Laura Zwolinski: Greetings, and welcome! This is the second of four special needs plans model of care trainings for Contract Year 2027. Laura Zwolinski: Today, we will concentrate our review on MOC2, which covers care coordination for SNP enrollees. We look forward to reviewing the MOC2 requirements with you, and detailing the key changes made to component elements and factors for contract year 2027. Laura Zwolinski: Again, my name is Laura Zielinski, I am the NCQA Task Lead for the SNP Model of Care Review Activities, and I am joined today by my colleagues Sri Patel and Madeline Vamcott. Laura Zwolinski: Next slide, please. Laura Zwolinski: Today's training session will include a housekeeping refresher of important topics reviewed during the MOC1 training that we think are helpful to reiterate. Laura Zwolinski: A detailed review of the six care coordination elements included in MOC2 and their component factors. Laura Zwolinski: We'll recap training information. Laura Zwolinski: And then remind plans about the post-training survey that is available for you to provide feedback to us. Laura Zwolinski: Next slide. Laura Zwolinski: We're going to start off by reviewing some housekeeping items. We understand that we reviewed these items during the MOC1 training, but believe that this is helpful contextual information for plans or attendees who do not watch the trainings in order. Please feel free to fast-forward through this information if you've already listened to it. Laura Zwolinski: In terms of the training format for contract year 2027, we pre-recorded four separate training sessions. Each one is specific to one of the four MOC standards. Laura Zwolinski: All four of these recordings are available on NCQA's SNP approval website. Laura Zwolinski: We strongly encourage you to watch all four of these trainings. Laura Zwolinski: NCQA and CMS will continue to hold two pre-submission technical assistance, or TA, calls, to create a form in which plans can pose live questions. Laura Zwolinski: The first of these sessions will take place from 2 to 4 p.m. Eastern Standard Time. Laura Zwolinski: on March 19th, 2026, and the second will take place from 2 to 4 p.m. Eastern Standard Time on April 16th. Laura Zwolinski: These TA calls will be recorded and made available to plans via the SNP approval website. Laura Zwolinski: As questions arise for you during today's session on MOC2, please document your questions so that they are ready for you to ask during the TA calls. Laura Zwolinski: Lastly, we'd like to collect planned feedback on our training sessions so that we can continue to improve them. Laura Zwolinski: At the end of the slide deck for this training, there will be a link that directs you to an online evaluation survey. Laura Zwolinski: We'd like to encourage plans to share your feedback and questions with us. Laura Zwolinski: Next slide Laura Zwolinski: We want to draw your attention to this slide to emphasize some of the high-level changes made for contract year 2027. Laura Zwolinski: First and foremost, we want to underscore that there have been changes made to element and factor requirements. Laura Zwolinski: These changes reflect the revised MOC matrix for contract year 2027, which CMS released in January 2026. Laura Zwolinski: The contract year 2027 SNP Model of Care scoring guidelines were updated to align with this revised MOC matrix and include substantial changes and revisions. Laura Zwolinski: To make sure that you understand the revisions and the corresponding changes that you need to address in your model of care documentation, we strongly encourage you to review this year's Model of Care matrix and scoring guidelines. Laura Zwolinski: As well as to listen carefully to all four training recordings. We also would encourage you to attend the TA calls being held in March and April. Laura Zwolinski: Lastly, given that there have been some substantial shifts in the requirements and the ordering of factors, please make sure that the model of care that you submit for contract year 2027 reflects the element and factor order included in the contract year 2027 scoring guidelines. Laura Zwolinski: This supports a more efficient review process and ensures that your document aligns with the most current guidance. We thank you in advance for your continued efforts to support and improve the MOC review process. Laura Zwolinski: Next slide. Laura Zwolinski: Please note that, throughout the slide deck, new requirements for contract year 2027 are indicated by a red star bullet point. Laura Zwolinski: Items that were clarified for Contract Year 2027 are denoted by an exclamation point bullet. We will emphasize these items throughout today's training session. Laura Zwolinski: In addition, we'd like to note that we have included regulations within the explanations in the contract year 2027 scoring guidelines. Laura Zwolinski: When applicable, we will be sure to emphasize these regulations as we review specific elements and their related factors. Laura Zwolinski: Next slide. Laura Zwolinski: We'd like to note a few things about changes included in the contract year 2027 SNP Model of Care Scoring Guidelines. Laura Zwolinski: Substantive changes and clarifications made to the scoring guidelines are noted in the Summary of Changes section towards the beginning of the description of each element. Laura Zwolinski: The Summary of Changes section includes the significant changes or clarifications made for the three most recent versions of the scoring guidelines. For this year, this includes changes made for contract years 2027, 2026, and 2025. Laura Zwolinski: Any updates made for the current version of the guidelines have been specifically labeled as a CY2027 update. However, those changes made in contract years 2026 or 2025 that still stand are not labeled with the year. Laura Zwolinski: Again, please be sure to carefully review the contract year 2027 Model of Care Matrix. Laura Zwolinski: Scoring guidelines, the current regulations, and review the training slides and recordings carefully so that you understand the updates, additions, and reordering of responses that you need to make in your model of care to align with new or updated requirements. Laura Zwolinski: Next slide, please. Laura Zwolinski: We wanted to remind plants that the contract year 2027 SNP Model of Care Scoring Guidelines are currently posted to NCQA's SNP approval website. Laura Zwolinski: Along with the model of care matrix and all training recordings and associated slide decks. Laura Zwolinski: This is also where you can access login information and details for the upcoming TA calls, and where the recordings from those calls will be posted. Laura Zwolinski: Next slide. Laura Zwolinski: This slide provides an overview of the contract year 2027 SMIT model of care approval timeline. Laura Zwolinski: Please note that the timeline has shifted compared to prior years. Laura Zwolinski: At this point, we've posted the model of care matrix and scoring guidelines, as well as recorded and posted the model of care trainings for Model of Care Standards 1 through 4. Laura Zwolinski: As previously mentioned, NCQA and CMS will host two pre-submission technical assistance calls. Laura Zwolinski: The first will be held on Thursday, March 19th, 2026, and the second will be held on Thursday, April 16th. Laura Zwolinski: Contract year 2027 SNP Model of Care submissions are due in HPMS on Friday, May 29th, 2026, no later than 8 p.m. Eastern Standard Time. Laura Zwolinski: NCQA will download and review the submissions, and subsequently enter scores into HPMS by the end of July. Laura Zwolinski: This submission timeline change aligns with the CMS model of care submission process, with the Medicare Advantage statutory bid submission deadline, and state Medicaid agency contracting processes. Laura Zwolinski: Beginning this year and moving forward, the model of care submission deadline will move to the Friday before the first Monday in June, which is the day final bids are due to CMS. Laura Zwolinski: In 2026, final bids are due to CMS on Monday, June 1st. Laura Zwolinski: NCQA will upload scores to HPMS by the end of July. Then, on Monday, August 3rd, CMS will distribute Notice of Intent to Deny Letters, or NOIDs. Laura Zwolinski: Noise are sent to plans that score less than 50% on any one or more elements. Laura Zwolinski: Or, that score less than 70% overall. Laura Zwolinski: These SNPs are required to address deficiencies during a designated period called the cure. Laura Zwolinski: A TA call with instructions for how to cure documentation will be held on Tuesday, August 4th, and all CURE submissions are due in HPMS by 8pm Eastern Standard Time on Thursday, August 13th. Laura Zwolinski: Following the cure review period, CMS will issue approvals and denials on September 1st. Laura Zwolinski: Next slide. Laura Zwolinski: This slide includes information related to technical assistance. Laura Zwolinski: You can access training recordings as well as training slides and other resources on the NCQA SNP approval website. Laura Zwolinski: We've included the direct link Laura Zwolinski: to the contract year 2027 Model of Care Matrix and scoring guidelines on this slide. Before submitting any inquiries, we do recommend that you first review these training materials. Laura Zwolinski: For inquiries related to model of care requirements or regulation questions. Laura Zwolinski: Please contact CMS at the address included in the middle column of this slide. Laura Zwolinski: And enter SNP MOC Inquiry in the subject line. Laura Zwolinski: Please submit SNP application inquiries via the SNP mailbox. Laura Zwolinski: Type the address included in the right column of this slide, and then select the SNP mailbox. Once you do this, enter SNP application inquiry in the subject line. Laura Zwolinski: And that concludes the housekeeping and general updates section of today's training. Laura Zwolinski: Next slide, please. Laura Zwolinski: We're now going to move into the content of today's training on MOC2, which covers numerous components of care coordination. Laura Zwolinski: With that, I'll go ahead and hand it over to my colleague, Sri, to present the first element in MOC2. Next slide. Shree Patel: Thank you, Laura. Before we dive into the specifics of each of the elements under MOC2, I want to remind plans that the regulations require that all SNPs coordinate the delivery of care and measure the effectiveness of delivery. Shree Patel: This helps ensure that the needs of the SNP enrollees, their preferences for health services, as well as the sharing of that information across healthcare staff and facilities, are continuously evaluated and met over time. Shree Patel: Now we will take a look at MOC 2 Element A, which focuses on SNP staff structure. Next slide, please. Shree Patel: Please note that for contract year 2027, the number of factors in MOC2 Element A has been reduced from 7 to 6. Shree Patel: MOC2 Element A focuses on how the plan's staff structure facilitates care coordination, and how staff work in… to provide effective, efficient, safe, and high-quality care for its enrollees. Shree Patel: There are 6 factors under MOC 2 Element A, and responses to all of these factors should be comprehensive and address care coordination activities. I will now review each factor to highlight requirements and emphasize items that plans should include and fully address in their model of care documentation. Shree Patel: Please note that we have made clarifications in the scoring guidelines, which have been reflected in the training slides. Next slide, please. Shree Patel: For Factor 1, Shree Patel: The plan must describe the clinical staff roles and responsibilities, including clinical oversight functions that both employed and or contracted staff perform. Shree Patel: Previously, some of this information was required in Factor II. Shree Patel: Please note that plans must identify and define staff who directly or indirectly affect care coordination. At minimum, please be sure to identify and detail the staff responsible for the five clinical functions listed in the scoring guidelines for this factor. Shree Patel: These are direct enrollee care and education on health self-management techniques, care coordination, pharmacy consultation, behavioral health counseling, and clinical oversight. Shree Patel: For Factor 2, previously some of this information was required in Factor 3. To meet this factor, you will need to provide a copy of the SNP's organizational chart that includes said staff. Shree Patel: We are not looking for the organizational chart for the entire plan. For example, human resources, payroll department, etc. Shree Patel: If you are unable to embed the org chart within the factor description itself, you must include the organizational chart as an appendix to the model of care documentation. Shree Patel: A separate document upload will not be acceptable. Shree Patel: Please note that we are looking for an organizational structure that includes staff directly or indirectly responsible or involved in enrollee care and coordination only. The departments that should be included in the org chart include clinical oversight, including quality improvement. Shree Patel: Care coordination, direct and early care and education on self-management techniques, pharmacy consultation, behavioral health counseling. Shree Patel: Please note that for both Factor 1 and 2, the organization must specify and make clear whether each role is performed by employed or contracted staff. Shree Patel: Any staff who performs both administrative and clinical staff functions should be clearly outlined. Shree Patel: Plans must specify whether each role is performed by employed or contracted administrative staff. As to note, contracted staff does not refer to in-network providers. Next slide, please. Shree Patel: For Factor 3, plans were previously required to detail their contingency plans to avoid a disruption in care and services when existing staff can no longer perform their roles and meet their responsibilities. To include a description of their plans to ensure an ongoing continuity of critical staff function. Shree Patel: Examples include backup of key staff personnel, turnover, planned and unplanned absences. In prior years, plans may have included some of this information under Factor 4. Shree Patel: Please note that an addition for contract year 2027 requires that plans also describe disaster preparedness and recovery plans in the event of an emergency. Shree Patel: We need to know what types of disruptions may occur, and how the plan attends to address them to avoid potential issues in delivery of care and services to the SNP enrollees. Shree Patel: For Factor 4, the plan is expected to conduct model of care training for both its employed and contracted staff. Contacted staff do not include physicians or other providers or their staff that the plan contracts with as a part of its provider network. Shree Patel: Plans must describe the training strategies and content, as well as the method by which training is conducted. This may include, but is not limited to, face-to-face training, web-based instruction, and audio or video conferencing. Shree Patel: In addition, plans are required to submit a sample of training content. For plans undergoing a renewal, please include a sample of training slides. Shree Patel: The example slides must be specific and substantive. Please do not submit title and or overview slides in the absence of specific training content, as these do not meet the intent of the factor. Shree Patel: If training slides are still under development at the time of initial submission, the plan must instead provide a narrative description of training content. Shree Patel: Please do not provide general information, such as a table of contents or bullet lists with different topic ideas, or areas, in the absence of substantive details. For both the initial and renewal submissions, we really need to understand Shree Patel: what each of the MOC-specific trainings will cover in detail. Shree Patel: This allows us to gauge whether the information being explained to staff is comprehensive enough to make sure that they are equipped with the knowledge and skills needed to take care of the needs of the SNP enrollees. In addition, if training slides cannot be easily embedded within the description of the factor itself. Shree Patel: Please be sure to include them as an appendix. A separate document upload will not be acceptable. Shree Patel: Please note that plans will likely have included these MOC training requirements under Factor 5 last year. Next slide, please. Shree Patel: Factor 5 requires that plans describe how the SNP documents and maintains training records as evidence that employees and contracted staff have actually completed the model of care training. Shree Patel: For example, documentation may include, but is not limited to, the copies of dated attendee lists, results of the model of care competency testing, web-based attendance confirmation, and electronic training records. Shree Patel: Please be sure to detail both the training Shree Patel: Both the tracking and the storage process for this factor for both employed and contracted staff. Shree Patel: In the past years, plans may have included information required to meet this factor under Factor VI. Shree Patel: For Factor VI, plans must describe any challenges associated with the completion of model-of-care training for employed and contracted staff. Further, plans must describe the specific actions that will be taken ensured employed or contracted staff has completed the required training. Shree Patel: Please be sure to fully detail the action steps the SNP will take. A general statement is not specific enough and does not meet the intent of the factor. We need to understand the specific actions that will be undertaken. Shree Patel: In addition, as a part of the description for this factor, please make sure to explain any challenges associated with the completion of model-of-care training for SNP employed and contracted staff. Shree Patel: SNPs may have included some of this information required to meet this factor under Factor VI in previous years. Shree Patel: Next slide, please. Shree Patel: This slide presents a table of the summary of changes for Model of Care to Element A, which are listed in the contract year 2027 scoring guidelines. Shree Patel: First, we wanted to note the overall shift in focus for this element, reducing the number of factors from 7 to 6 by removing former factor 1, and shifting the subsequent factors up. Shree Patel: Factor 3 was expanded to require that plans need to address disaster and emergency preparedness plans in addition to general contingency plans. Shree Patel: Previously clarified Factor IV requirements for the staff training materials based on whether plans are submitting an initial or renewal plan. These requirements still apply in contract year 2027. Shree Patel: For Factor VI, we added that plans are required to outline detailed steps taken to ensure completion of staff MOC training. Next slide, please. Shree Patel: That brings us to the end of Model of Care 2 Element A. I'd like to review a few key takeaways regarding the do's and don'ts to consider as you prepare your documentation. Shree Patel: In terms of dues for the element. Shree Patel: Please be sure to refer to the factor explanations in the Model of Care guidelines to make sure that your response is comprehensive and includes all of the required information. Shree Patel: This is true for all factors in this element, but I really want to highlight this tip for factor 1 and 2, as these factors include a variety of items that need to be adequately described in order to meet the intent of the factor. Shree Patel: Please be sure to provide these particular explanations in detail to guide the development of a complete response in your model of care documentation. Shree Patel: Specific to Factor 2, please be sure to specify the educational degrees of key clinical staff. Shree Patel: Please remember to include plans for the backup of key personnel in Factor 3. Shree Patel: And finally, please be sure to clearly distinguish between employed and contracted staff for factors 1, 2, and 5. If the processes refer to all staff, please identify all staff encompassed, both employed and contracted staff. Shree Patel: In terms of don'ts for the element, above and beyond staff responsibilities, please don't forget to describe administrative and clinical oversight functions in Factor 1. Shree Patel: And finally, please do not provide generalized training content for Factor V in the form of table of contents or title or overview slides. Shree Patel: Renewal plans must provide actual samples of training content information in order to meet the intent of the factor, while initial plans may provide a complete and comprehensive description of training content if their training plan has not yet been operational. Shree Patel: Please don't forget to tailor your responses to the new and or clarified requirements for this element. Again, this element has had some shifts in factor location this year, so please be sure that responses included within Shree Patel: the factor are appropriate to the factor heading and presented in the order specific to the scoring guidelines. That wraps up MOC2A, and I'll pass it over to Laura now to discuss the next element. Next slide, please. Laura Zwolinski: Thank you, Sri. We're now going to shift our attention to Element MOC2B, which focuses on the Health Risk Assessment, or the HRA. Next slide, please. Laura Zwolinski: Before reviewing the requirements for this element, we'd like to review some HRA-specific items that are included in current regulations for context. Laura Zwolinski: First and foremost, all enrollees must have an HRA. That is, regulations require that all SNPs conduct a comprehensive HRA for each SNP enrollee. Laura Zwolinski: The HRA tool must assess the enrollee's medical, functional, cognitive, psychosocial, and mental health needs. In addition, as of 2024, the HRA tool must also include one or more questions on housing stability, food security, and access to transportation. Laura Zwolinski: An important point we'd like to stress is that for HRAs to be considered complete for purposes of fulfilling Part C reporting requirements, they must include direct, enrollee, and or caregiver input. Laura Zwolinski: Regulations also require that results from the initial HRA and annual reassessment are addressed in the enrollee's Individualized Care Plan, or ICP. Laura Zwolinski: Next slide. Laura Zwolinski: We also wanted to review the regulations in terms of HRA completion timing and outreach attempts to enrollees. For new enrollees, the initial HRA must be completed within 90 days, either before or after the effective enrollment date. Laura Zwolinski: For existing members, a reassessment must be conducted annually. Laura Zwolinski: Plans must also make at least 3 non-automated outreach attempts to reach each enrollee to schedule the initial or annual HRA. Laura Zwolinski: Send a follow-up letter to all non-respondents. Laura Zwolinski: Document the contact attempts for enrollees who are unable to be reached, and lastly, document enrollee refusal for those who decline to participate in the HRA process. Laura Zwolinski: Next slide. Laura Zwolinski: The intent of MOC2 Element B focuses on how SNPs conduct the HRA. Laura Zwolinski: For this element, we ask that you clearly define the methodology and tools used to administer the HRA to enrollees. Laura Zwolinski: The narrative should detail how HRA results are stratified and used to determine each enrollee's risk tier. Laura Zwolinski: We also want you to describe how HRA results are used to develop and update the ICP for each enrollee, in addition to detailing how HRA information is disseminated to and used by the ICT. Laura Zwolinski: The HRA impacts the development of the individualized care plan and the ongoing coordination of interdisciplinary care team activities. Laura Zwolinski: Given this, it is important that plans fully address each factor in this element. Laura Zwolinski: We want to emphasize that, for contract year 2027, factors in this element were shifted to better align with the order of clinical operations, so please make sure that your responses are presented in the order specified in the scoring guidelines. Laura Zwolinski: Next slide. Laura Zwolinski: There are four factors in MOC2 Element B, and we'll review each factor to note the requirements, and emphasize areas to pay close attention to, as well as underscore any changes for this year. Laura Zwolinski: Factor 1 requires that plans describe how they conduct the initial HRA and annual reassessment. Laura Zwolinski: The plan must specify the methodology used to administer the HRA. For instance, is a questionnaire mailed? Alternatively, are you conducting phone interviews or in-person assessments? Laura Zwolinski: Please be sure to describe the HRA administration process completely, remembering to identify the who, what, where, when, and how, and to detail the data collected through the HRA. Laura Zwolinski: This description must also detail how the HRA assesses the medical, functional, cognitive, psychosocial, and mental health needs for each SNP enrollee. Laura Zwolinski: All of these parameters must be addressed to gain credit for this factor. Laura Zwolinski: This year, we also newly specified a number of additional items and details that need to be addressed to earn credit for Factor 1. Laura Zwolinski: These changes are denoted by the star bullets on this slide, and please pay close attention to these items. Laura Zwolinski: First, plans must identify and describe the HRA tool or tools that they are using. Laura Zwolinski: Second, you'll need to indicate the timing of the initial HRA and annual reassessments, which must align with the regulations. That is, within 90 days of the effective enrollment date for new enrollees, and annual leave for existing members. Laura Zwolinski: Most plans are already providing this information, however, please be sure to if you are not already. Laura Zwolinski: Third, you must identify the qualified personnel who conduct the initial and annual HRAs, specifying the applicable licensure. Laura Zwolinski: Plans must also detail the process they use to attempt to reach enrollees to complete the HRA. Laura Zwolinski: This includes specifying the method used to contact enrollees, as well as how many attempts are made, and must align with current regulations. Laura Zwolinski: We understand that you will not be able to reach everyone, but we want to be sure that you clearly delineate the process you take to attempt to reach everyone to complete an HRA, and your process for documenting refusals after multiple and ongoing attempts have been exhausted. Laura Zwolinski: And the last new change is that plans must describe how they address challenges associated with enrollees who decline to participate in HRA completion or are unable to be reached. Laura Zwolinski: As in prior years, plans must continue to detail how they use the HRA to reassess enrollees after the completion of the initial assessment. Laura Zwolinski: And there must also be a provision to reassess enrollees if warranted, by a health status change or care transition, such, for instance, such as a hospitalization. Laura Zwolinski: Next slide. Laura Zwolinski: For Factor 2, the model of care must explain the detailed process the SNP uses to review, analyze, and stratify HRA results. Laura Zwolinski: New this year, we specify that plans must describe each risk tier, as well as provide the inclusion criteria and acuity level for each of these tiers. Laura Zwolinski: The narrative for Factor 2 must also describe how the SNP uses stratified results to improve the care coordination process. Laura Zwolinski: Please note that this is a new standalone factor for contract year 2027. Laura Zwolinski: However, please be advised that plans likely included a portion of the information required to meet this factor under Factor 4 of this element in prior years. Laura Zwolinski: For Factor 3, the SNP must include a description of the policies and procedures it uses to develop and update the ICP for each enrollee. Laura Zwolinski: The response must also describe how the SNP ensures that the results from the initial HRA, annual reassessment, and any subsequent updates are addressed in the ICP. Laura Zwolinski: With each health status change or care transition, or any subsequent reassessment, there should be an update made to the information in the ICP, and plans should explain the process for updating the ICP based on HRAs and health status changes. Laura Zwolinski: Please note that, due to the reordering of factors in this element, plans may have included some of this required information under Factor 2 in prior years. Laura Zwolinski: Next slide, please. Laura Zwolinski: Lastly, Factor IV requires that plans describe the process for disseminating all HRA information, so that is, initial, annual, or other reassessments to the ICT, and detail how the ICT subsequently uses this information for care management and coordination. Laura Zwolinski: The model of care must detail the mechanisms, that is the communication plan, used to ensure communication of information to the ICT. Laura Zwolinski: the provider network, enrollees and or their caregivers or designated representatives, as well as other SNP personnel involved with overseeing the enrollee's ICP. Laura Zwolinski: Due to the reordering of factors in this element, we wanted to clarify that plans may have included some of this required information under Factor III in prior years. Laura Zwolinski: Next slide. Laura Zwolinski: This slide presents a summary of the changes made to MOC 2 Element B for Contract Year 2027. Laura Zwolinski: First, as previously noted, the order of factors was revised to better align with the clinical order of operations. Laura Zwolinski: There were a variety of changes made to Factor 1, some of which include a focus on how the HRA is conducted. Laura Zwolinski: the tools used, the personnel responsible for conducting HRAs, and the specific timing and methodology used, amongst others. Please review the scoring guidelines closely for Factor 1 to ensure that you address all necessary requirements. Laura Zwolinski: For Factor 2, we specify that plans need to describe each risk stratification tier in terms of inclusion criteria and acuity level. Laura Zwolinski: For Factor 3, we clarify that plans need to describe the process used to verify HRA results are addressed in the ICP. Laura Zwolinski: Lastly, for Factor 2, we previously clarified that plans must describe how the stratification process improves care coordination, and this requirement still stands. Laura Zwolinski: Next slide. Laura Zwolinski: Before moving on from this element, I'd like to review a few important takeaways. Please take stock of the items on this slide, particularly those denoted by special bullet points. Laura Zwolinski: In terms of the do's for this element. Laura Zwolinski: For all factors, please make sure that you speak to the who, what, where, when, and how for all processes that need to be described. Laura Zwolinski: This allows us to understand processes holistically. Laura Zwolinski: For Factor 1, please be sure to describe how the HRA assesses the medical, functional, cognitive, psychosocial, and mental health needs of the population. Laura Zwolinski: As part of Factor 1, be sure to address the new items denoted by star bullet points. These include describing the HRA tool or instrument. Laura Zwolinski: Indicating the timing for initial and annual HRAs, and specifying HRA contact attempts and the process used to document these attempts and any refusals. Laura Zwolinski: And finally, for Factor 2, please be sure to fully describe the risk stratification tiers. Laura Zwolinski: In terms of the don'ts for this element, please don't forget to tailor your responses to the new or clarified requirements for this element. Laura Zwolinski: Again, this element had some shifts in factor location this year, so please make sure that responses are included within the appropriate factor heading and presented in the order specified in the scoring guidelines. Laura Zwolinski: That concludes our review of MOC2 Element B. At this time, I will hand things back over to Sri to review the next element. Next slide, please. Shree Patel: Thank you, Laura. Now I'll review MOC2, Element C, the face-to-face encounter. Next slide, please. Shree Patel: The regulations require that enrollees must be seen by either a member of their interdisciplinary team, or the plan's case management and coordination staff, or contracted plan healthcare providers. Shree Patel: This must be done at least annually within the first 12 months of enrollment as feasible, and with the enrollee's consent either in person or through a virtual, real-time, interactive telehealth encounter. Next slide, please. Shree Patel: The face-to-face encounter is part of the overall care management strategy, and the intent and focus of the MOC2 Element C factor is to describe the in-person or real-time visual or interactive face-to-face encounter. Shree Patel: Outline the coordination of services between the member and plan staff or contracted plan healthcare providers. Shree Patel: Ensure follow-up communications and activities with the enrollee slash caregiver are coordinated. Identify the qualified staff that can provide the face-to-face encounters, and identify the services provided to the enrollee on behalf of the SNP during the face-to-face encounter. Shree Patel: Please note that for contract year 2027, the number of factors for this element was reduced from 6 to 5. Next slide, please. Shree Patel: There are currently five factors for this element, which we will review over the next few slides. We'll emphasize key points and important information to be aware of as you prepare your documentation for contract year 2027. Shree Patel: For Factor 1, the plan must detail the process, including the policies, procedures, purpose, timing, and intended outcomes of the face-to-face encounter. Please do not forget to describe the intended outcomes. This is something that plans often forget to do. Shree Patel: Plants must specify that encounters occur within the first 12 months of enrollment, and at least annually thereafter, as well as detail how they ensure that this happens. Shree Patel: In addition, please be sure to describe how the plan obtains the enrollee's consent for the encounters. Shree Patel: As a note, the member's consent for face-to-face encounter can be obtained in advance. For example, the face-to-face encounter requirement can be explained, and the member's Shree Patel: consent can be obtained at the time of the HRA. Plants must address enrollee consent for both virtual and in-person encounters. Shree Patel: information exchanged between providers and the plan in the process of paying claims would provide verification that the enrollee met face-to-face with a qualified provider, and consent would be inherent in the enrollee's visit with their provider. Shree Patel: If the enrollee refuses an annual face-to-face encounter, or if the SNP was unable to reach the enrollee after a reasonable number of attempts, the plan is considered to have complied with this requirement, despite the lack of a qualified encounter. Shree Patel: Plans should document the reason that a face-to-face encounter is not feasible to demonstrate where there was no face-to-face encounter in the year, there was still no failure to violate the regulation. Shree Patel: For Factor 2, the organization must identify the qualified, employed, and or contracted staff that will deliver needed care and services to the enrollee via the face-to-face encounter, and must specify how the face-to-face encounter will be conducted, that is, what mode would be used. Shree Patel: Please note that face-to-face encounters are restricted to those that are in-person or virtual real-time interactive telehealth encounters. Shree Patel: Qualified providers must be a member of the enrollee's interpledationary team, or part of the plan's case management and coordination staff, or contracted plan healthcare providers. Shree Patel: These providers include the enrollee's regular primary care physician, a specialist related to the enrollee's chronic condition, a behavioral health provider, health educator, health… social health worker, MLTSS plan staff, or related MLTSS health Shree Patel: Care provider, including community health workers. Shree Patel: And finally, plans must confirm that the platforms used to support the face-to-face encounter, whether it is in-person or virtual, are secure and maintain confidentiality. Shree Patel: Note that oftentimes, plans forget to indicate that their systems are secure and are scored down on Factor 2. Please ensure that this information is present in order to receive credit for Factor 2. Next slide, please. Shree Patel: For Factor 3, the organization must describe how the SNP will verify through data collection, for example, through claims data, that the enrollee has participated in a qualifying face-to-face encounter in circumstances in which the encounter is provided by internal staff. Shree Patel: As well as when the encounter requires external or contracted providers to render treatment or services on behalf of the SNP. Shree Patel: Please be sure to detail this verification process and speak to reporting and tracking. Shree Patel: Please detail the process for reviewing enrollee claims data and identify responsible staff. Shree Patel: A change for contract year 2027 now requires plans to describe any follow-up communications with the enrollee slash caregiver during the face-to-face encounter verification process, if applicable. Shree Patel: For Factor 4, the MLC must detail the types of clinical functions and assessments that may be performed during a face-to-face encounter. Examples of the necessary services or engagement during the required encounter include, but are not limited to. Shree Patel: Engaging with the enrollee to manage, treat, or oversee or coordinate their healthcare, such as providing preventative care included in the Individualized Care Plan, the ICP. Shree Patel: Annual wellness visits and or physicals, completion of the health risk assessment, such as the one annually required for all SNPs. Shree Patel: Care plan review, or other similar care coordination activities. Shree Patel: and health-related education where the enrollee receives information or instructions critical to the maintenance of their health or implementation of processes to maintain the enrollee's health, such as the administration of a medication. Next slide, please. Shree Patel: Please note that this is a new factor for contract year 2027. Elements of this factor combine information from former factors 5 and 6 into a single factor. Shree Patel: For the new Factor 5, please detail the process for how health concerns and active or potential health issues are identified during encounters are addressed. Please include a description of how enrollees or their caregivers are educated about potential issues that may develop. Shree Patel: Plans must speak to enrollee and caregiver education. In previous years, some plans did not address the enrollee-slash-caregiver education aspect of the factor, or they only addressed active and not potential health issues, and therefore did not earn credit for this factor. Shree Patel: SNPs must describe how they will conduct care coordination activities necessary to follow up on needed care or services. For example, this includes, but is not limited to, the handling of referrals and scheduling of tests and procedures. Shree Patel: This includes how the SNP determines and conducts these care coordination activities when the plan reviews data associated with the face-to-face encounter between an enrollee and a provider. Shree Patel: Please be sure to detail care coordination activities that need to occur after the face-to-face encounter is completed. Shree Patel: Detail how the plan ensures that appropriate follow-ups, referrals, and scheduling for needed care or services are completed after the face-to-face encounter. An example of this would be a description of scheduling procedures, or tests, or how referrals are handled. Shree Patel: Plans may have included some of this information in Factor VI in prior years. Next slide, please. Shree Patel: This slide presents a table of the summary of changes listed in the contract year 2027 scoring guidelines for MOC2 Element C. Shree Patel: First, for Factor 1, for CY2027, it was previously clarified and re-emphasized that plans must address the consent process for in-person and virtual face-to-face encounters. Shree Patel: Prior Factor 5, addressing health concerns, was combined with Prior Factor VI, care coordination activities into new Factor 5. Shree Patel: For new Factor 5, it was emphasized this year that plans must address how they ensure that appropriate follow-up activities are completed after the face-to-face encounter. Lastly, Factor 6 was removed. Next slide, please. Shree Patel: In terms of the do's and don'ts for MOC2 Element C, Shree Patel: Please be sure to, for Factor 1, describe how enrollee consent is obtained for both in-person and virtual encounters. This is an area where many plans were scored down in the past. Shree Patel: For Factor 2, be sure to confirm the security and confidentiality of platforms and systems used for encounters. Shree Patel: New for CY2027 for Factor 3, make sure to describe follow-up communications with the enrollee slash caregiver during the face-to-face encounter verification process. Shree Patel: Make sure you detail the types of assessments conducted during the face-to-face encounters in Factor 4. And finally, plans must address how they ensure that the appropriate follow-up activities are completed after the face-to-face encounter. Shree Patel: For the don'ts. Shree Patel: For MOC2, Element C. For Factor 1, don't forget to specify that the first face-to-face encounter occurs within 12 months of enrollment and annually thereafter. Shree Patel: For Factor 3, don't forget to provide a description for how the plan verifies face-to-face encounters occur. Shree Patel: For Factor 5, don't forget to describe your plan's process for care coordination following the face-to-face encounters. Matt wraps up MOC 2, Element C. With that, I will hand things back over to Laura to review the next element. Next slide, please. Laura Zwolinski: We're now going to review MOC 2 Element D, which is about the development, implementation, and maintenance of the Individualized Care Plan, or ICP. Laura Zwolinski: Next slide. Laura Zwolinski: Before reviewing the detailed requirements for this element, we'd like to review some of the current regulations related to the ICP. Laura Zwolinski: First, we'd like to emphasize that all enrollees must have an ICP. Laura Zwolinski: MOC2 element D is based on CMS regulations that all SNPs must develop and implement a comprehensive, individualized plan of care for each enrollee that is person-centered, considers the enrollee's preferences, including for the delivery of services and benefits. Laura Zwolinski: It includes the healthcare needs identified in the HRA. Laura Zwolinski: CMS firmly believes that the ICP is an essential tool for managing care for all beneficiaries. Laura Zwolinski: Regulations also require that SNPs develop the ICP through an interdisciplinary care team, or an ICT, and that they involve the enrollee and or the enrollee's caregivers in the ICP development process. Laura Zwolinski: We want to strongly emphasize that a person-centric ICP must be developed for all enrollees. Laura Zwolinski: ICP development is not limited to enrollees stratified in medium or high-risk groups, or limited only to those in a care management program. Laura Zwolinski: That is, there are no exceptions for enrollees, stratified, and low-risk categories. Laura Zwolinski: Please note that this is an area that some plans have encountered difficulty in the past due to the inclusion of language that limits their responsibility for developing and implementing a tailored ICP for all members. Laura Zwolinski: Next slide. Laura Zwolinski: Please also note that there are specific time requirements for the development of the ICP. Laura Zwolinski: ICPs must be created within 90 days of conducting the initial HRA, or 90 days after the effective enrollment date, whichever is the later of the two. Laura Zwolinski: The regulations also require that SNPs update the ICP as warranted by changes in health status or care transitions. Laura Zwolinski: In addition, SNPs must document attempts to contact enrollees who are unable to be reached, as well as document an enrollee's refusal when they decline to participate in the ICP process. Laura Zwolinski: Next slide, please. Laura Zwolinski: CMS recognizes that HRA results and enrollee and caregiver involvement are valuable in developing an ICP. Laura Zwolinski: However, we want to emphasize that SNPs are still expected to formulate an ICP in the absence of these resources. That is, plans are still required to develop a person-centered ICP for an enrollee, even if there is no completed HRA for that enrollee. Laura Zwolinski: Your model of care must include provisions for creating an ICP for those enrollees who are not responsive or who refuse to be involved in the HRA process. Laura Zwolinski: Plans have multiple resources at their disposal to create ICPs for these individuals, and can use sources, including, but not limited to. Laura Zwolinski: medical records, claims data, and face-to-face encounters, among other sources. Again, to emphasize, all enrollees must have an ICP. This is not limited to only high-risk members, and there are no exceptions for enrollees stratified in low-risk categories. Laura Zwolinski: Next slide, please. Laura Zwolinski: The intent of MOC2 Element D is to describe how the ICP is developed, implemented, maintained, and communicated. Laura Zwolinski: As part of this element, we ask that plans describe the essential elements of the ICP, Laura Zwolinski: detail the SNP's process for developing and modifying the ICP, as well as specify who is responsible. Laura Zwolinski: Address how the enrollee and or caregivers are involved in the ICP development process. Laura Zwolinski: In addition, how does the plan document, maintain, and share the ICP with enrollees or their caregivers? Laura Zwolinski: And lastly, how does the SNP communicate ICP updates and modifications to stakeholders? Laura Zwolinski: We want to call out here that the number of factors in this element this year was reduced from 5 to 4. Laura Zwolinski: Given this, please make sure that your factor-specific responses are presented in the correct order. Laura Zwolinski: Next slide. Laura Zwolinski: Now let's go ahead and discuss this element in more detail at the factor level. Laura Zwolinski: For Factor 1, the model of care must describe how the SNP incorporates essential components into the person-centered ICP. Laura Zwolinski: These include the enrollee's self-management goals and objectives. Laura Zwolinski: Personal healthcare preferences, a description of services specifically tailored to the enrollee's needs. Laura Zwolinski: The roles of the caregiver, And the evaluation and identification of goals met were not met. Laura Zwolinski: The plan must provide a detailed description of the process employed by the plan to reassess the current ICP and determine appropriate alternative actions when an enrollee's goals are not met. Laura Zwolinski: Next slide, please. Laura Zwolinski: For Factor 2, the model of care must describe how the SNP develops an ICP for each enrollee to deliver appropriate care. Laura Zwolinski: At a minimum, the SNP must describe the process used to develop the ICP, and detail how the results of the initial HRA and annual reassessment are included in the ICP. Laura Zwolinski: New for this year, SNPs need to specify the timing of ICP development, which must comply with the regulations. That is, within 90 days of conducting the initial HRA, or 90 days after the effective date of enrollment, whichever is later. Laura Zwolinski: SNPs must also identify the personnel responsible for developing the ICP. Laura Zwolinski: Including roles and functions, professional requirements, and credentials necessary to perform these tasks. Laura Zwolinski: While this is not newly requested information for contract year 2027, please note that plans may likely have included this information under Factor III in the past. Laura Zwolinski: SNPs must also include information on how the enrollee or their caregivers are involved and participate in the ICP development process. Laura Zwolinski: The model of care must also include a description of the frequency at which SNP personnel review, update, and modify the ICP based on the evaluation of enrollee goals, as prioritized by the enrollee. Laura Zwolinski: Based on changes in healthcare needs or status, or the availability of more recent HRA information. Laura Zwolinski: Also newly specified for this year, the plan must describe how the SNP addresses challenges associated with enrollees who decline to participate in the ICP process or who are unable to be reached, as well as how it documents the attempts to contact the enrollee or the enrollee's refusal to participate. Laura Zwolinski: We also want to draw your attention to the new DSNP-only requirement for this factor. Laura Zwolinski: This component of Factor 2 only applies to DSNPs and requires that they describe how the ICP is used to coordinate Medicare and Medicaid services, and how the DSNP or Affiliated Medicaid plan provides these services, including long-term services and supports, and behavioral health services. Laura Zwolinski: The inclusion of this DSNP-specific item does not impact the number of factors on which DSNPs are scored for this element. Laura Zwolinski: However, DSNPs do need to address this item in addition to the others noted on this slide to earn credit for Factor 2. Laura Zwolinski: Next slide, please. Laura Zwolinski: For Factor III, the SNP must describe how the ICP is maintained and updated based on changes in health status or care transitions. Laura Zwolinski: As an example, this can be from information collected from more recent HRA assessments, or following hospitalizations or other care transitions. Laura Zwolinski: New for Contract Year 2027, we are requiring some additional details for this factor, as shown by the star bullets on this slide. Laura Zwolinski: First, SNPs must address where the ICP is documented and stored. Laura Zwolinski: Second, for contract year 2027, the SNP must detail how the plan ensures that the ICT, provider network, appropriate stakeholders, and enrollees and their caregivers have access to the ICP. Laura Zwolinski: In addition, the plan must describe the delivery mechanism for providing the ICP to these stakeholders. Laura Zwolinski: For example, mail, fax, patient portal, or other methods. Laura Zwolinski: Also new for this year, the plan must specify how the SNP provides enrollees and or their caregivers with copies of or electronic access to their ICP. Laura Zwolinski: Please be aware that plans may have included this information under Factor 4 in prior years. Laura Zwolinski: For Factor 4, the SNP must describe how it communicates ICP updates and modifications to enrollees. Laura Zwolinski: and or their caregivers, as well as the ICT, applicable network providers. Laura Zwolinski: other SNP personnel and stakeholders as necessary. Please note that plans may have included this information under Factor V in prior years. Laura Zwolinski: Throughout this element, we want to note that, since many members may have a responsible person assisting with their care coordination, it is important that SNPs address the role and significance of caregivers throughout. Laura Zwolinski: Next slide. Laura Zwolinski: This slide includes a table of the summary of changes for MOC2 Element D for contract year 2027. Laura Zwolinski: First, we reduced the total count of factors from 5 to 4. Laura Zwolinski: For Factor 2, there were a variety of changes for this year. Laura Zwolinski: First, we specify that SNPs must identify how often the ICP is modified. Laura Zwolinski: Second, plans are now required to address the challenges associated with enrollees who decline to participate in the ICP process, or who cannot be reached. Laura Zwolinski: We also added a DSNP-only component to Factor II that requires DSNPs to describe the coordination of Medicare and Medicaid services. Please make sure to review the requirements closely. Laura Zwolinski: For Factor 3, plans must now indicate where the ICP is stored, and how it shares and ensures that enrollees and other stakeholders have access to the ICP. Laura Zwolinski: Next slide. Laura Zwolinski: This slide captures a few key points to keep in mind as you prepare your response to this element. Laura Zwolinski: Please make sure to detail the essential components of the ICP for Factor 1. Laura Zwolinski: For Factor 2, specify ICP development timing. Laura Zwolinski: Describe how the SNP addresses challenges when enrollees decline to participate or are unreachable. Laura Zwolinski: And for DSNPs, describe how the ICP is used to coordinate Medicare and Medicaid services, and how the plan provides these services. Laura Zwolinski: For Factor 3, specify where the ICP is documented and maintained, and how it is shared with enrollees and stakeholders. Laura Zwolinski: Please don't forget to discuss the involvement of the enrollee and caregivers in ICP development. Laura Zwolinski: maintenance, and communication across Factors 2, 3, and 4. Laura Zwolinski: Don't forget to tailor responses to the new and clarified requirements across the element. Laura Zwolinski: And lastly, don't forget to ensure responses are included within the appropriate factor and presented in the order specified in the CUI 2027 scoring guidelines. Laura Zwolinski: And that concludes our review of this element, so let's go ahead and move on to the next. Next slide, please. Laura Zwolinski: Let's continue on to MLC2 Element E, which focuses on the enrollee's Interdisciplinary Care Team, or ICT. Laura Zwolinski: And ICT is a collaborative group of healthcare professionals from different disciplines who work together to implement, monitor, and manage a unified, personalized care plan. Laura Zwolinski: An ICT focuses on treating the whole person by addressing the enrollee's medical, behavioral, and social care needs, amongst other needs. Laura Zwolinski: The enrolling and their caregiver are an integral part of this team. Next slide, please. Laura Zwolinski: MOC2 Element E is based on CMS regulations that require all SNPs to use an ICT in the management of care for each enrolled individual. Laura Zwolinski: Like the ICP, all enrollees must have an ICT. Laura Zwolinski: It is important to note that the development of each ICT must include a multidisciplinary approach and be based on the specific needs of each SNP enrollee. Laura Zwolinski: Again, there are no exceptions for those enrollees categorized as low risk. Laura Zwolinski: The ICT must be comprised of providers whose training and credentials collectively address the health needs of the enrollee. Laura Zwolinski: Please note that the ICT is a multidisciplinary approach to care coordination. It should involve more than the PCP and the enrollee. For instance, various applicable specialists, pharmacists, social workers, and others that support the provision of community resources to meet enrollee needs. Laura Zwolinski: Next slide, please. Laura Zwolinski: The intent of MOC2 element ETH is to describe… sorry, one second. Laura Zwolinski: The intent of MOC2 Element E is to describe the important components of the ICT. Laura Zwolinski: The following questions will guide you through successfully addressing this section of the model of care. Laura Zwolinski: Who are the key members of the ICT, and how does the plan determine these members? Laura Zwolinski: What roles and responsibilities do these ICT members hold? Laura Zwolinski: How does the plan facilitate enrollee and or caregiver participation in the ICT? Laura Zwolinski: How does the ICT contribute? Laura Zwolinski: Oh, Madeline, I think we're on different sides. Laura Zwolinski: Can you go… yeah. I'll start over at the top here. Laura Zwolinski: The intent of MOC2 Element E is to describe the important components of the ICT. Laura Zwolinski: The following questions will guide you through successfully addressing this section of the model of care. Laura Zwolinski: Who are the key members of the ICT, and how does the plan determine these members? Laura Zwolinski: What roles and responsibilities do these ICT members hold? Laura Zwolinski: How does the plan facilitate enrollee and or caregiver participation in the ICT? Laura Zwolinski: How does the ICT contribute to improving the enrollee's health status? Laura Zwolinski: What communication modes are utilized within the ICT? Laura Zwolinski: And what evidence demonstrates its regular occurrence. We also want to clarify that the ICT may meet virtually using various forms of communication and technology. Laura Zwolinski: However, the description must detail the specifics, such as how the meeting occurs, the frequency, etc. Laura Zwolinski: Please keep in mind that some factor components were shifted or expanded for MOC2 element E this year. Laura Zwolinski: Next slide, please. Laura Zwolinski: For Factor 1, SNPs must describe the process they use to determine the membership of the ICT, as well as the rationale for inclusion of these ICT members. Laura Zwolinski: SNPs must also explain how the enrollee's HRA and ICP are used to determine the composition of the ICT, and describe how they identify when additional team members are needed to meet the developing needs of an enrollee. Laura Zwolinski: Please note that plans may have included information for the second and third bullets noted here under Factor II in prior years. Laura Zwolinski: For Factor 2, SNPs must describe the roles and responsibilities of each member of the ICT, Laura Zwolinski: Including how each contributes to the development and implementation of an effective interdisciplinary care process and improved health status for the enrollee. Laura Zwolinski: As part of this description, you must specify how the expertise, training, and capabilities of the ICT members align with the identified clinical and other needs of the SNP enrollees. Laura Zwolinski: Plans may reference MOC2 Element A or MOC3 Element… excuse me, MOC3 Element A to provide a full description of these roles and associated credentials and expertise. Laura Zwolinski: Enrollees and their caregivers play a critical role in the ICT. Laura Zwolinski: Given this, the requirements related to enrollee and caregiver involvement have expanded this year. Laura Zwolinski: Beyond explaining how the SNP facilitates enrollee and caregiver participation in the ICT, plans must also specifically Laura Zwolinski: Describe how the SNP informs and invites enrollees and their caregivers to participate as active members of the ICT. Laura Zwolinski: In detail how enrollees or their caregivers are provided with needed resources, and how the plan facilitates access for enrollees to ICT team members. Laura Zwolinski: Again, please detail how your plan includes the member and caregiver in the ICT process proactively. It is insufficient to state that information is provided upon request. Laura Zwolinski: Next slide. Laura Zwolinski: For Factor 3, the model of care must describe how the SNP uses clinical managers, case managers, and other plan staff to ensure that interdisciplinary care processes are effective in meeting enrolling needs on a continuous basis. Laura Zwolinski: Also newly emphasized and clarified this year, SNPs must explain how they analyze enrollee needs and outcomes data to evaluate and continually manage and improve the health status of SNP enrollees. Laura Zwolinski: And to implement and manage changes or adjustments to the ICT composition, as needed. Laura Zwolinski: For Factor 4, the SNP must describe the communication plan for ongoing information exchange with the ICT. Laura Zwolinski: The communication plan should address how the SNP maintains effective and ongoing communication between SNP personnel. Laura Zwolinski: the ICT, enrollees, caregivers, community organizations, and other stakeholders. Laura Zwolinski: How knowledgeable SNP personnel oversee the implementation of this communication plan? Laura Zwolinski: The types of evidence used to verify that communications have taken place, for example, written ICT meeting minutes, or documentation in the ICP, Laura Zwolinski: And how communication is conducted with enrollees who have hearing impairments, language barriers, or cognitive deficiencies. Laura Zwolinski: We also want to draw your attention to the new DSTIP-only requirement for this factor. Laura Zwolinski: This component of Factor IV only applies to DSNPs and requires that they explain how the ICT coordinates with Medicaid providers when there are needed Medicaid-covered services Laura Zwolinski: Either medical or social, that the plan does not cover, if applicable. Laura Zwolinski: The inclusion of this DSNP-specific item does not impact the number of factors on which DSNPs are scored for this element. Laura Zwolinski: However, DSTEBs need to address this item, in addition to the others noted on this slide, to earn credit for Factor 4. Laura Zwolinski: Next slide. Laura Zwolinski: This slide presents a table of the summary of changes made to MOC2 Element E for contract year 2027. Laura Zwolinski: First, please note that the focus of Factor 1 was shifted to emphasize the description of the plan's process for determining ICT membership, rather than on the ICT composition itself. Laura Zwolinski: Factor 2, beyond a description of the roles and responsibility of ICT members, now requires a description of expertise and training. Laura Zwolinski: In addition, the information required around the facilitation of enrollee and caregiver participation in the ICT has been expanded. Laura Zwolinski: Factor 3 was updated to request information on the SNP's use of enrollee health outcomes data to inform changes to the ICT membership. Laura Zwolinski: And lastly, we added a DSNP-only component to Factor IV that requires DSNPs to describe ICT coordination with Medicaid providers when there are needed Medicaid-covered services that the plan does not cover, if applicable. Laura Zwolinski: Next slide, please. Laura Zwolinski: To recap, a few points for preparing your documentation for this element. Please make sure that you, for Factor 2, remember to specify how the expertise and training of ICT members aligns with enrollee needs, and be sure to explain how the SNP actively involves enrollees and caregivers in the ICT. Laura Zwolinski: For Factor 3, be sure to explain how the SNP uses health outcomes data to manage enrollee health status and inform needed adjustments to the ICT. Laura Zwolinski: for Factor 4, Be sure to describe how the SNP maintains and documents ongoing communication across the ICT membership. Laura Zwolinski: For DSNPs, please make sure that you address the new DSNP-specific component of Factor 4. Laura Zwolinski: Again, this requires an explanation of how the ICT coordinates with Medicaid providers when there are needed Medicaid-covered medical or social services that the plan does not cover, if applicable. Laura Zwolinski: Also, don't forget to explain how the ICT communicates with enrollees who have hearing impairments, language barriers, or cognitive deficiencies, and please be mindful to craft your responses to address any new or clarified requirements for this element, presenting them in the order indicated in the scoring guidelines. Laura Zwolinski: And that concludes the review of this element. I will hand it back over to Sri now to review our final MOC2 element. Laura Zwolinski: Next slide. Shree Patel: We are now going to review MOC2 Element F, which covers care transition protocols. Next slide, please. Shree Patel: I want to emphasize that the regulations require SNPs to coordinate care for all enrollees. There are no exceptions. Care coordination must include low-risk enrollees. Shree Patel: Ensure that it does not limit oversight or planning to providers within your network. I mention this because sometimes we see in the past language in these MOCs similar to that above, and that will be scored down. Shree Patel: The objective of the care transition element is for organizations to maintain the connectivity between providers and enrollees, regardless of network affiliation. The focus is on providing care for enrollees in a manner that prevents them from falling through the cracks. Shree Patel: Ensuring that much-needed care and follow-through is carried out. Shree Patel: I know that you are aware of the need to ensure member-slash-caregiver understanding of transition protocols and subsequent notification and follow-up. We invite you to look closer at the regulatory language. Shree Patel: Please ensure coordination of the delivery of care across healthcare settings, providers, and services to assure continuity of care. Shree Patel: Please coordinate the delivery of specialized benefits and services that meet the needs of the most vulnerable beneficiaries among the three target special needs populations, including frail-slash-disabled beneficiaries and beneficiaries near the end of life. Shree Patel: Please ensure to coordinate communication among plan personnel, providers, and beneficiaries. Next slide, please. Shree Patel: We want to ensure that enrollee services continues across the continuum of care. Please detail the extra services and benefits that meet the specialized needs of the most vulnerable populations, as evidenced by the measures from the Shree Patel: Physio, social, functional, and end-of-life domains are appropriately delivered. Shree Patel: Plans must use evidence-based practices and nationally recognized clinical protocols. First and foremost, the… Shree Patel: First and foremost, the requirements we spoke of must coordinate care for all enrollees undergoing transition. Shree Patel: Keep in mind that the transfer of care plan elements must occur for all care transitions, for both in-network and out-of-network providers. Shree Patel: Next slide, please. Shree Patel: For MOC2F, the intent is to address transitions of care and describe the personnel responsible for coordinating those transitions. Shree Patel: Please keep in mind that the planned transition efforts must be managed before, during, and after a transition. Unplanned transitions must be managed during if known, and after the transition occurs. Shree Patel: SNPs must detail the types of care settings and the specific personnel responsible for coordination and communication. Describe how staff share the essential components of the ICP with the receiving setting. Most importantly, who has access to this information. Shree Patel: How will staff responsible for transitions know the member-slash-caregiver are fully aware of the self-management activities? For example, understanding his or her health concerns and when to notify the provider, and emphasizing the need-slash-importance for routine and follow-up care. Shree Patel: Last but certainly not least, you must describe how the member slash caregiver are informed of this important contact throughout the transition period. Next slide, please. Shree Patel: For Factor 1, please describe the process for coordinating transitions to facilitate care continuity. Shree Patel: For example, how is a transition identified? What steps are taken? New for CY2027. Ensure that this process is explained for both planned and unplanned transitions. For planned Shree Patel: transitions in care, the MOC must describe the steps that are taken place before, during, and after the transition occurs. For unplanned transitions of care, the MOC must describe the steps taken during, if known, and after the transition occurs. Shree Patel: Also new for CY2027, for DSNPs only, please explain how the plan will coordinate with providers for Medicaid-covered services during care transitions. Shree Patel: CSNPs and ISNPs will not have to include this within their narrative. This does not impact the total number of factors on which DSNPs are scored for this element. DSNPs must address this in addition to other aspects noted above to earn credit for Factor 1. Shree Patel: Also clarified for CY2027 is care coordination is required for all enrollees, not just high-risk or medium-risk enrollees. Shree Patel: Factor 2 asks what personnel are responsible for coordination efforts. Shree Patel: This includes case managers, providers. Does the responsibility change per SNP type? For example, ISNPs or institutional equivalent SNPs? Who insures the follow-up services? For example, scheduling appointments and needed resources. Next slide, please. Shree Patel: For Factor 3, Factor 3 requires that plans must address the process for both planned and unplanned transitions. Please describe how the elements of the enrollee's ICP when the enrollee experiences a transition of care. Shree Patel: To be specific, plans must detail the process used, example, methodology for transferring the elements of the ICP. Shree Patel: Who is responsible? How communication occurs, for example, is important to note, such as hard copies, email, virtual meetings, etc. Again, care coordination is required for all enrollees, and is not limited to medium and high-risk stratified enrollees. Shree Patel: Factor 4 requires information on the transfer of enrollee personal health information. The organization must describe the process for ensuring that SNP enrollees and or their caregivers must have access to and can adequately use personal health information to coordinate care for the member. Shree Patel: The description must specify the method of access. Shree Patel: For example, hard copies or electronics. Next slide, please. Shree Patel: For Factor 5, Shree Patel: MOCs must describe how enrollees and or their caregivers will be educated about their condition, how they will demonstrate understanding of changes in their condition, such as improvement or worsening conditions, and the use of appropriate self-management activities. Shree Patel: Self-management activities can include regular assessment of progress, goal setting, and problem-solving support to reduce crises and improve health outcomes. Shree Patel: For Factor VI, the organization must describe the process it uses to notify enrollees and or their health… their caregivers of the personnel responsible for supporting them through transitions between any two care settings. Shree Patel: In other words, how does the member or their caregiver understand who is responsible for addressing their issues, questions, or concerns related to transition? Next slide, please. Shree Patel: This slide shows what does not meet the requirements. If transitions of… for example, if transitions of care are provided only to those enrollees determined to be high-risk enrollees, does this meet the requirements included in MOC Element F? Shree Patel: The answer is no. Shree Patel: There are no exceptions when it comes to transitions of care. Regulations require SNPs to coordinate the delivery of care for all enrollees. It is the SNP's responsibility to ensure that treatment protocols and needed resources related to transition of care across healthcare setting and providers are delivered to all enrollees. Shree Patel: In addition, we re-emphasize the need for detailing your process for coordinating health information in Factor III. Next slide, please. Shree Patel: We want to… Shree Patel: emphasize some points about transitions. While some plans may hand off transitions of care to the utilization management unit, there must be continuity of care before, during, and after transitions. For enrollees considered low risk. Shree Patel: not in care management. Plans need to identify who is responsible for follow-up during the actual transition, and once the enrollee arrives at the destination. Shree Patel: Last but not least, we've noticed a trend in not managing out-of-network transitions. We realize that some transitions may initiate during off hours or unbeknownst to plans. However, once you become aware, the expectation is for follow-up regardless of whether these transitions are moving in Shree Patel: Or out of a network facility. Shree Patel: Next slide, please. Shree Patel: This slide presents a table of summary of changes made to MOC2 Element F for contract year 2027. Shree Patel: First, it was specified that plans must explain the process used to manage both planned and unplanned transitions in care. Shree Patel: Further, Factor 1 now emphasizes that care coordination is required for all enrollees and is not limited to medium and high-risk stratified enrollees. We added a DSNP-only component to Factor 1 that requires DSNPs Shree Patel: to explain how the plan coordinates with providers for any Medicaid-covered services during the care transition. Shree Patel: Lastly, Factor 4 was revised to specify that plans must describe the method of granting enrollees access to their personal health information. Shree Patel: Next slide, please. Shree Patel: To recap MOC2F, do not include… please do… Shree Patel: To recap MOC 2, Element F, do include a description of your process for both planned and unplanned transitions. Shree Patel: For DSNPs, please explain how the plan coordinates with providers for any Medicaid-covered services during a care transition. Shree Patel: Please describe the specific personnel responsible for coordinating transitions. Shree Patel: Please be sure to also tell us how you ensured that important elements in the care plan are transferred with the member, as well as how do you ensure the member and caregiver have access to all of the information they may need to follow up with providers. Shree Patel: In terms of don'ts, please don't forget to note how enrollees slash caregivers are educated about how health condition changes and how they demonstrate understanding of the treatment plan and actions to be taken. Shree Patel: Please also do not forget to include your process for planned and unplanned transitions. Next slide, please. Shree Patel: This slide defines some of the language you may hear us use and or see in feedback provided by the reviewer. Shree Patel: For conflicting language. Conflicting language usually denotes when a plan provides a statement that contradicts documentation in another section of the narrative. Shree Patel: For example, one section notes all members are in case management, while another paragraph notes care management is only for medium and high-risk members, or care management is available upon request. Shree Patel: For conflicting language, if any language does not read the requirements, even though one other part in a different area may, credit will not be awarded. Shree Patel: Limiting language will also not be accepted. Limiting language removes the responsibility of the plan to carry out requirements related to all members and or care transitions specified in the regulations. These qualifiers run counter to the intent of the MLC requirements that apply to all members. Shree Patel: In recent years, we've seen an increase in use of this type of language. Shree Patel: Some examples of Inclusive language include, transitions of care are provided to all. Shree Patel: Services and resources are coordinated for all members. Examples of limiting language that will not be awarded credit include transitions of care are limited to in-network providers, services are limited to high-risk members. Shree Patel: Utilization of opt-in program for care coordination. Just a reminder, limiting language will not count towards Shree Patel: Receiving credit for a factor. Next slide, please. Shree Patel: To summarize the new DSNP-specific requirements, 3 new DSNP-only requirements were added to MOC2 for contract year 2027. The following are additions that DSNPs only must include to get credit for the associated factor. Shree Patel: Please note that DSNPs must fulfill these requirements in addition to other requirements for the specified factor. The DSNP-only requirements do not impact the total number of factors evaluated for the element. Shree Patel: Next slide, please. Shree Patel: We will now review some training reminders. Next slide, please. Shree Patel: To review what was shared at the beginning of the presentation, this slide provides information on the training and education session scheduled for plans for contract year 2027. Shree Patel: Training recordings for all four recorded training sessions are now posted to the SNP approval website at snipmoc.ncqa.org under the Resources section. Shree Patel: In addition, the training slides are also posted to this site. Shree Patel: NCQA and CMS will hold two technical assistance calls to allow ample time for plans to ask questions in a live forum. The first of these sessions will take place from 2 to 4 p.m. Eastern Standard Time on March 19th Shree Patel: 2026. And the second will take place from 2 to 4 p.m. Eastern Standard Time on April 16, 2026. Shree Patel: The TA calls will be recorded and available to plans. Shree Patel: Finally, the CURE TA call is scheduled from 2 to 4 p.m. Eastern Standard Time on August 4th, 2026. Plants that score less than 50% on one or more elements, or those that score less than 70% overall, are required to cure and should attend the session. Next slide. Shree Patel: We have included a short post-training survey to collect your comments and feedback regarding this training session. Please click on the link embedded in the slide deck posted to the SNP approval website to access this survey. Shree Patel: Please note that the survey will request feedback on training for MOC2 specifically. We will use any survey results received to continue to improve future training sessions, and we thank you kindly in advance for taking the time to complete the survey. Shree Patel: We'll also plan to review any common questions we receive on particular elements or factors during the pre-submission TA calls. Next slide. Shree Patel: Thank you for your time and attention during the MOC2 training on care coordination. This concludes the training session.