Background

The Affordable Care Act (ACA) amended section 1859(f) of the Social Security Act to require that, starting in 2012, all SNPs be approved by NCQA based on standards developed by the Secretary. As provided under 42 CFR §§ 422.4(a)(iv), 422.101(f), and 422.152(g), the NCQA approval process is based on evaluation and approval of the SNP Model of Care (MOC), as per CMS guidance.

Specifically, the ACA requires that all SNPs, new, existing or those seeking to expand service areas, be approved by NCQA effective beginning January 1, 2012. For 2013 and subsequent years, only new SNPs or those seeking service area expansions are required to submit an application for SNP approval to CMS. The NCQA SNP approval process is a separate and distinct process from that of the Structure and Process (S&P) measuures evaluation. The SNP approval process focuses solely on the MOC requirements. The MOCs are submitted to CMS via HPMS, then reviewed and scored by NCQA based on scoring guidelines developed by CMS.

Scoring of the MOC includes evaluation of the following clinical and non-clinical elements by NCQA surveyors:

1. Description of the SNP-specific Target Population
2. Measurable Goals
3. Staff Structure and Care Management Goals
4. Interdisciplinary Care Team
5. Provider Network having Specialized Expertise and Use of Clinical Practice Guidelines and Protocols
6. Model of Care Training for Personnel and Provider Network
7. Health Risk Assessment
8. Individualized Care Plan
9. Communication Network
10. Care Management for the Most Vulnerable Subpopulations
11. Performance and Health Outcome Measurement

The elements noted may contain one or more factors, which NCQA scores on a scale of 0-4. SNPs must provide in depth and detailed responses to all elements and factors. A minimum score of seventy (70) percent is considered passing. To relieve the burden of annual reporting, CMS implemented a multi-year approval process granted to those plans that receive higher MOC scores.

Multi-year SNP Approval time-periods are as follows:

• Three (3) years = Eighty-five (85) percent or higher .
• Two (2) years = Seventy-five (75) percent to eighty-four (84) percent range
• One (1) year = Seventy (70) percent to seventy-four (74) percent range

Requirements

For more information on the SNP Approval Application requirements and process, please go to the following Web site: http://www.cms.gov/SpecialNeedsPlans/03_SNPMOC.asp#TopOfPage 

Timeline

Click on the Timeline link to view 2013's dates.

* For more information on trainings and technical assistance calls, please refer to the SNP Approval Training Sessions link above.

Scoring

The elements noted may contain one or more factors, which NCQA scores on a scale of 0-4. SNPs must provide in depth and detailed responses to all elements and factors. A minimum score of seventy (70) percent is considered passing. To relieve the burden of annual reporting, CMS implemented a multi-year approval process granted to those plans that receive higher MOC scores.

Multi-year SNP Approval time-periods are as follows:

• Three (3) years = Eighty-five (85) percent or higher
• Two (2) years = Seventy-five (75) percent to eighty-four (84) percent range
• One (1) year = Seventy (70) percent to seventy-four (74) percent range

CY 2014 Reporting Requirements