1. Open Dialogue with CMS on Key Regulatory Issues
Vanessa Duran, Director
Division of Policy, Analysis & Planning
Medicare Drug & Health Plan Contract Administration Group
October 28, 2011

2. Overview
Summary of the CY 2012 SNP Model of Care (MOC) approval process
Review of MOC implementation
Highlights of the CY 2013 Parts C & D regulation

3. SUMMARY OF THE CY 2012 SNP MOC APPROVAL PROCESS

4. NCQA SNP MOC Approval
All SNPs must be approved by the National Committee for Quality Assurance (NCQA) based on standards developed by CMS.
CMS established the SNP Model of Care (MOC) as the basis of NCQA’s approval of SNPs.

5. Standards for NCQA SNP Approval
Multi-year approval schedule:
Incentives for SNPs to exceed our minimum passing score of 70%
Decreased burden for MAOs and CMS
Benchmarks for approvals:
3-year: scores of 85% or greater
2-year: scores of 75-84%
1-year: 70-74%

6. Approval Process Implementation
MOC approval implemented as part of the SNP application process:
Leveraged an existing process
Provided two opportunities for MAOs to cure MOCs (to include improving already passing scores) in parallel with MA application process

7. Implementation Challenges
New process for all SNPs
First time CMS has developed benchmarks for the Models of Care (MOC) and reviewed and scored them on specified standards.
Timing of the regulatory process
Regulations and specific standards for approval not released until after the first submission

8. Throughout the approval process, CMS and NCQA hosted:
Technical Assistance
Throughout the approval process, CMS and NCQA hosted:
4 Initial Review TA calls
2 Cure 1 TA Calls
1 Cure 2 TA Call
Many one-on-one TA calls with individual MAOs

9. SNP MOC Approval Results
No SNPs were non-renewed as a result of the MOC review and approval process
Most plans received multi-year approvals
MOC approval information posted at:

10. Taking Stock of 2012 Approval Process
“Lessons Learned” session with the industry this fall
Review of MOC implementation for a sample of plans in 2012
Stable MOC elements and scoring criteria for 2013

11. Evaluation of moc implementation

12. MOC Review
Goal: To determine whether SNPs are indeed implementing their NCQA-approved MOCs
Reviews of 150 contracts, including all SNP types
Representative sample of SNP types and geographic locations
Timeline: April November 2012. 
Individual results from these reviews will be shared with SNPs

13. Highlights of the CY 2013 Parts C & D regulation

14. CY 2013 Parts C & D Proposed Rule
CMS 4157-P was published in the Federal Register on October 11th
Public comment period ends December 12th
Proposals specifically impacting SNPs:
New Benefit Flexibility for FIDE SNPs
Application Requirements for SNPs

15. Benefit Flexibility for FIDE SNPs
Proposal to give certain high-quality FIDE SNPs new flexibility to offer additional Medicare supplemental benefits beyond those that CMS currently allows for other MA plans
Proposal developed jointly by the Medicare Contract Administration Group & the Medicare-Medicaid Coordination Office

16. Benefit Flexibility for FIDE SNPs (cont.)
Considering supplemental benefits that may prevent health status decline and reduce the quantity & cost of health care needs
Types of supplemental benefits may include:
Personal care services in the home
Non-skilled nursing activities in the home
Custodial care
In-home food delivery

17. Benefit Flexibility for FIDE SNPs (cont.)
Proposed criteria to qualify for proposed benefit flexibility:
FIDE SNP
Operational in current and previous contract year
High-quality (as defined by CMS in the CY 2013 draft/final call letter)
Other criteria that CMS establishes

18. Application Requirements for SNPs
Proposal broadens our regulations on application requirements and evaluation and determination procedures to also apply to SNP applicants
Current regulations pertain only to applicants that have been determined unqualified to enter into an MA contract, and do not provide for appeal rights to applicants who have been determined unqualified to offer a SNP

19. Application Requirements for SNPs (cont.)
The proposed provision would:
Specify the documentation SNP applicants must provide to complete an application
Provide SNP applicants with the same rights and responsibilities as applicants applying to contract as MAOs
Provide each applicant that has been determined unqualified to offer a SNP the same right to an administrative review process as each applicant that has been determined unqualified to enter into an MA contract

20. Questions? Vanessa Duran, 410-786-8697, vanessa.duran@cms.hhs.gov
Jaya Ghildiyal, ,
Sabrina Ahmed, ,
Vanessa Sammy, ,