BluePeak Advisors Case Study
Achieving near-perfect NCQA scores while building a fully operational, audit-ready Model of Care framework.
Executive Summary
In late 2024, a Medicare-Medicaid Plan (MMP) that was transitioning into a Fully Integrated Dual Eligible Special Needs Plan (FIDE) engaged BluePeak Advisors to guide its transition, which required operational enhancements to ensure compliance with new regulations.
One critical component of any new Special Needs Plan is a strong Model of Care (MOC). The MOC is the foundational blueprint for how the plan intends to coordinate services, manage clinical needs, and deliver high-quality care to its members enrolled in a FIDE. BluePeak’s client had limited experience with the more robust operational and documentation requirements of dual eligible special needs plans (D-SNPs) and had no prior experience writing a National Committee for Quality Assurance (NCQA)-scored MOC.
BluePeak delivered comprehensive education, strategic guidance, and full MOC development support. This included analytics to define the SNP population, drafting of all four required MOC elements, creation of quality objectives, and cross departmental engagement to ensure operational feasibility. Midway through the process, BluePeak quickly pivoted to develop a second MOC for a Coordination Only Dual-Eligible Special Needs Plan (CO D-SNP) after an internal change of direction by our client.
BluePeak’s client submitted both MOCs on time, achieved near-perfect NCQA scores and secured three-year approvals for both plans. During our client work, BluePeak also aligned MOC execution, Stars strategy, and regulatory compliance in one unified framework, ensuring a successful quality program.
Objective
The objective was to write comprehensive and accurate MOCs, allowing BluePeak’s client to successfully transition its MMP to a FIDE and add a CO D-SNP for plan year 2026.
The successful submission would enable the plan to continue serving vulnerable members in its service area while meeting new federal integration requirements. BluePeak aimed to not only ensure that all MOC elements would be approved by NCQA for three years, but that they could be operationalized by the plan and avoid unnecessary audit scrutiny down the road.
The Challenge
Background
In 2022, Neighborhood partnered with BluePeak to address the operational and regulatory challenges associated with Medicare compliance. As part of this collaboration, Neighborhood sought BluePeak’s assistance in transitioning from an MMP Demonstration Plan to a DSNP. This transition necessitates the annual submission of a compliant bid to the Centers for Medicare and Medicaid Services (CMS). Despite CMS providing guidance and process documents, the bid submission is a complex process that requires expertise in both technical aspects and financial and industry acumen to understand the downstream implications of bid decisions. Without proper understanding and consideration, organizations risk significant financial, operational, and compliance issues. BluePeak’s comprehensive understanding of Medicare compliance and bid submission processes provided Neighborhood with the necessary expertise to navigate complex regulatory landscapes.
Methodology
BluePeak dedicated several months in early 2024 to building complete CMS- and NCQA-compliant MOCs for both contracts.
This work included:
- Conducting population research and analyzing state-provided data to define the FIDE and CO D-SNP populations.
- Delivering detailed education on MOC elements, NCQA scoring, operational impacts, and downstream audit considerations.
- Facilitating work sessions across departments to obtain accurate clinical, operational, and quality information.
- Drafting all MOC elements using best practices and aligning them with new federal integration standards.
- Collaborating closely with the plans leadership and SMEs to ensure accuracy, feasibility, and readiness for NCQA review.
Solutions Implemented
1
Education and Readiness
- Developed and delivered tailored presentations for leadership and operational teams highlighting the MMP to SNP transition, federal duals integration requirements, and key operational changes.
- Conducted MOC specific training to explain NCQA scoring, submission requirements, critical content areas, and the operational implications of each commitment made in the MOC.
- Provided a detailed MOC template and guided Neighborhood departments through the process of gathering content aligned with regulatory expectations and best practices.
2
Population Analysis
- Analyzed state demographic and clinical data to define the SNP’s target population and support the rationale for offering a FIDE.
- Identified and described the Most Vulnerable Population and their enhanced care coordination interventions. This is most often missed by plans and is critical for Element 1 scoring.
3
FIDE MOC Development
- Authored all components of the MOC, including but not limited to:
- Comprehensive population descriptions
- Eligibility tracking methods
- Health Risk Assessment (HRA) and Individualized Care Plan (ICP) processes
- Interdisciplinary Care Team (ICT) structure and care coordination workflows
- Provider network adequacy and specialist access
- Quality measurement strategy and continuous improvement processes
- Ensured all commitments in the MOC aligned with future operational reality and CMS audit expectations.
4
CO D-SNP MOC Development
- Leveraged the FIDE framework to rapidly build a second MOC after the plan determined the need for a CO D-SNP.
- Adapted elements to reflect the CO D-SNP’s care coordination scope, ensuring compliance with NCQA standards under a shortened timeline.
5
Development of a Comprehensive MOC & Stars Implementation Grid
- In parallel with the work to capture both MOC operational and compliance processes and protocols, BluePeak developed a detailed MOC and Stars Implementation Grid to ensure every requirement outlined in the MOC could be operationalized, monitored, and tied to measurable performance outcomes. This grid served as the bridge between the written MOC and day‑to‑day execution, outlining tasks, accountable owners, timelines, data dependencies, and compliance checkpoints.
- The result was a robust, practical tool that not only supported NCQA approval, but positioned BluePeak’s client for long‑term quality program success under its new D‑SNP products, aligning MOC execution, Stars strategy, and regulatory compliance in one unified framework.
Results
Outcome
97.5%
NCQA Score Achieved
Near-perfect scores for both MOCs with no requested cures or rewrites.
Near-perfect scores for both MOCs with no requested cures or rewrites.
3 Year
NCQA Approval Secured
Both the FIDE and CO D-SNP MOCs received full three-year approvals.
Both the FIDE and CO D-SNP MOCs received full three-year approvals.
2
MOCs Successfully Approved
FIDE SNP and Coordination-Only D-SNP Models of Care approved by NCQA.
FIDE SNP and Coordination-Only D-SNP Models of Care approved by NCQA.
From documentation to execution: a fully aligned Model of Care built for compliance, performance, and audit readiness.
- With BluePeak’s comprehensive expertise and hands on partnership, both MOCs achieved NCQA scores of 97.5%, with no requested cures or rewrites, resulting in three year approvals for the FIDE and the CO D-SNP.
- Beyond the written MOCs, BluePeak delivered a robust MOC and Stars Implementation Grid that translated every MOC requirement into operational steps, timelines, and accountable owners. This tool gives BluePeak’s client a clear roadmap for executing the MOC, ensuring compliance with federal integration standards, and strengthening the plan’s alignment with Stars measures tied to care coordination, HRA timeliness, ICP updates, and member experience. The grid also positioned Neighborhood for smoother CMS audits by connecting MOC commitments to day to day workflows.
- BluePeak remains engaged with our client to assist with future updates and resubmission of the MOCs under NCQA’s revised scoring guidelines at the end of the current approval cycle.
