How to Build a SNP Model of Care That Passes NCQA Scoring

May 9

MEDICARE / SNP | 8 MIN READ

Every Special Needs Plan operating under Medicare Advantage is legally required to have a documented Model of Care — but having one and having one that survives NCQA scoring are two very different things. CMS requires SNPs to submit their MOC for NCQA review, and NCQA scores each submission against a defined set of standards and factors using a percentage-based rubric. Plans that score below 70% overall, or below 50% on any single element, face a cure process. Plans approved only through cure are limited to a one-year approval, and a failed cure puts the SNP designation itself at risk.

Most first-submission MOCs come back with deficiencies in three predictable areas: population definition (particularly the Most Vulnerable Population), care coordination workflows that reflect aspiration rather than operations, and quality measurement without concrete targets. This guide breaks down what CMS and NCQA actually expect inside each MOC standard, where plans get tripped up, and what a well-constructed MOC looks like in practice — including the structural changes NCQA introduced for CY 2027.

What Is a Model of Care?

A Special Needs Plan Model of Care is a comprehensive operational document that describes how a plan will identify, assess, and coordinate care for its enrolled population. CMS defines the MOC as a quality improvement tool — not a marketing document — and holds SNPs accountable for implementing what they put in writing (CMS Medicare Managed Care Manual, Chapter 5).

There are three SNP types, and each carries distinct MOC expectations. Dual-Eligible SNPs (D-SNPs) must document how they coordinate Medicare and Medicaid benefits and navigate state-specific Medicaid requirements — and as of CY 2025, Fully Integrated Dual Eligible (FIDE) and Highly Integrated Dual Eligible (HIDE) SNPs face additional aligned enrollment and integration mandates that flow through multiple MOC elements. Chronic Condition SNPs (C-SNPs) must demonstrate clinical expertise specific to the chronic condition they serve, whether cardiovascular disease, diabetes, end-stage renal disease, or another qualifying category. Institutional SNPs (I-SNPs) must show how their model addresses the clinical complexity of long-term care populations. NCQA reviewers are trained to flag generic MOC language that could apply to any plan type as a red flag for inadequate specificity.

The Four MOC Standards and Where Plans Go Wrong

NCQA's SNP MOC framework is organized around four standards — MOC 1 through MOC 4 — each scored on a 0 to 100 percent scale based on the factors met within its sub-elements. Plans must achieve an overall score of at least 70 percent and a minimum of 50 percent on each individual element to obtain approval. Plans that fail either threshold enter the cure process, and plans approved through cure receive only a one-year approval regardless of the corrected score.

For CY 2027, NCQA reduced the number of scored elements but significantly deepened the specificity required within each one. Industry observers have described it as one of the most substantial restructurings the MOC framework has seen in years. Here is what each standard requires and where plans most often fall short.

MOC 1: Description of the SNP Population

Plans must describe both their general enrollee population (MOC 1A) and their Most Vulnerable Population, or MVP (MOC 1B). This includes demographics, health status, health disparities, co-morbidity prevalence, utilization patterns, and the unique clinical and social needs that distinguish the SNP population from a standard Medicare Advantage plan. The CY 2027 framework explicitly requires a clear, data-driven contrast between the general population and the MVP — if the two profiles read identically, the plan loses points.

The most common failure here is describing the population in broad strokes — stating that enrollees have "multiple chronic conditions" without specifying which conditions, at what prevalence, with what utilization, and in what service-area geography. CMS and NCQA expect this section to read like an evidence-based population health brief grounded in plan-specific data, not a marketing paragraph or repurposed regional statistics. Plans that miss the mark in MOC 1 are at heightened risk of falling below the 50 percent threshold, which automatically triggers the cure process and locks the plan to a one-year approval.

MOC 2: Care Coordination

MOC 2 is the most operationally dense standard, and the one most frequently cited in deficiency notices. It covers SNP staff structure, the Health Risk Assessment Tool (HRAT) and risk stratification methodology, the Individualized Care Plan (ICP), the Interdisciplinary Care Team (ICT), care transitions, and member communication. Plans must describe a complete, end-to-end process: how care coordinators identify high-need members, conduct HRAs, perform risk stratification, develop and update care plans, engage the ICT, manage transitions across care settings, and re-engage members who are non-responsive to outreach.

The MOC must name the tools and frequency for assessments, define how risk stratification results drive care coordinator caseloads, and explain how members who have no Medicare-covered services — a new CY 2027 emphasis — are identified and contacted. Vague commitments like "care coordinators will follow up as needed" score at or near zero. Reviewers need to see workflows, timelines, documentation standards, and escalation paths. Care transition protocols in particular must address how the plan receives discharge notifications, the timeframe for post-discharge contact, how medication reconciliation is handled, and where accountability sits between the care team and the receiving provider. Plans without a documented post-discharge follow-up protocol and clear handoff accountability routinely receive partial credit at best.

A consistent CY 2027 failure mode in MOC 2: care coordination descriptions that reflect ideal workflows rather than actual operations. NCQA has been explicit that it is evaluating what is actually happening, not what the plan hopes to do.

MOC 3: SNP Provider Network

Plans must demonstrate that the provider network is built to serve the specific needs of the SNP population. For a C-SNP serving cardiovascular members, the network section should address specialist access, hospital affiliation with cardiac programs, and integration with community resources like cardiac rehabilitation. For a D-SNP, network documentation should address how Medicaid-covered providers are coordinated alongside Medicare providers and how the plan handles members who see providers outside both networks. For I-SNPs, network adequacy must reflect the long-term care setting and the specialized clinical staffing that population requires.

CY 2027 also raises expectations around clinical practice guideline oversight — how the plan monitors guideline adherence, how it adapts guidelines as evidence evolves, and how it documents ongoing enrollee oversight. A generic network adequacy statement drawn from the plan's standard Medicare Advantage submission will not satisfy this standard.

MOC 4: MOC Quality Measurement and Performance Improvement

Plans must identify specific quality metrics they will track, set measurable goals and benchmarks for HRA completion, ICP completion, and ICT engagement, explain how performance data is collected and analyzed, and describe how findings feed back into plan operations. The metrics must be directly tied to the SNP population's condition or eligibility category — a D-SNP tracking diabetes HbA1c control rates and medication adherence is more credible than a generic list of HEDIS measures.

Alongside MOC 1, MOC 4 is the highest-risk area for cure under CY 2027 scoring. The most common failures are quality goals without measurable targets, benchmarks, timeframes, or remediation strategies — and risk stratification models that describe tiers without explaining how those tiers actually change outreach intensity, care planning, or follow-up. NCQA looks for a closed feedback loop: how does the plan know if its care coordination model is working, and what changes when it is not? Plans that cannot describe a concrete quality improvement cycle here will score poorly regardless of how strong their care coordination language is.

Scoring and Approval Periods

NCQA assigns one of three approval periods: one year, two years, or three years. Plans that score below 70 percent overall or below 50 percent on any individual element enter the cure process — and plans approved through cure receive a one-year approval regardless of the corrected score. There is one critical exception that catches new SNP operators off guard: C-SNPs receive only a one-year approval period regardless of MOC score, per CMS rules. For C-SNPs, the goal is not extending the approval window but ensuring the plan passes outright and avoids the operational drag of an annual cure cycle.

The Renewal Cycle and Off-Cycle Revisions

Plans with a one-year approval re-submit annually. Plans with two- or three-year approvals re-submit at the end of their approval period — not every year. But that does not mean the MOC sits untouched in the interim. When a plan undergoes material changes — new service areas, changes in benefit design, updated risk stratification tools, organizational restructuring affecting care coordination — CMS requires an off-cycle MOC revision, submitted through the HPMS MOC Module with a summary of changes and a red-lined revised MOC.

Plans that treat the MOC as a static submission artifact between renewal cycles accumulate compliance risk. Operations evolve, but if the MOC language does not evolve with them, the next renewal score will drop sharply — and the gap between documented process and actual operation is exactly what NCQA is now built to surface. The strongest performers treat the MOC as a living operational document, updated continuously as workflows change, and present a renewal that mirrors the plan's current state.

What the Data Shows About SNP Growth and Stakes

SNP enrollment has grown dramatically. According to KFF analysis of CMS enrollment data, SNPs grew from 2.6 million enrollees in 2018 to 7.3 million in 2025, and reached more than 8 million enrollees in early 2026 — now accounting for 23 percent of all Medicare Advantage enrollment, up from 13 percent in 2018. Through 2024, D-SNPs drove the majority of that growth, expanding from 2.2 million to 5.5 million enrollees and comprising over 90 percent of total SNP enrollment growth from 2018 to 2024.

A significant 2025 market shift saw C-SNPs become the fastest-growing SNP type: C-SNPs accounted for 75 percent of total SNP enrollment growth between 2024 and 2025, adding 476,300 new enrollees compared to just 159,400 new D-SNP enrollees. Analysts attribute this acceleration to new 2025 federal integration requirements for FIDE and HIDE D-SNPs, which mandated aligned enrollment and Medicaid coordination standards that some insurers sought to avoid by expanding C-SNP offerings. The regulatory environment has tightened in parallel: CMS has increased its scrutiny of MOC quality, NCQA has restructured the MOC framework for CY 2027, and CMS has signaled continued oversight focus through its annual Call Letter guidance.

For health plans, the stakes are not abstract. A SNP designation is a revenue and market access asset. Losing it — or operating under a one-year approval that requires annual re-scoring — affects star ratings, member retention, and the ability to expand into new service areas or SNP types. Plans that invest in MOC quality as an operational capability rather than a compliance burden tend to see the downstream benefits in star ratings, care coordination efficiency, and member outcomes.

Five Practical Steps to Strengthen Your MOC Before Submission

First, audit your current MOC against NCQA's scoring guidelines for the contract year you are submitting, factor by factor — not just against the CMS regulatory language. The scoring rubric tells you specifically what earns full credit versus partial credit within each element. Second, identify your population data sources and confirm they are current and plan-specific. NCQA reviewers look for specificity and recency, with a clear data-driven contrast between the general population and the Most Vulnerable Population. National or regional proxy data will not carry MOC 1B.

Third, map your care coordination workflows to paper before writing the MOC language. If you cannot draw the process — from member identification through risk stratification through care plan development through ongoing monitoring and re-engagement — you cannot describe it with the specificity NCQA requires. The CY 2027 standard is operational reality, not aspirational design. Fourth, get your governance structure on record. Document who sits on the committee responsible for MOC oversight, their titles, how often they meet, how they receive performance data, and how they drive corrective action. Fifth, read last year's deficiency letter, if you have one, before you start writing. Deficiency patterns are not random. If a reviewer flagged your care coordination language last cycle, the same language recycled this cycle will receive the same score.

The Bottom Line

A Model of Care that earns a high NCQA score is not produced by a compliance team working in isolation four weeks before a submission deadline. It is produced by a plan that understands its enrolled population, has mapped its care delivery processes, and can describe both with precision and evidence. CMS's requirements are publicly available in Chapter 5 of the Medicare Managed Care Manual, and NCQA's scoring criteria are available to plans as part of the review process. The gap between plans that pass with high scores and plans that receive deficiency notices is almost never about access to information. It is about operational discipline and the willingness to build the MOC from the ground up as a true reflection of how care is actually delivered.

If your plan is preparing for an initial MOC submission, approaching a renewal under the CY 2027 framework, or working through a cure process, OpsKR Consulting builds SNP Models of Care from the operational level up. We work directly with care management, compliance, and clinical teams to produce MOC documentation that reflects what your plan actually does — and scores accordingly.

Sources: CMS Medicare Managed Care Manual, Chapter 5 (Special Needs Plans); NCQA SNP Model of Care Approvals and Scoring Guidelines (snpmoc.ncqa.org); CY 2026 SNP MOC Training FAQs (NCQA, January 2025); CMS Annual Call Letter Guidance; CHRONIC Care Act of 2018 (Pub. L. 115-182); KFF, "A Closer Look at the Growing Role of Special Needs Plans in Medicare Advantage" (September 2025) and "Medicare Advantage Enrollment Grew by About 1 Million People, Mainly Due to Special Needs Plans" (February 2026); BluePeak Advisors, "CY 2027 Model of Care — What SNP Plans Need to Know" (March 2026).

OpsKR Consulting LLC