  • 2-Year Approval – score of 75%-84%
  • 1-Year Approval – score 70%-74%

NCQA and CMS consider SNPs MOC scores below 70% as “failing.” SNPs that receive a score below 70% during the initial review, have an opportunity to resubmit their MOCs and achieve a score of 70% or greater. This one-time opportunity is called a Cure. Any plan that requires a Cure can only achieve a 1-Year Approval status regardless of their final score.

We’re Here to Help

Cody Consulting will review your Model of Care (MOC) against the standards and scoring and provide suggestions to increase your score. We also address changes due to the implementation of the Bipartisan Budget Act (BBA) of 2018 and review the requirements for all MOC elements, including the new Face-to-Face Encounter element (MOC 2C).

Whether you have a C-SNP, D-SNP, or I-SNP, we can assist you to include the required elements and gain a higher score and approval on your MOC. To learn more, contact us today for a consultation.

About us: CODY® works with over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico. We help align internal operations with CMS guidelines to improve regulatory compliance, maximize performance, and streamline member/provider communications across the enterprise. CodySoft® and Membership Suite™, our proprietary suites of software, are designed specifically for health plans.