CY2026 CMS Model of Care Emphasizes Data, Populations, Goals, and Detailed Processes

By Nancy Ross Bell, RN

Estimated time to read: 3 minutes

The time is now to take action on your CY2026 Model of Care (MOC) for Special Needs Plans (SNP) as required by the Centers for Medicare & Medicaid Services (CMS).  

The CY2026 updates emphasize a rigorous data collection process and detailed analysis, measurable outcomes, precise descriptions of populations, including vulnerable subpopulations, integrating community services, enhanced continuity of care, and well-prepared staff who deliver care.

Two Actions to Take Now

• Contact MHR to schedule a consultation on your draft MOC before you submit it to CMS. Submission day to CMS is February 12, 2025.
  • MHR Consultant Jean Lockington is an executive reviewer for NCQA and can identify gaps you may have in the MOC before it is scored by NCQA. Please note that to avoid any conflict of interest, organizations for which Jean reviews MOCs on behalf of MHR are not assigned to her as an NCQA Surveyor for a SNP Model of Care.
• Review NCQA’s SNP Approval Model of Care for CY2026 NCQA’s two video presentations and slides on MOC Elements 1&2 and 3&4 describe in detail what must be included in your MOC.

Why Take the Extra Step for MHR to Assess Your MOC? 

• SNPs that receive a failing score for their initial MOC submission have just one cure opportunity to achieve a passing score. Why take the chance of failing and risk the ability to implement your SNP in CY2026?
• CMS requirements can change annually for each type of SNP. Don’t assume what was submitted in the past will suffice for CY2026. Avoid a cure or only a one-year approval for a Dual or Institutional SNP.  (Chronic SNPs only receive approval for a one-year approval period per CMS standards.)

Mark Your Calendar

Deadlines for the MOC are just months away.

• January 31, 2025: MHR completes its review of draft MOCs before the organization submits them to CMS.
• February 12, 2025 (8:00 p.m. ET): CMS downloads and sends MOCs to NCQA for review and scoring.
• April 14, 2025: NCQA uploads results to CMS, and Notices of Intent to Deny (NOIDS) are sent to organizations from CMS.
• April 24, 2025 (8:00 p.m. ET): Organizations that did not receive a passing score have one opportunity to cure their MOC(s) and submit them to NCQA by this date.
• May (up to mid-May) 2025: NCQA uploads cured submissions to CMS. CMS issues approvals and denials.
• January 1, 2026: Approved plans implement their SNP products

Selected Changes and Points of Emphasis for CY2026

The selected points highlighted below are for your action. Please note that multiple Factors were moved to realign with CY2026 changes and are not included in this summary. Reading the entire CY2026 Summary of Changes and the Standards and Guidelines for the SNP MOC is critical.

See NCQA’s training for all Factor-level details.

• Data: MOC 1 and other relevant sections with data
  • For CY 2026, data must be current and cannot predate more than three years from the current submission; i.e., data from earlier than 2021 is not acceptable. Specify data sources and years.
  • Specify data to the target population, i.e., each individual H contract number for all service areas for submission for CY2026.
• Populations: (MOC1)
• The overall SNP target population must be described in detail for the service areas and meet all factors (MOC 1A Factors 1-4).
• The most vulnerable subpopulation must be clearly described and differentiated from the general population (MOC 1B Factors 1-4).
  • Include either a list of current community partners and the services they provide to the most vulnerable enrollees or a description of the system used to house, research, identify, and access these resources (MOC 1B Factor 3).
• The methodology to identify vulnerable populations must specify the criterion or set of criteria used to determine if an enrollee is included in the most vulnerable population.
• SNPs renewing their contract(s) after year two of operations must provide their own historical data instead of other local, national, or proxy data (MOC 1B Factor 2).
• SNP Staff Structure and Training: (MOC 2)
  • The SNP must provide a copy of the organizational chart identifying staff directly or indirectly responsible for enrollee care and coordination outlined in Factors 1,2 (MOC 2A Factor 3).
  • The SNP must provide staff training materials based on initial or renewal MOC submission requirements (MOC 2A Factor 5).
• Health Risk Assessment (HRA):
  • Clarified that SNPs must describe the stratification process and how the use of stratified results improves the care coordination process (MOC 2B Factor 4).
• Face to Face Encounter:
  • Clarified that plans must address the consent process for both in-person and virtual face-to-face encounters (MOC 2C Factor 1).
  • Clarified that plans must address how the SNP determines and conducts care coordination activities when the plan reviews data associated with a face-to-face encounter between an enrollee and a provider (MOC 2C Factor 6).
  • Individualized Care Plan (ICP):
  • Clarified that SNPs must explain how stratified HRA results are incorporated into each enrollee’s ICP (MOC 2D Factor 2).
• Interdisciplinary Care Team (ICT):
  • Clarified that SNPs must provide a detailed explanation of how the stratified HRA results are used to determine the composition of the ICT (MOC 2E Factor 2).
• Care Transition Protocols:
  • Clarified that plans must address the process for planned and unplanned transitions and also specified that plans must describe how other health-related needs are provided during transitions in care (in addition to transferring important health information between settings) (MOC 2F Factor 3).
  • Emphasized that care coordination is required for all enrollees and is not limited to medium and high-risk stratified enrollees.
• Provider Specialized Expertise: (MOC 3)
  • Clarified that SNPs must provide the process and frequency for updating provider information in the provider directory (MOC 3A Factor 3).
• Use of Clinical Practice Guidelines (CPGs) and Care Transition Protocols (CTPs):
  • Clarified that SNPs must specify the person(s) or group/committee responsible for deciding to modify guidelines (MOC 3B Factor 3).
• MOC Training for Provider Network:
• Clarified that provider staff may include care coordination staff, admin staff, or other clinical or support staff (MOC 3C Factor 1).
• Ensure training slides for the provider network are specific to the providers versus those in MOC 2 for Care Coordinator training.
  • Measuring Patient Experience of Care (SNP Enrollee Satisfaction):
  • Clarified that if more than one enrollee survey is used, the SNP must provide the requested information for each survey (MOC 4C Factors 1 and 2).
  • Emphasized that the SNP must specify the sample size used for each survey (MOC 4C Factor 3).
• Quality Performance Improvement Plan (MOC 4A) & Measurable Goals and Health Outcomes: (MOC 4B)
• Renewal of SNP Plan: Elements A and B require an analysis of the goals of the previously approved MOC. The analysis must include benchmarks, goals, timeframes, data sources, a determination of whether goals were met/fulfilled or not met, and a plan of action to address improvements needed when goals are not met.
• SNPs must set completion goals at 100% and include all enrollees for Health Risk Assessments (HRA), Individualized Care Plans (ICP), and Interdisciplinary Care Teams (ICT) (MOC 4B).

Refer to NCQA’s Training slides for examples of table templates that may be used to detail plan goals and benchmarks as required by MOC 4A and MOC 4B.

Tips from MHR

As you are developing your MOC, ensure:

• All processes and descriptions are in detail! Include the who, what, when, where, and how for processes.
• What you write in the MOC can be truly implemented!
• Process steps are operationalized across your organization and externally with community partners according to your MOC.
• Responsible parties are designated for each process.
• Data collection meets requirements for the overall population and vulnerable populations.
• The quality program for the SNP should be integrated within your organization.
• Use a team approach in the development of the MOC.

Resources:

NCQA: Model of Care

(Timeline, Scoring Guidelines, Training, and Technical Assistance)

Medicare Managed Care Manual. Chapter 16-B: Special Needs Plans (Issued 11-22-24)

Blog: MHR’s Guide to Planning Your Model of Care for CY2026: Consultant Tips Included

Call to Action:

• Schedule a consultation with MHR on your CY2026 Model of Care.
• Contact your MHR Consultant or email us at [email protected]

MHR follows a quality review process for all blogs. This blog was written with insights from Jean Lockington. Please read more about Jean and MHR’s other Independent Consultants at ManagedHealthcareResources.com/About Our Consultants.  

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