Medicare Managed Care Manual 
Chapter 5 - Quality Assessment 
 
Table of Contents 
(Rev. 117, 08-08-14) 
Transmittals Issued for this Chapter 
 
10 Introduction 
20 Medicare Quality Improvement Program 
20.1 Chronic Care Improvement Program (CCIP) and Quality Improvement Projects 
(QIP) 
20.1.1 Chronic Care Improvement Program (CCIP) 
20.1.2 Quality Improvement Project (QIP) 
20.2 Additional Quality Improvement Program Requirements for Special Needs Plans 
(SNPs) 
20.2.1 Model of Care Elements 
20.2.2 Model of Care Scoring Criteria 
20.2.3 Special Needs Plans Health Risk Assessment Tool (HRAT) 
20.2.4 Structure & Process (S&P) Measures 
30 Standard MAO Reporting Requirements for HEDIS, HOS, and CAHPS 
General 
30.1 HEDIS Reporting Requirements 
30.1.1 HEDIS Compliance Audit Requirements 
30.1.2 Final Audit Reports, Use and Release 
30.2 Medicare HOS Requirements 
30.2.1 HOS-Modified 
30.2.2 HOS Data Feedback 
30.3 Medicare CAHPS Requirements 
40  Medicare Advantage (MA) Deeming Program Overview 
40.1 - Deeming Requirements 
40.2 - Deemed MAOs 
40.2.1 - Deemed Status and Surveys 
40.2.2 - Removal of an MAOs Deemed Status 
40.3 - CMSs Role in Deeming 
40.3.1 - Oversight of AOs 
40.3.2 - Enforcement Authority 
40.3.3 - Withdrawal of Approval 
40.4 - Obligations of AOs with Deeming Authority 
 
  40.4.1 - Reporting Requirements 
40.4.2 - Application Requirements 
40.4.3 - Application Notices 
40.4.4 - Withdrawing an Application 
40.5 - Reconsideration of a Decision to Deny, Remove or Not Renew Deeming Authority 
40.5.1 - Informal Hearing Procedures 
40.5.2 - Informal Hearing Findings 
40.5.3 - Final Reconsideration Determinations 
50 - Definitions 
 
 
  10 - Introduction 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
In early 2010, the Centers for Medicare & Medicaid Services (CMS) developed a Quality 
Improvement Strategy for the Medicare Advantage (MA) and Prescription Drug Plan (PDP) 
Programs based on the 2001 Institute of Medicine (IOM) report. That strategy was expanded in 
2011 to reflect the Department of Health and Human Services (HHS) National Strategy for 
Quality Improvement in Health Care.  
Based on the HHS strategy and the Affordable Care Act, HHS developed the National Quality 
Strategy (NQS) and the National Prevention Strategy (NPS) and CMS developed and released in 
June, 2012 its MA and PDP Quality Strategy, entitled Medicare Advantage and Prescription 
Drug Plan Quality Strategy: A Framework for Improving Care for Beneficiaries. CMS MA and 
PDP Quality Strategy was the culmination of a coordinated staff effort and leadership across 
CMS.  
The MA and PDP Quality Strategy is expected to serve as a framework to advance CMS 
continuous quality improvement efforts, establish a culture of improving quality of care and 
services in the MA and PDP programs and improve the quality of care for Medicare beneficiaries 
enrolled in those programs.  
The MA and PDP Quality Strategy include a vision, mission, five core values, and six goals as 
outlined below.  The vision is to ensure that Medicare beneficiaries enrolled in MAOs receive 
efficient, high quality care and services every time. The mission is to lead and develop the 
infrastructure, tools, and performance measures for MAOs to provide integrated coordinated care and 
the best services for every beneficiary across all plan types. The five core values are Robust, 
Consumer Friendly, Comparable, Comprehensive, and Transparent. These core values provide the 
necessary foundation in support of the MA and PDP Quality Strategy. Specific MA and PDP Quality 
Strategy goals are as follows:  
1.  Build Solid and Dedicated Medicare Leadership and Infrastructure; 
2.  Foster Communications and Partnerships Across All Levels of Government; 
3.  Lead the Health Care Industry in Providing Cutting Edge, Integrated Coordinated Care; 
4.  Monitor and Assess the Quality of Health Care Services; 
5.  Provide Incentives for Improving and/or Excelling on Quality Assessments; and,  
6.  Improve Beneficiaries Ability to Use Quality Measures to Evaluate and Compare Health 
Plans and Services 
The MA and PDP Quality Strategys vision, mission, core values, and goals collectively drive the 
quality of healthcare and ongoing quality improvement initiatives for all plans.   
All Medicare Advantage Organizations (MAOs) are required, as a condition of their contract 
with CMS, to develop a Quality Improvement program that is based on care coordination for 
enrollees. The MA and PDP Quality Strategy support that requirement by providing a framework 
for MAOs and PDPs as they work to improve care and patient health outcomes. The foundation 
of the MA and PDP Quality Strategy and the Quality Improvement program is improving care 
coordination and encouraging provision of health care using evidence-based clinical protocols.   
 
  The complete MA and PDP Quality Strategy report, as well as other pertinent MA quality-
related documents, are available on the CMS MA Quality Web site located at: 
http://www.cms.gov/Medicare/Health-Plans/Medicare-Advantage-Quality-Improvement-
Program/Overview.html. Please note that this Chapter does not address quality requirements for 
stand-alone PDPs.  Guidance on standalone PDP quality requirements can be found in Chapter 
7of the Prescription Drug Manual at: https://www.cms.gov/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovContra/downloads/Chapter7.pdf. 
 
20 - Medicare Quality Improvement Program 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
MAOs that offer one or more MA plans must have an ongoing Quality Improvement (QI) 
program for each of their plans. The purpose of a QI program is to ensure that MAOs have the 
necessary infrastructure to coordinate care, promote quality, performance, and efficiency on an 
ongoing basis. The requirements for the QI program are based in regulation at 42 CFR 422.152.  
For each plan, an MAO must: 
 
1.  Develop and implement a chronic care improvement program (CCIP) 42 CFR 
422.152(c); 
 
2.  Develop and implement a quality improvement project (QIP) 42 CFR 422.152(d);  
 
3.  Develop and maintain a health information system (42 CFR 422.152(f)(1)); 
4.  Encourage providers to participate in CMS and HHS QI initiatives (42 CFR 
422.152(a)(3)); 
 
5.  Implement a program review process for formal evaluation of the impact and 
effectiveness of the QI Program at least annually (42 CFR 422.152(f)(2)); 
 
6.  Correct all problems that come to its attention through internal surveillance, complaints 
or other mechanisms (42 CFR 422.152(f)(3));  
 
7.  Contract with an approved Medicare Consumer Assessment of Health Providers and 
Systems (CAHPS) vendor to conduct the Medicare CAHPS satisfaction survey of 
Medicare enrollees (42 CFR 422.152(b)(5)); and, 
 
8.  Measure performance under the plan using standard measures required by CMS and 
report its performance to CMS (42 CFR 422.152(e)(i)).  
 
9.  Develop, compile, evaluate, and report certain measures and other information to CMS, 
its enrollees, and the general public. Responsible for safeguarding the confidentiality of 
the doctor-patient relationship and report to CMS in the manner required cost of 
operations, patterns of utilizations of services, and availability, accessibility, and 
acceptability of Medicare approved and covered services (42 CFR 422.516(a)).  
 
 
  All MAOs, as part of their application to offer new MA products or expand the service area of an 
existing product, must submit a written Quality Improvement Program Plan (QIPP).  The QIPP 
outlines the elements of an MAOs QI Program and provides a framework for how a plan will 
execute each of the QI program requirements stipulated above. QIPPs are submitted to CMS as 
part of the contract and SNP application processes. QIPP templates are included in both the 
contract and SNP applications.    
 
20.1 - Chronic Care Improvement Program (CCIP) and Quality Improvement 
Projects (QIP) 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.152(c)  (d) 
 
As required by regulation, each MAO must develop and implement a CCIP and QIP as part of its 
required QI Program.  MAOs must conduct the same CCIP and QIP for all their non-SNP 
coordinated care plans offered under a specified contract, including employer group plans and 
Medical Savings Account plans (MSA) and Private Fee for Service (PFFS) plans that have 
contracted networks.  MAOs must also implement a CCIP and QIP specific to each SNP plan 
offered, including when an MAO offers multiple SNPs of the same type under a contract.  Only 
PFFS plans that do not have contracted networks, section 1833 and 1876 cost plans, and Program 
of All-Inclusive Care for the Elderly (PACE) plans are exempted from the CCIP and QIP 
requirements. 
The quality improvement model adopted by CMS for the CCIP/QIPs is based on The Plan-Do-
Study-Act (PDSA) quality improvement model. PDSA is an iterative, problem-solving model 
used for improving a process or carrying out change.  The four steps of the PDSA cycle provide a 
systematic, step-by-step, ongoing approach for quality improvement initiatives. Components of 
the PDSA are as follows: 
 
  Plan:  Describes the processes, specifications, and output objectives used to establish the 
CCIP/QIP; 
  Do:  Describes the progress of the implementation and the data collection plan; 
  Study:  Describes the analysis of data to determine what impact the program has had on 
members. 
  Act:  Summarizes action plan(s) based on findings; describes, in particular, the 
differences between actual and anticipated results, and describes specific actions or steps 
taken or planned based on current results.  
 
The MAOs first step in implementing a QIP or CCIP is submitting a complete, stand-alone 
Plan section of the PDSA model for approval by CMS.  Once that Plan is approved and 
implemented, MAOs are required to submit Annual Updates that are comprised of the Do, Study, 
and Act components of the PDSA model to report on the ongoing operations of that approved 
Plan. 
The Plans and Annual Updates for both CCIPs and QIPs are submitted to CMS through the 
Quality and Performance module of the Health Plan Management System (HPMS). CMSs 
 
  expectations regarding the information that is to be included in the Plan and Annual Update 
submittals are discussed in greater detail below. 
MAOs have access to detailed information about the submission requirements for the CCIP and 
QIP Plan and Annual Updates. Detailed information can be found in the CCIP and QIP User 
Guides available within the HPMS Quality and Performance module. 
20.1.1 - Chronic Care Improvement Program (CCIP) 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
A CCIP is a clinically focused initiative designed to improve the health of a specific group of 
enrollees with chronic conditions. Beginning CY 2012, CMS required that each MA plan 
conduct, over a 5-year period, a CCIP focused on reducing and/or preventing cardiovascular 
disease.  
CCIP Plan Section Description  
The CCIP Plan section describes all aspects of the proposed CCIP initiative, including, but not 
limited to: the opportunity for improvement, target goal, what specific interventions will be 
introduced to achieve the identified goal, members targeted for receipt of the intervention(s), and 
the expected results. Please note that we expect SNPs to develop interventions that are tailored to 
their specific target population. While an organization may choose the same basic intervention(s) 
for its SNP and non-SNP plans, we expect the intervention(s) and overall approach to 
appropriately address the unique characteristics and needs of the targeted populations. Below is a 
general summary of the required components of the CCIP Plan. 
 
  Basis for Selection - An overall description of the CCIP and rationale for selection that 
includes impact on the member, anticipated outcomes, and rationale for selection. 
  Program Design - Outlines the process used to identify the target population, risk 
stratification, and enrollment method. 
  Evidence-Based Medicine - Includes the clinical practice guidelines and standards of care 
to be employed.  
  Care Coordination Approach - Describes the expected collaboration and communication 
among a multidisciplinary team that may include providers, MAO staff and the targeted 
member.  
  Education - The method of education and the topics that will be addressed. Includes 
education directed to applicable providers and/or targeted members. 
  Outcome Measures and Interventions - Setting objectives in measurable terms; 
identifying the appropriate data source(s) to measure; and the methodology used to 
analyze the data to determine whether the initiative impacted the health status of the 
targeted population.  
  Communication Sources - Methods used to inform patients, physicians, and other 
providers on what is occurring in the CCIP and any changes necessary over time.   
 
MAOs with contracts that were operational in CY 2012 were required to submit the Plan Section 
of the CCIP for the first time through HPMS in 2012.  In subsequent years, newly operating 
MAO contracts and SNPs must submit the Plan section of the PDSA during the CMS-determined 
submission window in the fall of their first year of operation; the first Annual Update for those 
plans will be submitted the following year. 
 
  CCIP Annual Update Section 
The CCIP Annual Update is due during the CMS-determined submission window in the fall of 
the first year of implementation following approval of the CCIP Plan Section and annually 
thereafter, until program completion. The Annual Update should include the results or findings 
to date, based on the intervention(s); any barriers encountered during the update period; risk 
mitigation activities implemented to address barriers encountered; impact on the established goal 
or benchmark; and, next steps for the project. Below is a general summary of the components of 
the CCIP Annual Update.   
 
  Educational components - Includes the actual method(s) of education and the topics that 
were covered. The education may be patient and/or provider focused.   
  Intervention(s) - Specific actions/approaches implemented to achieve the stated goal.  
  A description of barriers encountered, if applicable, and the specific actions taken to 
mitigate those barriers.  
  Discussion of findings and analysis of results to date in relation to the established goal, 
benchmark, timeframe, total population, numerator, denominator, results and other data 
results. Identification of next steps based on internal evaluation and ongoing assessment 
of the CCIP, whether or not the goals were met, and any revisions to the intervention(s), 
methodology, goal, or other aspects of the initiative.   
  Best Practices - Any identified approaches that are proven to be reliable and appear to 
contribute to the success of the CCIP.   
  Lessons Learned - Description of pertinent knowledge gained through the CCIP 
experience.  
 
20.1.2 - Quality Improvement Project (QIP) 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
QIPs are initiatives focused on one or more clinical and/or non-clinical areas with the aim of 
improving health outcomes and beneficiary satisfaction. Beginning CY 2012, each MAO is 
required to conduct, over a 3-year period, a QIP focused on reducing 30-day all cause hospital 
readmission rates.   
 
QIP Plan Section Description  
The QIP Plan section describes all aspects of the proposed QIP initiative, including, but not 
limited to: the opportunity for improvement, target goal, what specific interventions will be 
introduced to achieve the identified goal, members targeted for receipt of the intervention(s), and 
the expected results.  Please note that we expect SNPs to develop interventions that are tailored 
to their specific target population. While an organization may choose the same basic 
intervention(s) for its SNP and non-SNP plans, we expect the intervention(s) and overall 
approach to appropriately address the unique characteristics and needs of the targeted 
populations. Below is a general summary of the required components of the QIP Plan. 
  
  Basis for Selection  An overall description of the QIP and rationale for selection that 
includes impact on the member, anticipated outcomes, and rationale for selection.  (Note: 
The QIP Plan Section specific to a SNP may include, if applicable, any Model of Care 
 
  elements which form the basis for the QIP, e.g., the Individualized Care Plan, the 
Interdisciplinary Care Team, etc.) 
  Program Design  An outline of the process used to identify the target population, risk 
stratification, and enrollment method.    
  Prior Focus  A description of any previous attempts to address the problem that the QIP 
will be addressing. This includes intervention-specific information about the previous 
attempt(s), including any outcomes achieved. 
  Examination of any anticipated barriers and the potential impact on the success of the 
QIP.  
  Outcome Measures and Interventions - Setting objectives in measurable terms; 
identifying the appropriate data source(s) to measure; and the methodology used to 
analyze the data to determine whether/how the initiative affected the health status of the 
targeted population.  
 
QIP Annual Update Section Description 
The QIP Annual Update is due during the CMS-determined submission window in the fall of the 
first year of implementation following approval of the QIP Plan Section, and annually thereafter, 
until project completion.  The Annual Update should include the results or findings to date, 
based on the intervention(s); any barriers encountered during the update period; risk mitigation 
activities implemented to address barriers encountered; the impact on the established goal or 
benchmark, and next steps for the project. Below is a general summary of the components of the 
QIP Annual Update. 
 
  Intervention(s) - Specific actions/approaches implemented to achieve the stated goal.  
  A description of Barriers encountered, if applicable, and the specific actions taken to 
mitigate those barriers.  
  Discussion of findings and analysis of results to date in relation to the established goal, 
benchmark, timeframe, total population, numerator, denominator, results and other data 
results. Identification of Next Steps based on internal evaluation and ongoing assessment 
of the QIP, whether or not the goals were met, and any revisions to the intervention(s), 
methodology, goal, or other aspects of the initiative.   
  Best Practices - Any identified approaches that are proven to be reliable and appear to 
contribute to the success of the QIP.   
  Lessons Learned - Description of pertinent knowledge gained through the QIP 
experience. 
20.2 - Additional Quality Improvement Program Requirements for Special 
Needs Plans (SNPs) 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
Section 1856(f)(7) of the Patient Protection and Affordable Care Act stipulates that all MAOs 
offering Special Needs Plans (SNPs) must submit an evidence-based Model of Care (MOC) to 
CMS for NCQA evaluation and approval in accordance with CMS guidance.  As provided at 42 
CFR 422.101(f) and 422.152(g), SNPs must develop and implement a MOC that provides the 
structure for care management processes and systems that will enable the health plan to provide 
 
  coordinated care for special needs individuals.  An MAO must develop separate MOCs to meet 
the needs of the targeted population for each SNP type it offers.  
 
All SNPs must submit the MOC Matrix Upload Document, as well as the MOC narrative, in 
HPMS during the MA/SNP application timeframe.  Refer to Section 40.1 and 40.2 of Chapter 
16b of the Medicare Managed Care Manual titled, Special Needs Plans for additional 
information regarding the application and MOC approval requirements.  The MOC was re-
organized and revised to promote clarity and enhance the focus on care coordination, care 
transition, care needs and activities. All SNPs that must submit a MOC will be required to use 
the revised MOC structure for the first time as part of the CY 2015 application cycle.  The MOC 
narrative must include the following four elements: 
 
1.  Description of the SNP Population; 
2.  Care Coordination; 
3.  SNP Provider Network; and 
4.  MOC Quality Measurement & Performance Improvement 
 
Section 20.2.2 below provides a detailed description of each of these elements. 
 
20.2.1 - Model of Care Elements 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
1.  Description of the SNP Population: 
The identification and comprehensive description of the SNP-specific population is an integral 
component of the MOC because all of the other elements depend on the firm foundation of a 
comprehensive population description.  It must provide an overview that fully addresses the 
full continuum of care of current and potential SNP beneficiaries, including end-of-life needs 
and considerations, if relevant to the target population served by the SNP. The description of 
the SNP population must include, but not be limited to, the following:  
   Clear documentation of how the health plan staff determines or will determine, verify, and 
track eligibility of SNP beneficiaries.   
  A detailed profile of the medical, social, cognitive, environmental, living conditions, and 
co-morbidities associated with the SNP population in the plans geographic service area.  
  Identification and description of the health conditions impacting SNP beneficiaries, 
including specific information about other characteristics that affect health such as, 
population demographics (e.g. average age, gender, ethnicity, and potential health 
disparities associated with specific groups such as: language barriers, deficits in health 
literacy, poor socioeconomic status, cultural beliefs/barriers, caregiver considerations, 
other). 
  Define unique characteristics for the SNP population served: 
 
 C-SNP: What are the unique chronic care needs for beneficiaries enrolled in a C-SNP? 
Include limitations and barriers that pose potential challenges for these C-SNP 
beneficiaries.   
 
 
   D-SNP: What are the unique health needs for beneficiaries enrolled in a D-SNP? Include 
limitations and barriers that pose potential challenges for these D-SNP beneficiaries.   
 
 I-SNP: What are the unique health needs for beneficiaries enrolled in an I-SNP?  Include 
limitations and barriers that pose potential challenges for these I-SNP beneficiaries as 
well as information about the facilities and/or home and community-based services in 
which your beneficiaries reside.   
 
A.  Sub-Population: Most Vulnerable Beneficiaries  
As a SNP, you must include a complete description of the specially-tailored services for 
beneficiaries considered especially vulnerable using specific terms and details (e.g., 
members with multiple hospital admissions within three months, medication spending 
above $4,000).  Other information specific to the description of the most vulnerable 
beneficiaries must include, but not be limited to, the following:  
 A description of the internal health plan procedures for identifying the most vulnerable 
beneficiaries within the SNP.  
 A description of the relationship between the demographic characteristics of the most 
vulnerable beneficiaries with their unique clinical requirements. Explain in detail how 
the average age, gender, ethnicity, language barriers, deficits in health literacy, poor 
socioeconomic status and other factor(s) affect the health outcomes of the most 
vulnerable beneficiaries.   
  The identification and description of the established partnerships with community 
organizations that assist in identifying resources for the most vulnerable beneficiaries, 
including the process that is used to support continuity of community partnerships and 
facilitate access to community services by the most vulnerable beneficiaries and/or their 
caregiver(s).  
2. Care Coordination: 
Care coordination helps ensure that SNP beneficiaries healthcare needs, preferences for 
health services and information sharing across healthcare staff and facilities are met over time. 
Care coordination maximizes the use of effective, efficient, safe, and high-quality patient 
services that ultimately lead to improved healthcare outcomes, including services furnished 
outside the SNPs provider network as well as the care coordination roles and responsibilities 
overseen by the beneficiaries caregiver(s). The following MOC sub-elements are essential 
components to consider in the development of a comprehensive care coordination program; no 
sub-element must be interpreted as being of greater importance than any other.  All five sub-
elements below, taken together, must comprehensively address the SNPs care coordination 
activities. 
A. SNP Staff Structure 
 
 Fully define the SNP staff roles and responsibilities across all health plan functions that 
directly or indirectly affect the care coordination of beneficiaries enrolled in the SNP.  
This includes, but is not limited to, identification and detailed explanation of: 
 
    Specific employed and/or contracted staff responsible for performing administrative 
functions, such as: enrollment and eligibility verification, claims verification and 
processing, other. 
  Employed and/or contracted staff that perform clinical functions, such as: direct 
beneficiary care and education on self-management techniques, care coordination, 
pharmacy consultation, behavioral health counseling, other. 
  Employed and/or contracted staff that performs administrative and clinical oversight 
functions, such as: license and competency verification, data analyses to ensure 
appropriate and timely healthcare services, utilization review, ensuring that providers 
use appropriate clinical practice guidelines and integrate care transitions protocols.  
 Provide a copy of the SNPs organizational chart that shows how staff responsibilities 
identified in the MOC are coordinated with job titles. If applicable, include a description 
of any instances when a change to staff title/position or level of accountability was 
required to accommodate operational changes in the SNP.  
 Identify the SNP contingency plan(s) used to ensure ongoing continuity of critical staff 
functions. 
 Describe how the SNP conducts initial and annual MOC training for its employed and 
contracted staff, which may include, but not be limited to, printed instructional materials, 
face-to-face training, web-based instruction, and audio/video-conferencing. 
 Describe how the SNP documents and maintains training records as evidence to ensure 
MOC training provided to its employed and contracted staff was completed. For 
example, documentation may include, but is not limited to: copies of dated attendee lists, 
results of MOC competency testing, web-based attendance confirmation, and electronic 
training records. 
 Explain any challenges associated with the completion of MOC training for SNP 
employed and contracted staff and describe what specific actions the SNP will take when 
the required MOC training has not been completed or has been found to be deficient in 
some way.  
 
B. Health Risk Assessment Tool (HRAT)  
The quality and content of the HRAT should identify the medical, functional, cognitive, 
psychosocial and mental health needs of each SNP beneficiary. The content of, and methods 
used to conduct the HRAT have a direct effect on the development of the Individualized Care 
Plan and ongoing coordination of Interdisciplinary Care Team activities; therefore, it is 
imperative that the MOC include the following:  
  A clear and detailed description of the policies and procedures for completing the HRAT 
including: 
  Description of how the HRAT is used to develop and update, in a timely manner, the 
Individualized Care Plan (MOC Element 2C) for each beneficiary and how the HRAT 
information is disseminated to and used by the Interdisciplinary Care Team (MOC 
Element 2D).  
  Detailed explanation for how the initial HRAT and annual reassessment are conducted 
for each beneficiary.   
  Detailed plan and rationale for reviewing, analyzing, and stratifying (if applicable) the 
results of the HRAT, including the mechanisms to ensure communication of that 
information to the Interdisciplinary Care Team, provider network, beneficiaries and/or 
 
  their caregiver(s), as well as other SNP personnel that may be involved with 
overseeing the SNP beneficiarys plan of care.  If stratified results are used, include a 
detailed description of how the SNP uses the stratified results to improve the care 
coordination process.   
 
C. Individualized Care Plan (ICP)  
 
 The ICP components must include, but are not limited to: beneficiary self-management 
goals and objectives; the beneficiarys personal healthcare preferences; description of 
services specifically tailored to the beneficiarys needs; roles of the beneficiaries 
caregiver(s); and identification of goals met or not met.   
 When the beneficiarys goals are not met, provide a detailed description of the process 
employed to reassess the current ICP and determine appropriate alternative actions.  
 Explain the process and which SNP personnel are responsible for the development of the 
ICP, how the beneficiary and/or his/her caregiver(s) or representative(s) is involved in its 
development and how often the ICP is reviewed and modified as the beneficiarys 
healthcare needs change.  If a stratification model is used for determining SNP 
beneficiaries health care needs, then each SNP must provide a detailed explanation of 
how the stratification results are incorporated into each beneficiarys ICP.  
 Describe how the ICP is documented and updated as well as, where the documentation is 
maintained to ensure accessibility to the ICT, provider network, beneficiary and/or 
caregiver(s).   
 Explain how updates and/or modifications to the ICP are communicated to the beneficiary 
and/or their caregiver(s), the ICT, applicable network providers, other SNP personnel and 
other stakeholders as necessary.   
 
D. Interdisciplinary Care Team (ICT) 
 
  Provide a detailed and comprehensive description of the composition of the ICT; include 
how the SNP determines ICT membership and a description of the roles and 
responsibilities of each member. Specify how the expertise and capabilities of the ICT 
members align with the identified clinical and social needs of the SNP beneficiaries, and 
how the ICT members contribute to improving the health status of SNP beneficiaries. If a 
stratification model is used for determining SNP beneficiaries health care needs, then 
each SNP must provide a detailed explanation of how the stratification results are used to 
determine the composition of the ICT. 
 Explain how the SNP facilitates the participation of beneficiaries and their caregivers as 
members of the ICT.   
 Describe how the beneficiarys HRAT (MOC Element 2B) and ICP (MOC Element 2C) 
are used to determine the composition of the ICT; including those cases where additional 
team members are needed to meet the unique needs of the individual beneficiary.   
 Explain how the ICT uses healthcare outcomes to evaluate established processes to 
manage changes and/or adjustments to the beneficiarys health care needs on a 
continuous basis.    
 
   Identify and explain the use of clinical managers, case managers or others who play 
critical roles in ensuring an effective interdisciplinary care process is being conducted.   
 Provide a clear and comprehensive description of the SNPs communication plan that 
ensures exchanges of beneficiary information is occurring regularly within the ICT, 
including not be limited to, the following: 
 Clear evidence of an established communication plan that is overseen by SNP personnel 
who are knowledgeable and connected to multiple facets of the SNP MOC.  Explain how 
the SNP maintains effective and ongoing communication between SNP personnel, the 
ICT, beneficiaries, caregiver(s), community organizations and other stakeholders.  
 The types of evidence used to verify that communications have taken place, e.g., written 
ICT meeting minutes, documentation in the ICP, other.  
 How communication is conducted with beneficiaries who have hearing impairments, 
language barriers and/or cognitive deficiencies.   
 
E. Care Transitions Protocols  
 
 Explain how care transitions protocols are used to maintain continuity of care for SNP 
beneficiaries. Provide details and specify the process and rationale for connecting the 
beneficiary to the appropriate provider(s).   
 Describe which personnel (e.g., case manager) are responsible for coordinating the care 
transition process and ensuring that follow-up services and appointments are scheduled 
and performed as defined in MOC Element 2A. 
 Explain how the SNP ensures elements of the beneficiarys ICP are transferred between 
healthcare settings when the beneficiary experiences an applicable transition in care. This 
must include the steps that need to take place before, during and after a transition in care 
has occurred.  
 Describe, in detail, the process for ensuring the SNP beneficiary and/or caregiver(s) have 
access to and can adequately utilize the beneficiaries personal health information to 
facilitate communication between the SNP beneficiary and/or their caregiver(s) with 
healthcare providers in other healthcare settings and/or health specialists outside their 
primary care network.   
 Describe how the beneficiary and/or caregiver(s) will be educated about indicators that 
his/her condition has improved or worsened and how they will demonstrate their 
understanding of those indicators and appropriate self-management activities. 
 Describe how the beneficiary and/or caregiver(s) are informed about who their point of 
contact is throughout the transition process. 
 
3. SNP Provider Network:  
The SNP Provider Network is a network of healthcare providers who are contracted to provide 
health care services to SNP beneficiaries.  Each SNP is responsible for ensuring their MOC 
identifies, fully describes, and implements the following for its SNP Provider Network: 
A. Specialized Expertise 
 
 Provide a complete and detailed description of the specialized expertise available to SNP 
beneficiaries in the SNP provider network that corresponds to the SNP population 
identified in MOC Element 1.  
 
   Explain how the SNP oversees its provider network facilities and ensures its providers are 
actively licensed and competent (e.g., confirmation of applicable board certification) to 
provide specialized healthcare services to SNP beneficiaries. Specialized expertise may 
include, but is not limited to: internal medicine, endocrinologists, cardiologists, 
oncologists, mental health specialists, other.  
 Describe how providers collaborate with the ICT (MOC Element 2D) and the beneficiary, 
contribute to the ICP (MOC Element 2C) and ensure the delivery of necessary specialized 
services.  For example, describe: how providers communicate SNP beneficiaries care 
needs to the ICT and other stakeholders; how specialized services are delivered to the SNP 
beneficiary in a timely and effective way; and how reports regarding services rendered are 
shared with the ICT and how relevant information is incorporated into the ICP. 
 
B. Use of Clinical Practice Guidelines & Care Transitions Protocols 
 
 Explain the processes for ensuring that network providers utilize appropriate clinical 
practice guidelines and nationally-recognized protocols.  This may include, but is not 
limited to: use of electronic databases, web technology, and manual medical record review 
to ensure appropriate documentation. 
 Define any challenges encountered with overseeing patients with complex healthcare 
needs where clinical practice guidelines and nationally-recognized protocols may need to 
be modified to fit the unique needs of vulnerable SNP beneficiaries.  Provide details 
regarding how these decisions are made, incorporated into the ICP (MOC Element 2C), 
communicated with the ICT (MOC Element 2D) and acted upon. 
 Explain how SNP providers ensure care transitions protocols are being used to maintain 
continuity of care for the SNP beneficiary as outlined in MOC Element 2E.  
 
C. MOC Training for the Provider Network  
 
 Explain, in detail, how the SNP conducts initial and annual MOC training for network 
providers and out-of-network providers seen by beneficiaries on a routine basis. This 
could include, but not be limited to: printed instructional materials, face-to-face training, 
web-based instruction, audio/video-conferencing, and availability of instructional 
materials via the SNP plans Web site. 
 Describe how the SNP documents and maintains training records as evidence of MOC 
training for their network providers. Documentation may include, but is not limited to: 
copies of dated attendee lists, results of MOC competency testing, web-based attendance 
confirmation, electronic training records, and physician attestation of MOC training. 
 Explain any challenges associated with the completion of MOC training for network 
providers and describe what specific actions the SNP Plan will take when the required 
MOC training has not been completed or is found to be deficient in some way.  
 
MOC Quality Measurement & Performance Improvement: 
The goals of performance improvement and quality measurement are to improve the SNPs 
ability to deliver healthcare services and benefits to its SNP beneficiaries in a high-quality 
manner. Achievement of those goals may result from increased organizational effectiveness 
and efficiency by incorporating quality measurement and performance improvement concepts 
 
  used to drive organizational change. The leadership, managers and governing body of a SNP 
organization must have a comprehensive quality improvement program in place to measure its 
current level of performance and determine if organizational systems and processes must be 
modified based on performance results.     
A. MOC Quality Performance Improvement Plan 
 
  Explain, in detail, the quality performance improvement plan and how it ensures that 
appropriate services are being delivered to SNP beneficiaries. The quality performance 
improvement plan must be designed to detect whether the overall MOC structure 
effectively accommodates beneficiaries unique healthcare needs. The description must 
include, but is not limited to, the following: 
 The complete process, by which the SNP continuously collects, analyzes, evaluates and 
reports on quality performance based on the MOC by using specified data sources, 
performance and outcome measures. 
 Details regarding how the SNP leadership, management groups and other SNP personnel 
and stakeholders are involved with the internal quality performance process. 
 Details regarding how the SNP-specific measurable goals and health outcomes objectives 
are integrated in the overall performance improvement plan (MOC Element 4B).   
 
B. Measureable Goals & Health Outcomes for the MOC 
 
  Identify and clearly define the SNPs measureable goals and health outcomes and 
describe how identified measureable goals and health outcomes are communicated 
throughout the SNP organization. Responses should include but not be limited to, the 
following:  
 Specific goals for improving access and affordability of the healthcare needs outlined for 
the SNP population described in MOC Element 1. 
 Improvements made in coordination of care and appropriate delivery of services through 
the direct alignment of the HRAT, ICP, and ICT. 
 Enhancing care transitions across all healthcare settings and providers for SNP 
beneficiaries.  
 Ensuring appropriate utilization of services for preventive health and chronic conditions.  
  Identify the specific beneficiary health outcomes measures that will be used to measure 
overall SNP population health outcomes, including the specific data source(s) that will be 
used.  
  Describe, in detail, how the SNP establishes methods to assess and track the MOCs 
impact on the SNP beneficiaries health outcomes.   
  Describe, in detail, the processes and procedures the SNP will use to determine if the 
health outcomes goals are met or not met.  
  Explain the specific steps the SNP will take if goals are not met in the expected time 
frame. 
 
C. Measuring Patient Experience of Care (SNP Member Satisfaction)  
 
 
    Describe the specific SNP survey(s) used and the rationale for selection of that particular 
tool(s) to measure SNP beneficiary satisfaction.  
  Explain how the results of SNP member satisfaction surveys are integrated into the 
overall MOC performance improvement plan, including specific steps to be taken by the 
SNP to address issues identified in response to survey results. 
 
D. Ongoing Performance Improvement Evaluation of the MOC 
 
  Explain, in detail, how the SNP will use the results of the quality performance indicators 
and measures to support ongoing improvement of the MOC, including how quality will 
be continuously assessed and evaluated.  
  Describe the SNPs ability to improve, on a timely basis, mechanisms for interpreting and 
responding to lessons learned through the MOC performance evaluation process.   
  Describe how the performance improvement evaluation of the MOC will be documented 
and shared with key stakeholders.  
 
E. Dissemination of SNP Quality Performance related to the MOC 
 
  Explain, in detail, how the SNP communicates its quality improvement performance 
results and other pertinent information to its multiple stakeholders, which may include, 
but not be limited to: SNP leadership, SNP management groups, SNP boards of directors, 
SNP personnel & staff, SNP provider networks, SNP beneficiaries and caregivers, the 
general public, and regulatory agencies on a routine basis.  
  This description must include, but is not limited to, the scheduled frequency of 
communications and the methods for ad hoc communication with the various 
stakeholders, such as: a webpage for announcements; printed newsletters; bulletins; and 
other announcement mechanisms. 
Identify the individual(s) responsible for communicating performance updates in a timely 
manner as described in MOC Element 2A. 
20.2.2 - Model of Care Scoring Criteria 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
The NCQA scoring approval process is based on scoring each of the clinical and non-clinical 
elements of the MOC as part of the SNP application.  The scoring guidelines were revised to 
align with the new MOC structure to be utilized starting with the CY 2015 application cycle and 
are modeled after the Structure & Process Measures format.  The revised scoring guidelines 
complement the new MOC structure and help SNPs better understand and meet the requirements 
of the revised MOC element structure.   
 
MOC 1: Description of SNP Population (General Population) 
Identification and a comprehensive description of the SNP-specific population are integral 
components of the 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 organizations 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. 
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Explanation  Element Target population characteristics 
The organizations 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 organizations 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: SubpopulationMost 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. 
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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 organizations 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 organizations 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 organizations 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. 
 
 
MOC 2: Care Coordination 
Care coordination helps ensure that SNP beneficiaries health care needs, preferences for health 
services and information sharing across health care staff and facilities are met over time. Care 
coordination maximizes the use of effective, efficient, safe, high-quality patient services 
(including services furnished outside the SNPs provider network) that ultimately lead to 
improved health care outcomes.  
The following MOC sub-elements are essential components to consider in the development of a 
comprehensive care coordination program; no sub-element must be interpreted as being of 
greater importance than any other. Taken together, all five sub-elements must address the SNPs 
care coordination activities comprehensively. 
Element A: SNP Staff Structure 
The organizations MOC must: 
1. Describe the administrative staffs roles and responsibilities, including oversight 
functions. 
2. Describe the clinical staffs roles and responsibilities, including oversight functions. 
3. Describe how staff responsibilities coordinate with the job title. 
4. Describe contingency plans used to address ongoing continuity of critical staff functions. 
5. Describe how the organization conducts initial and annual MOC training for its 
employed and contracted staff. 
6. Describe how the organization documents and maintains training records as evidence 
that employees and contracted staff completed MOC training. 
 
  7. Describe actions the organization takes if staff do not complete the required MOC 
training. 
 
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Explanation  Factor 1: Administrative staff roles and responsibilities 
The organizations MOC defines staff roles and responsibilities across all 
health plan functions for personnel that directly or indirectly affect the care 
coordination of SNP beneficiaries.  
The organizations MOC must identify and describe the specific employed and 
contracted staff responsible for performing administrative functions, including: 
  Enrollment and eligibility verification. 
  Claims processing. 
  Administrative oversight. 
Factor 2: Clinical staff roles and responsibilities 
The organization must identify and describe the employed and contracted staff 
that perform clinical functions, including: 
  Direct beneficiary care and education on self-management techniques. 
  Care coordination. 
  Pharmacy consultation. 
  Behavioral health counseling.  
  Clinical oversight. 
Staff oversight responsibilities must include any license and competency 
verification that relates to the specific population being served by the 
organization (e.g., geriatric training for I-SNP providers or special training for 
physicians and other clinical staff for a C-SNP services beneficiaries with 
HIV/AIDs; data analyses for utilization of appropriate and timely health care 
services; utilization review; and provider oversight to ensure use of appropriate 
clinical practice guidelines and integration of care transition protocols. 
Factor 3: Coordination of responsibilities and job title 
To show how staff responsibilities identified in the MOC are coordinated with 
job title, the organization must provide a copy of its organization chart and, if 
applicable, a description of instances when a change to staff title/position or 
level of accountability is required to accommodate operational changes in the 
SNP. 
 
  Factor 4: Contingency plan 
The organization must have a contingency plan (or plans) in place to avoid a 
disruption in care and services when existing staff can no longer perform their 
roles and meet their responsibilities. The organizations MOC must identify 
and describe contingency plans to ensure ongoing continuity of staff functions.  
Factors 5, 6: Initial and annual MOC training; maintaining training 
records 
The organization must conduct initial and annual MOC training for its 
employed and contracted staff. The MOC must describe the training strategies 
and content, as well as the methodology the organization uses to document and 
maintain training records as evidence that staff have completed MOC training. 
Contracted staff does not include physicians or other providers that the 
organization contracts with as part of the provider network.  
The description must include types of trainings and specific examples of slides 
or training materials. If the training plan is not currently operational, the 
organizations MOC must provide a description of the plans contents.  
Factor 7: Actions if training is not completed 
The organizations MOC must explain challenges associated with employed 
and contracted staff completing training and must describe actions the 
organization will take when the required MOC training has not been completed 
or has been found to be deficient.  
 
Element B: Health Risk Assessment Tool (HRAT) 
The organizations MOC includes a clear and detailed description of the policies and 
procedures for completing the HRAT that addresses: 
1. How the organization uses the HRAT to develop and update the Individualized Care 
Plan (ICP) for each beneficiary (Element 2C). 
2. How the organization disseminates the HRAT information to the Interdisciplinary Care 
Team (ICT) and how the ICT uses that information (Element 2D). 
3. How the organization conducts the initial HRAT and annual reassessment for each 
beneficiary. 
4. The detailed plan and rationale for reviewing, analyzing and stratifying (if applicable), 
the HRA results. 
 
   
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Explanation  The content of and methods used to conduct the HRAT have a direct effect on 
the development of the ICP and ongoing coordination of ICT activities. The 
HRAT must assess the medical, functional, cognitive, psychosocial and mental 
health needs of each SNP beneficiary.  
Factors 1&2: Use and dissemination of HRAT information  
The organization must include a description of how the HRAT is used to 
develop and update, in a timely manner, the ICP for each beneficiary and how 
the HRAT information is disseminated to and used by the ICT.  
Factor 3: Initial HRA and annual reassessment 
The organization must complete the HRAT for each beneficiary, for initial 
assessment, and must complete an HRAT annually thereafter. At minimum, the 
organization must conduct initial assessment within 90 days of enrollment and 
must conduct annual reassessment within one year of the initial assessment.  
The description must include the methodology used to coordinate the initial and 
annual HRAT for each beneficiary (e.g., mailed questionnaire, in-person 
assessment, phone interview) and the timing of the assessments. There must be 
a provision to reassess beneficiaries, if warranted by a health status change or 
care transition (e.g., hospitalization, change in medication, multiple falls). The 
organization must describe its process for attempting to contact beneficiaries 
and have them complete the HRAT, including provisions for beneficiaries that 
cannot or do not want to be contacted or complete the HRAT.   
Factor 4: Plan and rationale 
The organizations MOC must describe its plan and explain its rationale for 
reviewing, analyzing and stratifying HRAT results. It must include the 
mechanisms for communicating information to the ICT, provider network, 
beneficiaries and/or their caregiver(s) and other SNP personnel who may be 
involved with overseeing a beneficiarys plan of care. If the organization uses 
stratified results, the MOC must explain how the SNP uses the results to 
improve the care coordination process. 
 
   
 
 
 
Element C: Individualized Care Plan (ICP) 
The description of the organizations ICP must include: 
1. The essential components of the ICP.  
2. The process to develop the ICP, including how often the ICP is modified as 
beneficiaries health care needs change. 
3. The personnel responsible for development of the ICP, including how the beneficiary 
and/or caregiver(s) are involved. 
4. How the ICP is documented, updated and where it is maintained. 
5. How updates and modifications to the ICP are communicated to the beneficiary and 
other stakeholders. 
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Explanation  Factor 1: ICP essential components 
The organization must develop an ICP for each beneficiary, to deliver 
appropriate care to the beneficiary. The organizations ICP must include, but is 
not limited to:  
  The beneficiarys self-management goals and objectives. 
  The beneficiarys personal healthcare preferences. 
  A description of services specifically tailored to the beneficiarys needs. 
  Identification of goals (met or not met). 
 If the beneficiarys goals are not met, the organizations MOC must 
describe the process for reassessing the current ICP and determining 
the appropriate alternative actions. 
Factors 2, 3: ICP development process and personnel 
The organizations MOC must describe the process for developing the ICP and 
must detail the personnel responsible for developing the ICP. The description 
of responsible staff must include roles and functions, professional requirements 
and credentials necessary to perform these tasks, as well as how the beneficiary 
or their caregiver/ representative is involved in the ICP development. The MOC 
must also include a description of how the organization determines how often 
to review and modify, as appropriate, the ICP as the beneficiarys health care 
needs change.  
 
  Factor 4: ICP documentation and maintenance 
The organizations MOC must describe how the ICP is documented and 
updated and where the documentation is maintained so it is accessible to the 
ICT, provider network and beneficiaries and/or their caregiver(s).  
Factor 5: Updates and modifications 
The organizations MOC must describe how the organization communicates 
ICP updates and modifications to beneficiaries and/or their caregiver(s), the 
ICT, applicable network providers, other SNP personnel and other 
stakeholders, as necessary.  
 
 
 
Element D: Interdisciplinary Care Team (ICT) 
The organizations MOC must describe the critical components of the ICT, including: 
1. How the organization determines the composition of ICT membership. 
2. How the roles and responsibilities of the ICT members (including beneficiaries and/or 
caregiver[s]) contribute to the development and implementation of an effective 
interdisciplinary care process. 
3. How ICT members contribute to improving the health status of SNP beneficiaries. 
4. How the SNPs communication plan to exchange beneficiary information occurs 
regularly within the ICT, including evidence of ongoing information exchange. 
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Explanation  Factor 1: ICT membership 
The organizations MOC must describe the composition of the ICT, including 
how the SNP determines ICT membership and the roles and responsibilities of 
each member. The description must specify how the expertise and capabilities 
of the ICT members align with the identified clinical and social needs of the 
SNP beneficiaries. 
The organization must: 
  Explain how the SNP facilitates the participation of beneficiaries and their 
caregiver(s) as members of the ICT. 
  Describe how the beneficiarys HRAT and ICP are used to determine the 
composition of the ICT; including where additional team members are 
needed to meet the unique needs of a beneficiary. 
 
    Explain how the ICT uses health care outcomes to evaluate processes 
established to manage changes or adjustments to the beneficiarys health 
care needs on a continuous basis.  
Factors 2 and 3: ICT member roles and responsibilities 
The organizations MOC must describe how it uses clinical managers, case 
managers and others who play critical roles in providing an effective 
interdisciplinary care process; and how beneficiaries and/or their caregiver(s) 
are included in the process, are provided with needed resources and how the 
organization facilitates access for beneficiaries to ICT team members. 
Factor 4: Communication plan 
The MOC must describe the SNPs communication plan for promoting regular 
exchange of beneficiary information within the ICT. The MOC must show: 
  Clear evidence of an established communication plan that is overseen by 
SNP personnel who are knowledgeable and connected to multiple facets 
of the SNP MOC.  
  How the SNP maintains effective and ongoing communication among 
SNP personnel, the ICT, beneficiaries and/or their caregiver(s), 
community organizations and other stakeholders.  
  The types of evidence used to verify that communications have taken 
place (e.g., written ICT meeting minutes, documentation in the ICP). 
  How communication is conducted with beneficiaries who have hearing 
impairments, language barriers and cognitive deficiencies. 
 
Element E: Care Transition Protocols 
The organizations MOC describes the following care transition protocols: 
1. How the organization uses care transition protocols to maintain continuity of care for 
SNP beneficiaries. 
2. The personnel responsible for coordinating the care transition process. 
3. How the organization transfers elements of the beneficiarys ICP between health care 
settings when the beneficiary experiences an applicable transition in care. 
4. How beneficiaries have access to personal health information to facilitate 
communication with providers in other healthcare settings. 
5. How beneficiary and/or caregiver(s) will be educated about the beneficiarys health 
status to foster appropriate self-management activities. 
6. How the beneficiary and/or caregiver(s) are informed about the point of contact 
throughout the transition process. 
 
   
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Explanation  Definitions 
 Health care setting: The provider from whom or setting where a member 
receives health care and health-related services. In any setting, a designated 
practitioner has ongoing responsibility for a members medical care.  
 Settings include home, home health care, acute care, skilled nursing 
facility, custodial nursing facility, rehabilitation facility and 
outpatient/ambulatory care/surgery centers. 
 Transition: Movement of a member from one care setting to another as the 
members health status changes.  
 For example, moving from home to a hospital as the result of an 
exacerbation of a chronic condition or moving from the hospital to a 
rehabilitation facility after surgery. 
 Transition process: The period from identification of a member who is at 
risk for a care transition through completion of a transition.  
 This process includes planning and preparation for transitions and the 
follow-up care after transitions are completed. 
Factor 1: Continuity of care 
Older or disabled adults moving between different health care settings are 
particularly vulnerable to receiving fragmented and unsafe care when 
transitions are poorly coordinated; thus, an organization must work actively to 
coordinate transitions. The organization must specify the process and rationale 
for connecting beneficiaries with the appropriate providers. 
Factor 2: Care transition personnel 
The organization must identify and describe the personnel (e.g., case manager) 
responsible for coordinating the care transition process and for ensuring that 
follow-up services and appointments are scheduled and performed.  
 
 
Factor 3: Applicable transitions 
The organization must ensure that elements of the beneficiarys ICP are 
transferred between health care settings when the beneficiary experiences a 
transition in care. The MOC must describe the steps that take place before, 
during and after a transition in care has occurred for this process. 
 
 
  Factor 4: Beneficiary Personal Health Information 
Beneficiaries and/or their caregiver(s) need access to beneficiaries personal 
health information in order to communicate about care with healthcare 
providers in other healthcare settings and/or health specialists outside their 
primary care network. The organization must describe the process for ensuring 
that SNP beneficiaries and/or their caregiver(s) have access to and can 
adequately use personal health information to coordinate care for the 
beneficiary.  
Factor 5: Self-management activities 
The MOC must describe how beneficiaries and/or their caregiver(s) will be 
educated about their condition, how they will demonstrate understanding of 
changes in their condition (improvement, stable or worsening), and use of 
appropriate self-management activities. For example, they should be educated 
about signs and symptoms signaling a change in their condition and how to 
respond to such changes. Self-management activities can include regular 
assessment of progress, goal setting and problem solving support to reduce 
crises and improve health outcomes.  
Factor 6: Notification of point of contact 
The organization must describe the process it uses to notify beneficiaries and/or 
their caregiver(s) of the personnel responsible for supporting them through 
transitions between any two care settings. 
 
 
MOC 3: Provider Network 
The SNP provider network is a network of health care providers who are contracted to provide 
health care services to SNP beneficiaries. SNPs must ensure that their MOC identifies, fully 
describes and implements the following elements for their SNP provider networks. 
Element A: Specialized Expertise 
The organization must establish a provider network with specialized expertise that 
describes the following components of the network: 
1. How providers with specialized expertise correspond to the target population identified 
in MOC 1.  
2. How the SNP oversees its provider network facilities and oversees that its providers are 
competent and have active licenses.  
3. How the SNP documents, updates and maintains accurate provider information.  
4. How providers collaborate with the ICT and contribute to a beneficiarys ICP to 
provide necessary specialized services. 
 
 
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Explanation  The organization must have an adequate and specialized provider network that 
maintains the appropriate licensure and competency to address the needs of the 
target population.  
Factor 1: Specialized network 
The provider networks specialized expertise may include, but is not limited to, 
internal medicine, endocrinologists, cardiologists, oncologists, mental health 
specialists and other specialists that address the needs of the SNPs target 
population identified in MOC 1.  
Factors 2 and 3: Licensure and certification  
The organization must describe how it determines that its providers have active 
licenses and are competent to provide specialized health care services to SNP 
beneficiaries (e.g., confirmation of applicable board certification), The MOC 
should describe how it maintains current information on providers to maintain 
an accurate provider network directory.  
Factor 4: Collaboration with the ICT/ICP 
The MOC must describe how providers in the network collaborate with 
members of the ICT and help contribute to each beneficiarys ICP, including 
how providers either deliver or coordinate care, particularly specialized 
services. The MOC must describe how providers communicate beneficiary care 
needs to the ICT and to other stakeholders or providers, how the organization 
shares information (e.g., as reports on services) with the ICT and how providers 
incorporate relevant clinical information into beneficiaries ICPs. 
 
 
 
Element B: Use of Clinical Practice Guidelines and Care Transition Protocols 
The organization must oversee how network providers use evidence-based medicine, when 
appropriate, by: 
1. Explaining the processes for monitoring how network providers utilize appropriate 
clinical practice guidelines and nationally recognized protocols appropriate to each 
SNPs target population.  
2. Identifying challenges where the use of clinical practice guidelines and nationally 
recognized protocols need to be modified or are inappropriate for specific vulnerable 
SNP beneficiaries. 
 
  3. Providing details regarding how decisions to modify clinical practice guidelines or 
nationally recognized protocols are made, incorporated into the ICP, communicated to 
the ICT and acted upon by the ICT.  
4. Describing how SNP providers maintain continuity of care using the care transition 
protocols outlined in MOC 2, Element E. 
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Explanation  Factor 1: Utilization of guidelines and protocols 
Evidence-based clinical guidelines and protocols promote the use of nationally 
recognized and accepted practices for providing the right care at the right time. 
The organization must monitor how network providers utilize these guidelines, 
when appropriate. The organization may use electronic databases, Web 
technology, manual medical record review or other methods to oversee use of 
clinical practice guidelines.  
Factors 2 and 3: Exceptions to guidelines 
Certain clinical practice guidelines and protocols may not always be 
appropriate for some patients with complex health care needs. In these cases, 
the organization must identify challenges to using clinical practice guidelines 
and nationally recognized protocols for certain beneficiaries with complex 
healthcare needs and detail how the decision to modify or ignore such 
guidelines is made, incorporated into the patients ICP, communicated with the 
ICT and acted on by the patients ICT or by other providers.  
Factor 4: Care transition protocols 
Care transitions offer challenges for organizations to maintain continuity of 
care. The organization must explain how it oversees network providers to 
ensure that they follow the required care transition protocols outlined in MOC 
2, Element E. 
 
 
 
Element C: MOC Training for the Provider Network 
The organizations description of oversight of provider network training on the MOC must 
include: 
1. Requiring initial and annual training for network providers and out-of-network 
providers seen by beneficiaries on a routine basis.  
2. Documenting evidence that the organization makes available and offers training on the 
MOC to network providers. 
 
  3. Explaining challenges associated with the completion of MOC training for network 
providers. 
4. Taking action when the required MOC training is deficient or has not been completed. 
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Explanation  Factor 1: Initial and annual training 
The MOC must describe how the organization provides initial and annual 
training for network providers and any out-of-network providers seen by 
beneficiaries on a routine basis; and must describe the process for annual 
training for current providers, including how training is conducted (e.g., in-
person meetings, computer-based training), how often training occurs, training 
materials and examples of training content.  
Factor 2: Evidence of training 
The MOC must describe how the organization documents and maintains 
records  
(e.g., copies of dated attendee lists, Web-based training confirmation, electronic 
training records, physician attestation) as evidence that it makes training on the 
MOC available and offers it to all network providers.   
Factors 3 and 4: Deficient or incomplete training 
The MOC must describe specific actions taken by the organization if providers 
do not receive the required training and must explain challenges (e.g., 
geographically distant network, very large number of providers in network) 
associated with completion of the MOC trainings for network providers. The 
MOC may also describe actions the organization takes to offer incentives or 
other best practices to encourage provider training participation and 
compliance.  
 
 
MOC 4: MOC Quality Measurement and Performance Improvement 
The goal of performance improvement and quality measurement is to improve the SNPs ability 
to deliver high-quality health care services and benefits to its SNP beneficiaries. Achievement of 
this goal may be the result of increased organizational effectiveness and efficiency through 
incorporation of quality measurement and performance improvement concepts that drive 
organizational change.  
The leadership, managers and governing body of a SNP organization must have a comprehensive 
quality improvement program in place to measure its current level of performance and determine 
if organizational systems and processes must be modified, based on performance results.  
 
   
Element A: MOC Quality Performance Improvement Plan 
The organization must develop a MOC quality performance improvement plan that: 
1. Describes the overall quality improvement plan and how the organization delivers or 
provides for appropriate services to SNP beneficiaries, based on their unique needs.  
2. Describes specific data sources and performance and outcome measures used to 
continuously analyze, evaluate and report MOC quality performance. 
3. Describes how its leadership, management groups, other SNP personnel and 
stakeholders are involved with the internal quality performance process. 
4. Describes how SNP-specific measureable goals and health outcomes objectives are 
integrated in the overall performance improvement plan, as described in MOC 4, 
Element B. 
 
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Explanation  Definition 
Quality measurement and performance improvement: A collaborative 
process for improving an organizations ability to deliver high-quality health 
care services and benefits to SNP beneficiaries.  
Factors 14 
The organizations MOC must describe how the quality performance 
improvement plan specific to the MOC, is designed to detect whether the 
overall MOC structure effectively accommodates beneficiaries unique health 
care needs.  
The MOC must describe the SNPs process for continuous collection, analysis, 
evaluation and reporting on quality performance based on the MOC. The MOC 
should describe the frequency of these activities.  
The MOC must provide details about how the key personnel listed in factor 3 
are involved in internal quality performance processes. It should provide 
information about which personnel are involved, their role in analyzing quality 
performance information and the decision-making authority given to such 
personnel.  
The organization must specify data used for analyses, and must identify clear 
measures to determine if stated goals or outcomes are achieved. Measures must 
 
  have a benchmark or goal, specify time frames for achieving outcomes and 
state a plan for re-measurement if the goal is not achieved. 
 
 
 
Element B: Measureable Goals and Health Outcomes for the MOC 
The organization must identify and clearly define measureable goals and health outcomes 
for the MOC and: 
1. Identify and define the measurable goals and health outcomes used to improve the 
health care needs of SNP beneficiaries. 
2. Identify specific beneficiary health outcome measures used to measure overall SNP 
population health outcomes at the plan level.  
3. Describe how the SNP establishes methods to assess and track the MOCs impact on 
SNP beneficiaries health outcomes. 
4. Describe the processes and procedures the SNP will use to determine if health outcome 
goals are met.  
5. Describe the steps the SNP will take if goals are not met in the expected time frame. 
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Explanation  Factor 1 
A description of measurable goals must include benchmarks, specific time 
frames  
and how achieving goals will be determined. Responses should include, but not 
be limited to: 
  Specific goals for improving access and affordability of the healthcare 
needs outlined for the SNP population described in MOC 1. 
  Improvements made in coordination of care and appropriate delivery of 
services through the direct alignment of the HRAT, ICP and ICT. 
  Enhanced care transitions across all health care settings and providers for 
SNP beneficiaries.  
  Ensuring appropriate utilization of services for preventive health and 
chronic conditions.  
Factor 2 
For the stated health outcome measures, the organization must include the 
specific data sources it will use for measurement. The MOC should describe 
the specific measures the organization will use to meet the overall quality goals 
 
  detailed in factor 1, including expected timeframes for meeting those goals.  
Factors 3&4 
The MOC must describe the methods the organization uses to assess and track 
how its overall quality program, including the goals and specific measures it 
uses, affect the health outcomes of its beneficiaries. This may include the data 
collected, how it is collected and analyzed and how often it is collected and 
analyzed.  
For factor 4, the MOC must describe how it determines if the goals described in 
factor 1 are met. 
Factor 5 
The organization must describe the actions it will take if it determines that goals 
are not met within the specified timeframes.  
 
   
 
 
Element C: Measuring Patient Experience of Care (SNP Member Satisfaction) 
The organizations MOC must address the process of measuring SNP member satisfaction 
by: 
1. Describing the specific SNP survey used. 
2. Explaining the rationale for the selection of a specific tool. 
3. Describing how results of patient experience surveys are integrated into the overall 
MOC performance improvement plan. 
4. Describing steps taken by the SNP to address issues identified in survey responses. 
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Explanation  Factors 14 
The MOC must describe the types of surveys used to assess SNP member 
experience, the rationale for the use of a specific tool and how results are 
integrated into the overall performance improvement plan.  
Member feedback can include information about the overall SNP program or 
program staff (e.g., ICT or case managers), the usefulness of the information 
disseminated by the organization and the members ability to adhere to 
recommendations. 
Methodology. The organization must describe how it receives feedback from a 
broad sample of members, not only those who contact the organization to share 
feedback. Member feedback may be obtained by conducting focus groups or 
through member experience surveys. The organization must describe how it 
analyzes feedback to identify and address issues. Feedback must be specific to 
the experience with the SNP overall programs being evaluated.  
The organization must be able to describe the methodology it uses to collect 
patient experience surveys, including the sample size used.  
   
 
 
  Element D: Ongoing Performance Improvement Evaluation of the MOC 
The organizations MOC description must describe: 
1. How the organization will use the results of the quality performance indicators 
and measures to support ongoing improvement of the MOC. 
2. How the organization will use the results of the quality performance indicators 
and measures to continually assess and evaluate quality. 
3. The organizations ability for timely improvement of mechanisms for 
interpreting and responding to lessons learned through the MOC performance 
evaluation. 
4. How the performance improvement evaluation of the MOC will be documented 
and shared with key stakeholders. 
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Explanation  Factors 14 
The organization must provide a written description of the ongoing performance 
improvement evaluation of its MOC. This process must describe how the 
organization will use the results to assess and evaluate its quality performance 
indicators on a continual basis, including how the organization improves its 
ongoing performance by incorporating lessons learned. Lessons learned must be 
documented and communicated with key stakeholders. 
 
 
 
Element E: Dissemination of SNP Quality Performance Related to the MOC 
The organization must address the process for communicating its quality 
improvement performance by: 
1. Describing how performance results and other pertinent information are shared 
with multiple stakeholders. 
2. Stating the scheduled frequency of communications with stakeholders. 
3. Describing the methods for ad hoc communication with stakeholders. 
4. Identifying the individuals responsible for communicating performance updates 
in a timely manner. 
 
   
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Explanation  Factors 14 
The organization describes how quality performance results are routinely shared 
with stakeholders, and specifies the frequency of these communications and how 
ad hoc and other unplanned communications are disseminated.  
The organizations plan to disseminate information must include individuals 
responsible for providing communication (as described in MOC 2, Element A). 
The MOC must describe methods for communication (regular and ad hoc) with 
stakeholders and time frame for communication with stakeholders, who may 
include, but are not limited to: 
  SNP leadership. 
  SNP management groups. 
  SNP boards of directors. 
  SNP personnel and staff. 
  SNP provider networks. 
  SNP beneficiaries and caregiver(s). 
  The general public. 
  Regulatory agencies. 
 
 
20.2.3 - Special Needs Plans Health Risk Assessment Tool (HRAT) 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
At any time that a SNP is required to submit a SNP application, it is required to submit a 
copy of the HRAT in HPMS as a part of its SNP application.  The timeline for submitting 
the tool will mirror the timeline for SNP application submission/MA application for the 
current contract year.  There is no template available in HPMS for the health risk 
assessment submission. CMS reviews and approves all new health risk assessment tools 
and notifies SNPs that submitted deficient tools.   
Note that CMS requires SNPs to conduct a comprehensive HRA within 90 days of the 
effective date of enrollment of each beneficiary, and a re-assessment at least every 365 
days in accordance with established timeframes for reporting purposes. A detailed 
description of the process for conducting the HRAs must be included as part of MOC 
Element 2 (Care Coordination) Element B (HRA Tool) in Section 20.2.1 of this chapter.  
This description must include when and how the initial HRA and annual reassessments 
 
  are conducted for each beneficiary, e.g., conducted by phone interview, face-to-face, or 
written form completed by the beneficiary and/or caregiver. Direct beneficiary and/or 
caregiver input is necessary and expected in order to assess the individuals perception of 
his/her health status and health care needs.  Information obtained via the HRAT, in 
addition to objective assessments subsequently performed by qualified providers, 
contribute to the effective development and continuous update of the enrollees 
individualized care plan.  
Timely completion of HRAs is a Part C reporting requirement and, for the first time, in 
CY 2015, will be incorporated as part of the CMS Five-Star Quality rating system.  
Please note that only completed HRAs that comprise direct beneficiary and/or caregiver 
input will be considered valid for purposes of fulfilling the Part C reporting requirements.  
This means, for example, that HRAs completed only using claims and/or other 
administrative data, would not be acceptable. For details regarding the HRA reporting 
timeframes and deadlines, please see the current Medicare Part C Plan Reporting 
Requirements Technical Specifications document at: 
http://www.cms.gov/Medicare/Health-
Plans/HealthPlansGenInfo/ReportingRequirements.html.  
20.2.4 - Structure & Process (S&P) Measures  
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
In 2007, CMS contracted with the National Committee for Quality Assurance (NCQA) to 
develop a strategy to evaluate the quality of care provided by SNPs.  That strategy 
resulted in development of a tool to collect information that is meant to provide CMS 
with a better understanding of how SNPs perform on a set of standardized national 
performance measures that assess internal SNP processes and operations that affect the 
enrolled Medicare beneficiaries quality of care (see Section 30.1 of this chapter for 
information regarding SNP-specific HEDIS measures). S&P measures address the SNP 
structures, systems and processes in place to address quality of care in the following 6 
areas:  
 
1.  Care Management; 
2.  Improving member satisfaction; 
3.  Clinical quality improvements; 
4.  Care transitions; 
5.  I-SNP relationships with facility; and 
6.  Coordination of Medicare and Medicaid coverage. 
 
The S&P measures rely on a review of plan policies and procedures, data reports, 
prepared materials and other documentation the plans use to implement their programs, 
analyze internal data, document processes and convey information to members and 
practitioners.  
NCQA collects S&P measure data from SNPs annually and provides an overview of 
performance results in a report submitted to CMS.  For additional information regarding 
 
  S&P measures, please see the NCQA Web site at: 
http://www.ncqa.org/Programs/OtherPrograms/SpecialNeedsPlans.aspx. 
30 - Standard MAO Reporting Requirements for HEDIS, HOS, and 
CAHPS 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 417.106(a)(3) 
42 CFR 417.418 
42 CFR 422.152(b)(5) 
42 CFR 422.152(e)(i) 
42 CFR 422.516 
General 
 
This section provides information regarding the annual Medicare HEDIS, HOS, and 
CAHPS reporting requirements. Performance measures that are derived largely from MA plan 
and beneficiary information form the basis of the CMS Star Ratings used to assess the 
quality of MA plans. Additional information regarding the Star Ratings may be found at 
http://www.cms.gov/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovGenIn/PerformanceData.html. In addition, CMS makes 
summary, contract-level performance measures available to the public through media that 
are beneficiary-oriented including the Medicare Plan Finder tool at 
http://www.medicare.gov. 
30.1 - HEDIS Reporting Requirements 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
HEDIS is a trademark product of NCQA.  All Medicare Advantage plans must submit 
audited summary-level HEDIS data to NCQA, and this includes cost contracts with 
closed enrollment.  Patient-level data must be reported to the CMS designated patient-
level data contractor.  Information about HEDIS reporting requirements is posted in 
HPMS.  During the contract year, if an HPMS contract status is listed as a consolidation, 
a merger, or a novation, the surviving contract must report HEDIS data for all members 
of the contracts involved.  If a contract status is listed as a conversion in the data year, the 
contract must report if the new organization type is required to report. 
 
CMS collects audited data from all benefit packages designated as SNPs and contracts 
with ESRD Demonstration Plans that had 30 or more members enrolled as reported in the 
SNP Comprehensive Report (which can be found at 
http://www.cms.hhs.gov/MCRAdvPartDEnrolData/SNP/list.asp#TopOfPage). 
 
The data collection methodologies for HEDIS are either the administrative or hybrid 
types. The administrative method is from transactional data for the eligible populations 
and the hybrid method is from medical record or electronic medical record and 
 
  transactional data for the sample.  
MAOs new to HEDIS must become familiar with the requirements for data 
submissions to NCQA, and make the necessary arrangements as soon as possible. The 
organization should work with an NCQA Licensed Organization 
(www.ncqa.org/audit.aspx), to arrange for a HEDIS Audit and is responsible for 
determining fees and entering into contracts.  HEDIS Compliance Audits result in 
audited rates or calculations at the measure level and indicate if the HEDIS measures 
can be publicly reported.  All HEDIS measures selected for public reporting must have 
a final, audited result.  The auditor approves the rate or report status of each HEDIS 
measure and survey included in the audit.  For HEDIS measures, the auditor approves 
the rate of report status of each measure and survey included in the audit as follows: 
 
  A rate or numeric result.  The organization followed the specifications and 
produced a reportable rate or result for the measure. 
 
  Small Denominator (NA).  The organization followed the specifications but the 
denominator was too small (<30) to report a valid rate. 
 
  Benefit Not Offered (NB).  The organization did not offer the health benefit 
required by the measure (e.g., mental health, chemical dependency). 
 
  Not Reportable (NR).  The organization calculated the measure but the rate was 
materially biased, or the organization chose not to report the measure or was not 
required to report the measure. 
 
Following are requirements for MAOs with special circumstances: 
 
1.  MAOs with Multiple Contract Types - An MAO cannot combine small contracts 
of different types, e.g., risk and cost, into a larger reporting unit. 
 
2.  MAOs  with  contract  conversions:  For  HEDIS  measures  with  a  continuous 
enrollment requirement and for enrollees who converted from one type of contract 
to  another  (within  the  same  organization),  enrollment  time  under  the  prior 
contract will not be counted. 
 
3.  MAOs with New Members Aging-in from their Commercial Product Line    
These MAOs must consider aging in members eligible for performance 
measure calculations assuming that they meet any continuous enrollment 
requirements. That is, plan members who switch from an MAOs commercial 
product line to the MAOs Medicare product line are considered continuously 
enrolled. Please read the General Guidelines of HEDIS Volume 2: Technical 
Specifications for a discussion of age-ins (see Members who switch product 
lines) and continuous enrollment requirements. 
 
4.  MAOs with Changes in Service Areas - MAOs that received approval for a 
service area expansion during the previous year and those that will be reducing 
 
  their service area effective January 1 of the next contract and reporting year must 
include information regarding those beneficiaries in the expanded or reduced 
areas based on the continuous enrollment requirement and Utilization of the 
particular measure being reported. 
 
5.  HMOs with Home and Host Plans - The home plan must report the data related to 
services received by its members when out of the plans service area. As part of 
the Visitor Program/Affiliate Option (portability), the host plan is treated as 
another health care provider under the home plans contract with CMS. The home 
plan is responsible for assuring that the host plan fulfills the home plans 
obligations. Plan members that alternate between an MAOs visitor plan and the 
home plan are considered continuously enrolled in the plan. 
 
6.  New Contracts - MAOs whose effective date is January 1st of the measurement 
year will not report HEDIS performance measures for the corresponding 
reporting year.  
 
7.  Non-renewing/Terminating MAOs - Entities that meet the HEDIS reporting 
requirements but which have terminated contracts effective January 1st of the 
reporting year will not be required to submit a HEDIS report or participate in 
the Medicare CAHPS or Medicare HOS surveys. 
 
8.  MAOs with Continuing Section 1876 Cost Contracts - For cost contracts, CMS 
has modified the list of HEDIS measures to be reported. Cost contractors will 
not report the inpatient Utilization measures. The measures to be reported are 
listed on Exhibit I.A. CMS does not require cost contractors to report inpatient 
(e.g., hospitals, skilled nursing facilities (SNFs)) measures because MAOs with 
cost-based contracts are not always responsible for coverage of the inpatient stays 
of their members. Cost members can choose to obtain care outside of the plan 
without authorization from the MAO. Thus, CMS and the public would not know 
to what degree the data for these measures are complete. 
 
10. Section 1876 Cost Contracts:  Cost contracts will provide patient-level data for all 
the HEDIS Effectiveness of Care and the Utilization measures for which they 
submit summary level data. 
 
11. Mergers and Acquisitions  An entity that acquires and is novating an existing 
Medicare contract must file a HEDIS report since the membership; benefits and 
medical delivery system are essentially unchanged.  Therefore, during 
negotiations for the acquisition it is essential that parties agree on a method of 
data exchange that will permit the acquiring organization to file a HEDIS report 
covering the measurement year in which the transaction occurred.  If the Health 
Plan Management System (HPMS) contract status is listed as a consolidation, a 
merger, or a novation during the measurement year, the surviving contract must 
report HEDIS data for all members of the contracts involved.  If a contract 
status is listed as a conversion in the measurement year, the contract must report if 
 
  their new organization type is required to report. 
 
CMS annually provides guidance in the month of August for the upcoming reporting 
year.  This information is in an annually-issued HPMS memorandum from CMS, entitled 
Updated Requirements for Reporting of HEDIS, HOS, and CAHPS Measures.  All 
MA contracts by their specific organization type, are listed, that are required to report 
HEDIS.  There is no minimum enrollment requirement for submitting MA HEDIS.  
The HPMS Memorandum provides information about required HEDIS measures for 
reporting, changes in the data specifications, data submission schedule and deadlines, and 
instructions about data submission.  All MA contracts shall use the annual guidance in 
the CMS HPMS Memorandum issued annually in August regarding the HEDIS 
requirements for the upcoming reporting year. 
 
Refer to the annual HEDIS, Volume 2: Technical Specifications for Health Plans for 
measure specifications and general guidelines for calculations and sampling. 
 
Medicare Advantage contracts that are required to report HEDIS summary-level data 
must also provide the patient-level data used to calculate the summary-level data for each 
MA contract.  Submission of the patient-level HEDIS data is not required for the SNP-
specific HEDIS measures.  
 
Reporting HEDIS for Medicare 
 
All members covered under the contracts listed below are included in Medicare HEDIS 
reporting.  CMS communicates directly with all contracted organizations and benefit 
plans on HEDIS reporting requirements (e.g., plan type, enrollment criteria).  HEDIS 
reporting is required for: 
 
  Medicare Advantage (MA contracts); 
  Section 1876 cost contracts with active enrollment; 
  Medical Savings Account (MSA) contracts; 
  Private Fee-for-Service (PFFS) contracts; 
  Employer/Union Only Direct Contract PFFS contracts; 
  Special Need Plans (SNPs) offered by MA contracts;  
  Certain demonstration projects. 
 
Exclusions: 
 
The Medicare Hospice benefit is considered a gap in enrollment, and contracts shall 
exclude MA members electing the hospice benefit through Traditional Medicare or FFS 
Medicare, and choose to remain enrolled in the MA plan, beginning on the date when the 
hospice benefits begin. 
 
CMS collects patient-level data with patient-level identifiers for the numerator and the 
denominator of each required HEDIS measure because this allows CMS to match 
 
  HEDIS data to other patient-level data for special projects of national interest and 
research, such as an assessment of whether certain groups (e.g., ethnic, racial, gender, 
geographic) are receiving fewer or more services than others. 
 
CMS is committed to assuring the validity of the summary data collected before it is 
released to the public, and to making the data available in a timely manner for beneficiary 
information.  MAOs and 1876 cost contracts must submit summary measures, after 
completing the NCQA HEDIS Compliance Audit required by Medicare, by mid-June of 
each reporting year. MAOs, including PPO, PFFS, and 1876 cost contracts must submit 
HEDIS patient-level data at the same time. CMS requires the submission of the 
following patient-level data on the same date as summary data to ensure that the patient-
level data match the summary data. Auditors will review patient-level data for the 
numerator and denominator of audited measures when checking for algorithmic 
compliance during the HEDIS audit. The summary data are sent to NCQA and the 
patient-level data are sent only through the designated CMS secure data submission 
system to the CMS contractor. 
 
1.  Summary Data 
 
a.  Required Measures - MAOs that held Medicare contracts in the measurement 
year and meet the criteria in the previous section of this chapter must report 
summary data for all required HEDIS measures except for the HOS 
measures. The HEDIS measures Flu Vaccination for Adults 65 and older, 
Pneumococcal Vaccination Status for Older Adults, and Medical Assistance 
with Smoking and Tobacco Use Cessation are collected through the CAHPS 
survey instrument.  MAOs must attempt to produce every Medicare required 
measure, and report a numerator and denominator even if the numbers are 
small, i.e., the denominator is less than 30. 
 
b.  Data Submission - NCQA will annually post Health Organization Questionnaires 
(HOQ) on the NCQA Web site in late January.  MAOs must accurately complete 
the HOQ in order to receive the appropriate Interactive Data Submission System 
(IDSS).  MAOs must submit HEDIS results for the measurement year using this 
web-based tool. 
 
2.  Patient-Level Data - Analysis of data with patient-level identifiers for the 
numerator  and denominator of each measure allows CMS to match HEDIS data 
to other  patient-level data for special projects of national interest and research, 
such as an assessment of whether certain groups (e.g., ethnic, racial, gender, 
geographic) are receiving fewer or more services than others. 
 
a.  Required Measures  MAOs must provide patient-level data identifying the 
contribution of each beneficiary to the denominator and numerator of every 
required summary measure. 
 
b.  Data Submission  Patient-level HEDIS data are submitted via the CMS 
 
  Enterprise FTP client system that contracts use to submit other beneficiary 
specific information to CMS.  Contracts use their existing system that 
connects to the designated CMS secure data transmission system to upload 
patient-level data files.  The CMS contractor accesses the patient-level data 
through the same secure system to perform data validations.  Contracts must 
retain the data used for reporting for six years.  As specified in 42 CFR 
422.504 and 423.505, all MA contracts are required to maintain the privacy 
and security of protected health information and other personally identifiable 
information of Medicare enrollees.  There have been questions expressed 
about the provision of behavioral health measures in the patient-level data 
files.  Contracts are accountable for providing patient-level data, unless 
prohibited by State laws.  In such cases, contracts must notify CMS with 
appropriate documentation of the legal prohibition for consideration. 
30.1.1 - HEDIS Compliance Audit Requirements 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
Because of the critical importance of ensuring accurate data, CMS continues to require an 
external audit of the HEDIS measures before public reporting. MAOs and 1876 cost 
contracts are responsible for submitting audited data, according to the audit methodology 
outlined in Volume 5: HEDIS Compliance Audit: Standards, Policies and Procedures. 
 
CMS requires each MAO and 1876 cost contract to contract with an NCQA licensed 
organization for an NCQA HEDIS Compliance Audit. The licensed audit firms are 
listed on NCQAs Web site at http://www.ncqa.org/.  CMS requires that the licensed 
organizations follow the established standards, policies and procedures in NCQAs 
HEDIS, Volume 5.  All contracts must ensure that the site visit audit team is led by a 
NCQA Certified HEDIS Compliance Auditor.  In addition, the plans chief executive 
officer, president, or other authorized person, such as the medical director, will be 
required to provide an electronic attestation to the validity of the plan-generated data in 
IDSS. 
30.1.2 - Final Audit Reports, Use and Release 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
Following the receipt by the MAO of the Final Audit Report from the NCQA-licensed 
audit firm, the MAO must make available a copy of the complete final report to the CMS 
ROs as needed. CMS ROs may request the report upon completion or as part of the pre-
site monitoring visit package. In addition, the reports should be available for review 
onsite during monitoring visits.  CMS will use the Final Audit Reports to support 
contract monitoring and quality improvement activities. CMS may use the assessment of 
the MAO's administrative and information systems capabilities that are contained in the 
audit report and may use the data to conduct post-submission validation. Final Audit 
Reports are subject to the Freedom of Information Act (FOIA). CMS will follow the 
FOIA requirements regarding any release of such report and will make a determination 
about the release of information in each audit report on a case-by-case basis.  
Information that both the MAO and CMS deem proprietary will not be released, unless 
 
  otherwise required by applicable law. 
30.2 - Medicare HOS Requirements 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
HOS reporting requirements specify that MAOs with Medicare contracts in effect on or 
before January 1 of the preceding year report the Baseline HOS, provided they have a 
minimum enrollment of 500 members as of February 1 of the current year.  In addition, 
all continuing MAOs that participated in the Baseline survey two years prior are required 
to administer a Follow-Up survey regardless of whether they meet the current years 
enrollment threshold. 
 
The following organizations with plan contracts in effect on or before January 1 of the 
previous year are included in the HOS: 
 
  All coordinated care contracts, including PFFS and MSA contracts; 
  Section 1876 cost contracts even if they are closed for enrollment;  
  Employer/union only direct PFFS contracts. 
 
Additionally, MAOs sponsoring fully integrated dual eligible (FIDE) SNPs may elect to 
report HOS at the FIDE SNP level to determine eligibility for a frailty adjustment payment 
under the Affordable Care Act, similar to those payments provided to PACE programs. 
Voluntary reporting will be in addition to the standard HOS requirements for quality 
reporting at the contract level.  
 
The Veterans RAND 12-Item Health Survey (VR-12), supplemented with additional case-
mix adjustment variables and four HEDIS Effectiveness of Care measures, will be used 
to solicit self-reported information from a sample of Medicare beneficiaries for the 
HEDIS functional status measure, HOS.  This measure is the first "outcomes" measure 
for the Medicare managed care population.  Because it measures outcomes rather than the 
process of care, the results are primarily intended for population-based comparison 
purposes, by reporting unit.  The HOS measure is not a substitute for assessment tools that 
MAOs are currently using for clinical quality improvement. Each year a baseline cohort 
will be drawn and 1,200 beneficiaries per reporting unit (i.e., contract) will be surveyed. If 
the contract-market has fewer than 1,200 eligible members, all will be surveyed. 
 
Additionally, each year the cohort measured two years previously at baseline will be 
resurveyed. The results of this re-measurement will be used to calculate a change score 
for the physical health and emotional well-being of each respondent.  Depending on the 
amount of expected change, the respondents physical and mental health status will be 
categorized as better, the same or worse than expected over the two-year period.  
Members who are deceased at follow-up are included in the worse physical outcome 
category.  Beneficiary level results are aggregated to derive the MAO, state, and HOS 
national percent better, same, and worse than expected values. 
 
To expedite the survey process, MAOs may be asked to provide telephone numbers or 
 
  verify telephone numbers for the respondents unable to be identified using other means. 
MAOs, at their expense, are expected to contract with any of the NCQA certified vendors 
for administration of the survey to do both the new baseline cohort and the re- 
measurement cohort (if the MAO participated when an earlier cohort was drawn for 
baseline measurement).  Contracts with vendors are expected to be in place by January of 
each reporting year to ensure survey implementation by early-April of the reporting year. 
Further details will be provided by NCQA regarding administration of the survey the 
preceding fall. 
30.2.1 - HOS-Modified 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
The HOS-Modified (HOS-M) is a shorter, modified version of the Medicare HOS and 
contains 6 ADL items as the core items used to calculate an annual frailty adjustment 
factor for PACE organizations. The survey also includes 12 physical and mental health 
status questions from the VR-12.  The HOSM survey is crosssectional, measuring 
the physical and mental health functioning of beneficiaries at a single point in time. 
 
HOS-M reporting requirements specify that all PACE organizations with a Medicare 
contract in effect on or before January 1st of the previous year and a minimum enrollment 
of 30 report the HOS-M for current year reporting. 
 
Similar to the HOS, the HOS-M design is based on a randomly selected sample of 1,200 
individuals from each participating PACE Organization.  All eligible members are 
included in the sample for plans with populations of less than 1,200. 
 
The survey protocols for the HOS and HOS-M data collection efforts are similar.  The 
HOS and HOS-M technical specifications are updated annually by NCQA and published 
each February in HEDIS Volume 6: Specifications for the Medicare Health Outcomes 
Survey.  Additional information is available from NCQAs web site at 
http://www.ncqa.org under HEDIS and Quality Measurement. 
 
30.2.2 - HOS Data Feedback 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
Individual member level data will not be provided to plans after baseline data collection. 
However, organizations will receive the following from CMS: 
 
1.  HOS Baseline Report - This report will be made available to all plans participating 
in the previous year's baseline cohort.  This quality improvement tool, which 
presents an aggregate overview of the baseline health status of each MAO's 
Medicare enrollees, was developed and extensively tested to ensure that MAOs 
would find the data useful and actionable.  Each MAOs QIO will also receive 
electronic copies of the baseline reports and is available to collaborate with MAOs 
on interpreting the data, identifying opportunities to improve care, assisting with 
planning effective, measurable interventions, and evaluating and monitoring the 
 
  results of your interventions.  Using data from the HOS to plan and conduct a 
quality improvement project may fulfill one of the QI program requirements.  All 
report distribution occurs electronically through HPMS. MAOs are also alerted of 
all HOS report and data availability through HPMS. 
 
2.  HOS Performance Measurement Report and Data - After the administration of 
each follow up cohort, a cohort specific performance measurement report is 
produced. Survey responses from baseline and follow up are merged to create a 
performance measurement data set. The HOS performance measurement results 
are computed using a rigorous case mix/risk adjustment model. The resulting 
aggregation of these scores across beneficiaries within a plan yields the HOS plan 
level performance measurement results. The performance measurement reports 
and corresponding data results are designed to support MAO quality improvement 
activities. 
 
3.  HOS-M Summary Reports - After each yearly administration of the Medicare 
HOS-M, a plan specific report is produced and is available for each organization 
participating in the survey. The HOS-M report focuses on PACE plans serving 
frail and elderly beneficiaries, and provides a summary of demographic 
information, physical and mental health status, and selected health status 
measures. The corresponding beneficiary level data for a report are also made 
available to participating PACE plans. 
 
All distribution of HOS-M reports occurs electronically to participating PACE 
organizations through HPMS.  Plans are also alerted of report and data 
availability through HPMS. 
 
4.  Survey Vendor Reports - The vendors administering the survey may provide you 
with reports on the progress of mail and telephone survey administration. Each 
report may consist of data on the number of surveys issued during the first and 
second survey mailings, the number of surveys returned completed or partially 
completed, the number of sampled members for whom a survey could not be 
obtained (e.g., due to death, disenrollment, language barrier), and mail and 
telephone response rate calculations. 
 
MAOs should not ask their survey vendor for additional analyses or member specific 
data. They are prohibited from providing this type of information.  Requests for 
interpretation of the data or more detailed analyses of the data should be directed to each 
MAOs State QIO. 
30.3 - Medicare CAHPS Requirements 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
The following organizations types of MAOs are included in the CAHPS survey 
administration provided that they have a minimum enrollment of 600 eligible members as 
of July 1st of the previous year. 
 
   
  All MA organizations, including all coordinated care contracts, PFFS, and MSA 
contracts. 
 
  1876 cost contracts even if they are closed for enrollment. 
 
  Employer/union only contracts. 
 
The Programs of All Inclusive Care for the Elderly (PACE) and HCPP 1833 cost 
contracts are excluded from the CAHPS administration. 
 
Medicare Advantage organizations and 1876 cost contracts are required to contract with 
an approved MA & PDP CAHPS vendor for the survey administration.  A list of 
approved survey vendors is available on www.MA-PDPCAHPS.org.  All approved 
survey vendors are trained by the CMS CAHPS Survey Coordination team. 
 
CMS issues HPMS memorandums about the CAHPS survey each year. 
 
If an approved CAHPS vendor does not submit a contracts CAHPS data by the data 
submission deadline, the contract will automatically receive a rating of one star for the 
required CAHPS measures for the data that are updated on Medicare Plan Finder (in the 
fall) which also impacts the MA Quality Bonus Payments. 
 
For additional information on the CAHPS survey, please email mp-
cahps@cms.hhs.gov. 
40  Medicare Advantage (MA) Deeming Program Overview 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.156, 422.157, 422.158 
 
Under section 1852(e)(4) of the Act, CMS established and oversees a program which 
allows private, national accrediting organizations (AOs) to deem compliance with certain 
Medicare requirements. The AOs may only grant deemed status for MAOs that it has 
fully accredited (and periodically re-accredited).  
 
Accreditation is an evaluative process (usually involving both on and off site surveys) in 
which a health care organization chooses to undergo an examination of its policies, 
procedures and performance by an external organization (accrediting body). . 
In addition to the standard accreditation process, an MAO may pay an additional 
fee to have the AO conduct various reviews that allow the AO to deem that the 
MAO is compliant with certain Medicare requirements.  
 
To deem an MAO, the AO must use standards (and the process for monitoring 
compliance) that CMS determines are no less stringent than the applicable Medicare 
requirements. 
 
   
Additionally, the AO is responsible for enforcing compliance on the accredited MAO 
when deficiencies are found in those areas to which the deemed status applies. AOs who 
obtain deeming authority are responsible for ensuring that MAOs meet the deeming 
requirements established by CMS.  
 
Organizations that seek the authority to deem must meet CMSs definition of a 
private, national AO, by demonstrating the following: 
 
1.  It is recognized as an accrediting body by the managed care industry and relevant 
national associations; 
 
2.  It has accredited and/or re-accredited MAOs in multiple states; 
 
3.  It contracts with or employs staff who are appropriately trained and have 
experience with monitoring managed care plans for compliance with the AOs 
specific accrediting standards; and 
 
4.  It contracts with or employs sufficient staff to provide accreditation services 
nationwide. 
40.1 - Deeming Requirements   
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.156 (a), (b), and (c); 423.165(b) (1), (2) and (3) 
 
As provided under section 1852(e)(4) of the Act,  MAOs may seek deeming for certain 
Medicare requirements in the following areas: 
 
1.  Quality assessment and improvement; 
 
2.  Confidentiality and accuracy of medical or other enrollee health records;  
 
3.  Anti-discrimination; 
 
4.  Access to services; 
 
5.  Information on advance directives; 
 
6.  Provider participation rules; 
 
Additionally, under 1860D-4(j) of the Act, Part D plan sponsors may seek deeming for 
certain Medicare requirements in the following areas: 
 
7.  Access to covered drugs;1 
 
 
  8.  Drug utilization management, quality assurance measures and systems, 
medication therapy management, and a program to control fraud, waste and 
abuse;1 and 
 
9.  Confidentiality and accuracy of enrollee prescription drug records.1 
 
The MAOs deemed status is effective on the later of: 
 
1.  The date on which the AO is approved by CMS; or 
2.  The date the MAO is deemed by the AO.  
40.2 - Deemed MAOs 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.156 (d) 
 
MAOs that seek deemed status via accreditation by a CMS-approved AO can include 
the cost of accreditation as an administrative cost in the construction of its bid 
submission.  Administrative costs that bear a significant relationship to the MA plan 
seeking deemed status are allowed to be included.  However, the cost for the 
accreditation should be allocated between an MAOs Medicare and non-Medicare 
lines of business using an appropriate cost allocation method, consistent with the bid 
instructions.  
 
1.  If an MAO decides to pursue deeming, the AO conducts its review of the MAO. 
a.  If the MAO has an accreditation decision that included its Medicare line of  
business (or the Medicare population was part of the overall accreditation 
review) and the AO used the standards that it submitted in its application 
for MA deeming authority, an agreement that relates specifically for MAO 
deemed status is signed.  The AO will only review the supplemental MA 
standards that were added to the AOs accreditation program in order for 
the AO to be granted MA deeming authority. 
 
b.  If this is a first time accreditation review or the organization is seeking 
reaccreditation with deemed status, an agreement is signed. The AO will 
review the MAO by using the AOs entire accreditation program for 
managed care plans (its regular accreditation program plus the MAO 
supplement). 
 
2.   The AO notifies CMS that the MAO has been approved for deemed status.  The AO 
will provide the date of the deemed status accreditation, the MAOs contract 
number, and any additional information that CMS may require. 
 
3.  CMS enters the deemed status into HPMS. 
                                                 
1 Please note that items 7-9 have not yet been implemented into the deeming program. 
 
   
40.2.1 - Deemed Status and Surveys 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.156(d) (1), (2) 
 
As noted in section 40.1 of this chapter, to be granted deemed status, an MAO must be 
accredited and periodically re-accredited by a CMS-approved AO.  In addition, an MAO 
deemed to meet Medicare requirements must submit to surveys to validate its AOs 
accreditation process. 
 
There are two types of validation surveys: 
 
1.  Observational (commonly referred to as concurrent); and  
 
2.  Retrospective (or look behind) surveys. 
 
An MAO that seeks deemed status must also agree to authorize its AO to release to CMS a 
copy of its most current accreditation survey, as well as any survey-related information 
that CMS may require (including CAPs and summaries of unmet CMS requirements). 
 
MAOs that are accredited by CMS-approved AOs   are still subject to CMS surveys. As 
noted, an approved accrediting organization may only deem an MAO for one or more of 
the nine areas described in section 40.1 of this chapter. If the AO only has deeming 
authority in one of the nine2 deemable areas, such as access to services, then CMS may 
conduct a survey to assess the other 8 areas, as well as non-deemable requirements such 
as grievances and appeals, beneficiary disclosure, marketing, enrollment, and organization 
determinations. CMS always retains the authority to investigate complaints about an 
MAO. 
40.2.2 - Removal of an MAOs Deemed Status 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.156(e) 
 
CMS will remove part or all of an MAOs deemed status if: 
 
1.  CMS determines, based on its own evaluation, that the MAO does not meet 
the Medicare requirements for which deemed status was granted; 
 
2.  CMS withdraws its approval of the AO that accredited the MAO; and/or 
 
3.  The MAO fails to meet the obligations of a deemed MAO, which are 
                                                 
2 Please note that only 6 of the 9 deeming requirements have been implemented into the deeming program. 
 
  addressed in section 40.2.2 of this chapter. 
 
CMS will not overrule an AOs decision without doing its own investigation.  
However, if CMS evaluation reveals that a condition is not met, CMS reserves the 
right to remove deemed status even though the AO has not removed accreditation 
with respect to that condition. 
 
Additionally, if CMS withdraws its approval of deeming authority from an AO, all 
MAOs with deemed status provided by that AO, will also be withdrawn.  The MAO 
will be notified of the withdrawal of deemed status via a public notice.  The AO must 
notify all its accredited MAOs within 10 days.  Upon removal of an MAOs deemed 
status, CMS immediately resumes responsibility for ensuring that the organization 
meets Medicare program requirements. 
40.3 - CMSs Role in Deeming 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.157(a)(d) 
 
CMS has many different roles in the deeming program. For example, CMS approves 
the applications of the organizations that are applying for the authority to deem. CMS 
may approve the organization for deeming authority if it demonstrates that its 
accreditation program is at least as stringent as CMS and it meets the application 
requirements described in section 40.4.1 of this chapter. CMS must approve an AO by 
deeming area, rather than by individual requirement.  However, an AO must have a 
comparable standard for every one of the MAO requirements within a deeming area. 
 
As mentioned above, CMS conducts validation surveys and other audits to ensure 
compliance with Medicare program requirements. CMS also conducts monitoring of 
non-deemable requirements. If, during the course of monitoring for non-deemable 
requirements, CMS staff determines that an MAO is not in compliance with a 
requirement for which it has been deemed, it will notify the AO of the failure; to ensure 
the AO initiates a corrective action process, when and if appropriate. CMS will not issue 
the corrective action requirement for deficiencies found in deemed areas. 
40.3.1 - Oversight of AOs 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.157(d) 
 
After approving an AO for deeming authority, CMS provides oversight of the AOs 
performance.  CMS has a number of mechanisms available to fulfill its oversight 
responsibilities, including: 
 
1.  Conducting equivalency reviews if CMS or the AO adds or changes requirements; 
 
2.  Conducting validation surveys to examine the results of the AOs survey; 
 
   
3.  Conducting onsite observations of the AOs operations and offices to verify the 
organizations representation and assess the organizations compliance with its 
own policies and procedures; and 
 
4.  Investigating accredited MAOs in response to serious complaints.  
 
If CMS staff detects a pattern of complaints in deemed areas, they contact the 
appropriate AO. 
40.3.2 - Enforcement Authority 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.156(f) 
 
CMS retains the authority to initiate enforcement actions against any MAO that it 
determines, on the basis of its own evaluation, no longer meets the Medicare 
requirements for which deemed status was granted. Enforcement actions may include the 
imposition of intermediate sanctions and civil money penalties (42 CFR 422 Subpart O) 
or the termination or non-renewal of the MAOs contract (42 CFR 422 Subpart K). 
40.3.3 - Withdrawal of Approval 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.157(d)(4) 
 
If an equivalency review, validation review, onsite observation, or CMS daily 
experience with the AO suggests that the AO is not meeting the requirements specified 
in 42 CFR 422, Subpart D, CMS will give the AO written notice of its intent to 
withdraw approval. 
 
CMS may withdraw an AOs approval for deeming authority at any time, if CMS 
determines that: 
 
  Deeming based on accreditation no longer guarantees that the MAO meets the 
requirements, and failure to meet those requirements could jeopardize the health or 
safety of Medicare enrollees and constitutes a significant hazard to the public 
health; or 
 
  The AO has failed to meet the obligations specified in sections 40 and 40.4 of this 
chapter. 
40.4 - Obligations of AOs with Deeming Authority 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.157 
 
 
  AOs must apply and enforce the standards that CMS determines, as a condition of 
approval, are at least as stringent as the applicable Medicare requirements. To be 
approved, an AO must comply with the application and reapplication procedures that are 
addressed in section 40.4.1 of this chapter. 
 
To prevent conflicts of interest, AOs must ensure the following: 
  When the AO deems an MAO, any individual associated with the AO who is also 
associated with the MAO, does not influence the deeming decision concerning 
that MAO; 
  That the majority of the membership of the AOs governing body is not comprised 
of managed care organizations or their representatives;  
  The AOs governing body acts without bias and has a broad and balanced 
representation of interests.  
To avoid actual conflicts of interests (or the appearance of conflicts of interests), CMS 
encourages any personnel involved in a conflict to recuse themselves from the deeming 
process for the MAO in conflict. 
Additionally, if CMS takes an adverse action based on accreditation findings, the 
approved AO must permit its surveyors to serve as witnesses. 
40.4.1 - Reporting Requirements 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.157(c) 
 
When an AO is approved by CMS for deeming authority, the AO agrees to certain 
ongoing activities, including: 
 
1.  Providing to CMS, in written form and on a monthly basis, all of the following: 
 
a.  Copies of all accreditation surveys, together with any survey-related 
information that CMS may require (including CAPs and summaries of unmet 
CMS requirements); 
 
b.  Notice of all accreditation decisions; 
 
c.  Notice of all complaints related to deemed MAOs; 
 
d.  Information about any MAO against which the AO has taken remedial or 
adverse action, including revocation, withdrawal or revision of the MAOs 
accreditation within 30 days of taking the action; and 
 
e.  Notice of any proposed changes to its accreditation standards or requirements 
or survey process. If an AO implements any changes before or without CMS 
approval, CMS may withdraw its approval. 
 
   
2.  If an AO finds a deficiency in an MAO that poses an immediate jeopardy to the 
organizations enrollees or to the general public, it must give CMS written notice 
of the deficiency within three days of identifying the deficiency. 
 
3.  When CMS gives notice that it is withdrawing its approval for deeming authority, 
the AO must notify all its accredited MAOs within 10 days. 
 
4.  AOs must provide, on an annual basis, summary data to be specified by CMS that 
relate to the past years accreditation activities and trends. 
 
5.  Within 30 days after CMS changes a Medicare MAO requirement, the AO must: 
 
a.  Send a written acknowledgement of CMS notice of the change; 
b.  Submit a new crosswalk reflecting the new requirement; and 
c.  Send a written explanation of how it plans to alter, within a time frame that 
CMS will specify in the notice of change, its standards and review process to 
conform to CMS new requirement. 
 
6.  AOs must have a mechanism for publicly disclosing the results of an MAOs 
accreditation survey. 
 
Accreditation surveys of MAOs performed by private AOs under section 1852(e)(4) of 
the Act may not be released to the public by CMS, except to the extent that such surveys 
relate to an enforcement action taken by the Secretary. AOs must, however, have 
methods to disclose the accreditation status of deemed MAOs. 
40.4.2 - Application Requirements 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.158 
 
A private, national AO may seek deeming authority for any or all of the 9 categories 
listed in section 40.1 of this chapter.  For each deeming category for which the AO is 
applying for deeming authority, it must, demonstrate that its standards and processes 
meet or exceed Medicare requirements within that particular category. 
 
A private, national AO applying for approval must furnish to CMS all of the following 
materials. When reapplying for approval, the organization need furnish only the 
particular information and materials requested by CMS. 
 
1.  The type(s) of MA coordinated care plans that they seek authority to deem; 
 
2.  A crosswalk that provides a detailed comparison of the organizations 
accreditation requirements and standards with the corresponding Medicare 
requirements; 
 
   
3.  A detailed description of the organizations survey process for each type of MAO 
it is seeking authority to deem, including: 
 
a.  Frequency of surveys performed, whether the surveys are announced or 
unannounced, and how far in advance surveys are announced; 
 
b.  Copies of survey forms and guidelines and instructions to surveyors; 
 
c.  A description of the organizations survey review and accreditation status 
decision making process; 
 
d.  The procedures used to notify accredited MAOs of deficiencies and the 
procedures to monitor the correction of those deficiencies; and 
 
e.  Procedures the organization uses to enforce compliance with their 
accreditation requirements; 
 
4.  Detailed information about the individuals who perform surveys for each type of 
MAO that the organization seeks authority to deem, including: 
 
a.  The size and composition of and the methods of compensation for its 
accreditation survey teams; 
 
b.  The education and experience requirements surveyors must meet to participate 
in its accreditation program; 
 
c.  The content and frequency of the in-service training provided to survey 
personnel; 
 
d.  The evaluation system used to monitor the performance of individual 
surveyors and survey teams; and 
 
e.  The policies and practices with respect to participation in surveys or in the 
accreditation decision process pertaining to an individual who is professionally 
or financially affiliated with the entity being surveyed. 
 
5.  A description of the data management and analysis system with respect to surveys 
and accreditation decisions, including the kinds of reports, tables, and other 
displays generated by the organizations data system; 
 
6.  The procedures it will use to respond to and investigate complaints or identify 
other problems with accredited organizations, including coordination of these 
activities with licensing bodies and ombudsmen programs; 
 
7.  The policies and procedures regarding withholding, denying and removal of 
 
  accreditation for failure to meet the organizations standards and requirements, 
and other actions the organization will take in response to non-compliance with 
their standards and requirements; 
 
8.  The policies and procedures regarding how the organization deals with 
accreditation of organizations that are acquired by another organization, have 
merged with another organization, or that undergo a change of ownership or 
management; 
 
9.  A description of all the types (full, partial, or denial) and categories (provisional 
conditional, or temporary) of accreditation offered by the  organization, the duration 
of  each category of accreditation, and a statement identifying the types and 
categories that would serve as a basis for accreditation if CMS grants the 
organization MA deeming authority; 
 
10. A list of all the MAOs that the organization has currently accredited, by State an 
type, and the category of accreditation and expiration date of accreditation held by 
each organization; 
 
11. A list of all the managed care organizations (MCOs) that the organization has 
surveyed in the past three years, the date each was accredited (if denied, the date it 
was denied), and the level (category) of accreditation it received; 
 
12. A list of all managed care surveys scheduled to be performed by the organization 
within the next 3 months indicating organization type, date, state, and whether 
each MCO is an MAO; 
 
13. The name and address of each person with an ownership or controlling interest in 
the AO; 
 
14. A written presentation that demonstrates that it will be able to furnish data 
electronically, in a CMS compatible format; 
 
15. A resource analysis that demonstrates that the organizations staffing, funding, and 
other resources are adequate to perform the required surveys and related activities. 
The resource analysis should include financial statements for the past 3 years 
(audited if possible) and the projected number of deemed status surveys for the 
upcoming year; and 
 
16. A statement acknowledging that, as a condition of approval, the organization 
agrees to comply with the ongoing responsibility requirements that are addressed 
in section 40 of this chapter. 
 
If CMS determines that it needs additional information for a determination to grant or 
deny the AOs request for approval, it will notify the AO and allow it time to provide 
the additional information. 
 
   
As part of the application process, CMS may visit the AOs offices to verify 
representations made by the organization in its application, including, but not limited to, 
reviewing documents, auditing meetings concerning the accreditation process, evaluating 
survey results or the accreditation status decision-making process, and interviewing the 
organizations staff. 
40.4.3 - Application Notices 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.158(e) 
 
Each application will be reviewed for completeness. Approximately 60 days after an 
application has been determined to be complete, CMS will publish a proposed notice in 
the Federal Register. This notice will announce that CMS has received an application 
from the AO and is considering granting the organizations application for MAO 
deeming authority. The proposed notice will also describe the criteria that CMS will 
use in evaluating the applications. CMS will provide a 30-day period for the public to 
comment on the proposed notice. 
 
After an application is determined to be complete, CMS has a 210-day period to review 
the application and the comments from the proposed notice. At the end of the 210 days, 
CMS will publish a final notice in the Federal Register indicating whether it has granted 
the AOs request for approval. If CMS has granted the request, the final notice will specify 
the effective date of the deeming authority and the term of approval for deeming authority, 
which may not exceed six years. 
 
Within 210 days of receipt of its completed application, CMS must provide the AO with 
a formal notice that: 
 
1.  Approves or denies the request; 
 
2.  Provides a detailed rationale in the case of a denial; and 
 
3.  Describes the reconsideration and reapplication procedures. 
 
For information regarding reconsideration of adverse determinations 
refer to section 40.4 of this chapter. 
40.4.4 - Withdrawing an Application 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
An AO may withdraw its application for approval at any time before it receives the 
formal notice of determination specified above. 
 
 
  40.5 - Reconsideration of a Decision to Deny, Remove or Not Renew 
Deeming Authority 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 422.158 
 
An AO that has received a notice of denial of its request for deeming authority (or 
specific deeming categories) may request reconsideration in accordance with the Subpart 
D of part 488.  CMS will reconsider any determination to deny, remove, or not renew the 
approval of deeming authority to private AOs, if the AO files a written request for 
reconsideration. The request must be filed within 60 days of the receipt of notice of the 
adverse determination. The request for reconsideration must specify the findings or issues 
with which the AO disagrees, and the reasons for the disagreement. 
 
In response to a request for reconsideration, CMS will provide the AO the opportunity 
for an informal hearing that will be conducted by a hearing officer appointed by the 
Administrator of CMS. The informal hearing will also provide the AO the opportunity to 
present in writing or in person, evidence or documentation to refute the determination to 
deny approval, or to withdraw or not renew deeming authority. 
40.5.1 - Informal Hearing Procedures 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 488.158(g), 488.201-488.211 
 
CMS will provide written notice of the time and place of the informal hearing at least10 
calendar days before the scheduled date. The hearing will be conducted in accordance 
with the following procedures: 
 
1.  The hearing is open to CMS and the organization requesting the re-consideration, 
including: 
 
  Authorized representatives; 
 
  Technical advisors (individuals with knowledge of the facts of the case or 
presenting interpretation of the facts); and 
 
  Legal counsel; 
 
2.  The hearing is conducted by the hearing officer who receives testimony and    
documents related to the proposed action; 
 
3.  The hearing officer may accept testimony and other evidence even though it  
would be inadmissible under the usual rules of court procedures; 
 
4.  Either party may call witnesses from among those individuals specified in this 
 
  section. 
 
5.  The hearing officer does not have the authority to compel by subpoena the 
production of witnesses, papers, or other evidence. 
40.5.2 - Informal Hearing Findings 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
42 CFR 488.209 
 
Within 30 days of the close of the hearing, the hearing officer will present the findings and 
recommendations to the AO that requested the reconsideration. The written report of the 
hearing officer will include separately numbered findings of fact and the legal conclusions 
of the hearing officer. 
40.5.3 - Final Reconsideration Determinations 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
The hearing officers decision is final unless the CMS Administrator, within 30 days of 
the hearing officers decision, chooses to review that decision. The CMS Administrator 
may accept, reject, or modify the hearing officers findings. Should the CMS 
Administrator choose to review the hearing officers decision, the Administrator will issue 
a final reconsideration determination to the AO on the basis of the hearing officers 
findings and recommendations and other relevant information. The reconsideration 
determination of the CMS Administrator is final. The final reconsideration determination 
against an AO will be published by CMS in the Federal Register. 
 
50 - Definitions 
(Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 
Unless otherwise stated in this chapter, the following definitions apply: 
 
Accreditation 
 
An evaluative process (usually involving both on and off site surveys) in which a health 
care organization chooses to undergo an examination of its policies, procedures and 
performance by an external organization (accrediting body).  
 
Accreditation Cycle for Medicare Advantage (MA) Deeming 
 
The duration of CMSs recognition of the validity of an accrediting organizations 
determination that a MAO is fully accredited. 
 
  Accrediting Organization (AO) 
A private, national accreditation organization that has been approved and authorized by 
CMS to deem that a MAO is in compliance with certain Medicare requirements. 
 
Annual Update 
The Annual Update is comprised of the information required in the components of the 
Do, Study, and Act sections of the Plan-Do-Study-Act quality improvement model 
specific to the CCIP and QIP initiatives.   
 
Benchmarking 
The process of measuring products, services, strategies, processes, and practices against 
known leaders/best-in-class companies/entities. 
 
Chronic Care Improvement Program (CCIP) 
An initiative with a clinical focus that includes interventions designed to improve the 
health of individuals who live with multiple or sufficiently severe chronic conditions, and 
includes patient identification and monitoring. Other programmatic elements may include 
the use of evidence-based practice guidelines, collaborative practice models involving 
physicians as well as support-services providers, and patient self-management techniques. 
 
Consumer Assessment of Healthcare Providers and Systems (CAHPS) 
A patients perspective of care survey, administered annually, in which a sample of 
members from provider organizations (e.g., MAOs, PDPs, PFFS) are asked for their 
perspectives of care that allow meaningful and objective comparisons between providers on 
domains that are important to consumers; create incentives for providers to improve their quality 
of care through public reporting of survey results; and enhance public accountability in health 
care by increasing the transparency of the quality of the care provided in return for the public 
investment. 
 
Corrective Action Plan (CAP) 
A formal process where CMS informs an MAO that it is out of compliance with one or 
more CMS requirements. The CAP may result from an audit or result from other ad-hoc 
compliance events unrelated to an audit. 
 
Deemed Status 
A designation granted to an MAO which concludes that the MAO has been reviewed by an 
AO for those standards within the categories that the AO has the authority to deem on 
behalf of CMS. 
 
Deeming Authority 
The authority granted by CMS to AOs to determine, on CMS behalf, whether a MAO 
evaluated by the accrediting organization is in compliance with certain Medicare 
requirements. 
 
Equivalency Review 
The process CMS employs to compare an AOs standards, processes and enforcement 
 
  activities to the comparable CMS standards, processes and enforcement activities. 
 
Fully Accredited 
Fully accredited is a designation that all the elements within the accreditation standards 
have been surveyed and fully met or have otherwise been determined to be acceptable 
without significant adverse findings, recommendations, required actions or corrective 
actions. 
 
Goal 
The measurable outcome of the process under study in QIPs and CCIPs.  
 
Healthcare Effectiveness Data and Information Set (HEDIS) 
A widely used set of health plan performance measures utilized by both private and 
public health care purchasers to promote accountability and assess the quality of care 
provided by managed care organizations. 
 
Health Outcomes Survey (HOS) 
The first outcomes measure used in the Medicare program. It is a longitudinal, self- 
administered survey that uses a health status measure, the VR-12, to assess both physical 
and mental functioning. A sample of members from each MAO health plan is surveyed. 
Two years later these same members are surveyed again in order to evaluate changes in 
health status.  
 
Health Outcomes Survey - Modified (HOS-M) 
The HOS-M is a modified version of the Medicare HOS. The HOS-M is administered to 
Medicare beneficiaries enrolled in Programs of All Inclusive Care for the Elderly 
(PACE). The instrument assesses the physical and mental health frailty level of the 
Program members to generate information for payment adjustment. 
 
National Committee for Quality Assurance (NCQA) 
A private, 501(c)(3) not-for-profit organization that has contracted with CMS to develop 
a set of measures to evaluate the structure, processes, and performance of SNPs. 
 
Quality 
The Institute of Medicine (IOM) defines quality as the degree to which health services 
for individuals and populations increase the likelihood of desired health outcomes and are 
consistent with current professional knowledge. 
 
Quality Improvement Organization (QIO) 
Formerly known as Peer Review Organization, this is an entity that CMS contracts with in 
each state to fulfill provisions in Title XI of the Act as amended by the Peer Review 
Improvement Act of 1982. These provisions relate to improving the quality of care for 
Medicare beneficiaries, protecting the integrity of the Medicare Trust Fund by ensuring 
that payments for services are reasonable and medically necessary and protecting 
beneficiaries by addressing care related complaints and other beneficiary issues. 
 
 
  Quality Improvement Project (QIP) 
An initiative that focuses on specified clinical and/or non-clinical areas. 
 
Sample 
A subgroup of units chosen from a diffuse and statistically representative group of units or 
population. 
 
Unit of Analysis for Deeming 
For deeming, CMS will recognize the deemed status of MAOs if they are accredited at 
the same jurisdictional level (whether contract, state, or multi-state) that CMS would 
have used it, rather than the AO, had conducted the survey. 
 
  Transmittals Issued for this Chapter 
Rev #  Issue Date  Subject  Impl Date  CR# 
R117MCM 08/08/2014  Chapter 5, "Quality Improvement Program"  08/08/2014 N/A 
R100MCM 08/05/2011  Chapter 5, "Quality Improvement Program"  08/05/2011 N/A 
R78MCM  01/20/2006  Revisions to Chapter 5, "Quality  N/A  N/A 
Improvement" 
R65MCM  03/18/2005  Surveys, Contracting Strategy and Appeals  N/A  N/A 
R64MCM  12/03/2004  Surveys, Contracting Strategy, Grievances  N/A  N/A 
and Appeals 
R63MCM  11/12/2004  Home Health Services  N/A  N/A 
R58MCM  08/13/2004  Definition of Fully Accredited Status  N/A  N/A 
R39MCM  11/14/2003  Submitting Patient Level Data  N/A  N/A 
R32MCM  10/03/2003  CAHPS and HEDIS  N/A  N/A 
R29MCM  08/01/2003  Chapter Reorganization  N/A  N/A 
R16MCM  09/27/2002  PPO/PFFS Quality improvement  N/A  N/A 
Requirements 
R13MCM  09/11/2002  HEDIS and QAPI  01/01/2004 N/A 
R10MCM  08/14/2003  Miscellaneous Changes  N/A  N/A 
R05MCM  01/02/2002  Miscellaneous Changes  01/02/2002 N/A 
R03MCM  10/01/2001  Initial Issuance of Chapter  N/A  N/A 
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