A special needs plan (SNP) model of care is the written, evidence-based plan for how an SNP serves its targeted enrollees, and 42 CFR 422.101(f) requires every SNP to have one and to submit it for evaluation and approval. It is for plan sponsors that have to write a model of care that covers the required duties. Integral Healthcare Solutions (IHS) drafts the narrative and structure for your clinical leaders to approve, and the plan submits it.
Last updated: November 2026
What does 42 CFR 422.101(f) require of a special needs plan model of care?
It requires an evidence-based model of care, defined duties and a score high enough to be approved. Paragraph (f)(1) says: "MA organizations offering special needs plans (SNP) must implement an evidence-based model of care with appropriate networks of providers and specialists designed to meet the specialized needs of the plan's targeted enrollees." Paragraph (f)(3)(i) says: "All SNPs must submit their model of care (MOC) to CMS for NCQA evaluation and approval in accordance with CMS guidance."
The governing text is 42 CFR 422.101(f), "Special needs plan model of care," in the eCFR text built November 4, 2026 (Title 42 last amended October 8, 2026), which we checked on November 5, 2026. The latest amendment to paragraph (f) is 91 FR 17581 (April 6, 2026). This page rests on the regulation only. The guidance documents that carry element definitions, matrices and submission schedules are separate materials that this page does not use, so confirm current guidance with your submission team.
| Paragraph | What it asks, in IHS's words | What answers it |
|---|---|---|
| (f)(1)(i) | Conduct a comprehensive initial health risk assessment within 90 days, before or after the effective date of enrollment, for all new enrollees. | HRA timeline and tracker |
| (f)(1)(iii)(B) | The risk assessment tool must include one or more questions, from a list of screening instruments CMS specifies in subregulatory guidance, on each of three domains: housing stability, food security and access to transportation. | Risk assessment tool review |
| (f)(1)(iv)(A) | To schedule the initial or annual HRA, make at least three attempts on different days at different times of day, excluding automated calls, unless the enrollee agrees or declines before three attempts. | Outreach documentation workflow |
| (f)(1)(vii) | Develop a comprehensive individualized plan of care within 90 days of conducting the initial HRA or 90 days after the effective date of enrollment, whichever is later. | Care plan timeline |
| (f)(1)(vii)(B) | Develop the plan through an interdisciplinary care team with active participation of the enrollee (or the enrollee's representative, as applicable), as feasible. | Interdisciplinary care team description |
| (f)(2)(i) | Target one of the three populations in 42 CFR 422.2 (page opened November 5, 2026): institutional (I-SNP), dual eligible (D-SNP) or chronic condition (C-SNP). A special needs individual must be MA eligible and meet the section's institutionalized/institutionalized-equivalent definition, be entitled to Medicaid under a State title XIX plan, or have a severe or disabling chronic condition as defined there and benefit from enrollment in a specialized MA plan. | Target population statement |
| (f)(2)(ii) | Have appropriate staff, employed, contracted or non-contracted, trained on the model of care to coordinate or deliver all services and benefits. | Staffing structure and training plan |
| (f)(3)(iii) | Each element must meet a minimum benchmark score of 50 percent and the model of care an aggregate minimum benchmark of 70 percent; a model of care is approved only if it meets both. | Self-scoring against the benchmarks |
| (f)(3)(iii)(A) | A model of care for a C-SNP that receives a passing score is approved for 1 year. | Renewal calendar |
| (f)(3)(iii)(B)(1) | A model of care for an I-SNP or D-SNP with an aggregate score of 85 percent or greater is approved for 3 years. | Renewal calendar |
| (f)(3)(iii)(B)(2) and (3) | An I-SNP or D-SNP model of care scoring 75 to 84 percent is approved for 2 years, and one scoring 70 to 74 percent for 1 year. | Renewal calendar |
| (f)(3)(iii)(C) | A model of care that fails the 50 percent element benchmark or the 70 percent aggregate benchmark gets a one-time opportunity to resubmit the corrected model of care for reevaluation; one corrected and resubmitted this way is approved for only 1 year. | Cure plan |
For D-SNPs that are applicable integrated plans under 42 CFR 422.561, paragraph (f)(1)(v) requires a single integrated Medicare-Medicaid HRA meeting paragraphs (f)(1)(i)-(iv) and 42 CFR 438.208(b)(3), beginning no later than contract year 2027. The table's deliverables are IHS's proposed work products, not prescribed forms. These are selected requirements, not the complete model-of-care standard.
Who needs it and what triggers it?
Every MA organization offering an SNP must implement the required model of care. IHS identifies these planning situations from 42 CFR 422.101(f), as read November 5, 2026:
- Preparing an initial model of care for evaluation and approval.
- Preparing for the end of an existing approval period.
- Correcting a model that missed an element or aggregate benchmark; the one-time cure allows reevaluation, with approval limited to 1 year if the corrected model meets both benchmarks.
How IHS helps
IHS assesses gaps against paragraphs (f)(1) and (f)(2), maps evidence, drafts missing content for clinical approval, conducts a mock review and supports readiness. Thomas G. Goddard leads program development; Maureen Plumstead leads NCQA accreditation and recognition. The drafts are a model-of-care narrative organized to those duties, a staffing and care coordination structure, an interdisciplinary care team description, HRA and care plan timelines with an outreach documentation workflow, a measure plan and a goal-fulfillment section for renewals. Integral Healthcare Solutions (IHS) was founded in 2002 by Thomas G. Goddard, JD, PhD, former Chief Operating Officer and General Counsel of URAC, and works across three practice lines: accreditation consulting, compliance services and program development. This build sits in our Program Development practice line.
Your plan supplies the target population definition, the provider network and staffing, the clinical leaders' approval of care processes, data on whether prior goals were met, your HRA tool and care management workflows, and the submission through CMS channels.
The limit: IHS does not submit the model of care to CMS or NCQA and does not communicate with either for the plan. IHS does not set clinical content, because the plan's clinical leaders approve it, and IHS does not guarantee a score.
What to have ready
Checklist references below are to 42 CFR 422.101(f), current eCFR built November 4, 2026 (page opened November 5, 2026).
- Your definition of the targeted enrollees and which of the three SNP populations you target (paragraph (f)(2)(i)).
- Your provider and specialist networks for the targeted enrollees (paragraph (f)(1)).
- Your initial HRA timing records and annual HRA process (paragraphs (f)(1)(i)-(ii)).
- Your outreach log showing attempts to reach each enrollee, including any enrollee who agreed or declined early (paragraph (f)(1)(iv)(A)).
- A sample individualized plan of care and the interdisciplinary team that built it (paragraphs (f)(1)(vii) and (f)(1)(vii)(B)).
- Staff rosters and training records on the model of care (paragraph (f)(2)(ii)).
- Prior model of care goals and outcome data for renewal, including how unmet goals will be achieved or revised (paragraph (f)(3)(ii)(A) and (C)).
- The current approval period and score, if you have one (paragraph (f)(3)(iii)).
If several are missing, book the free introductory call and bring what you have.
How does outside drafting support compare with other routes?
A plan can draft internally or use outside drafting support. Both routes require clinical review and submission in accordance with CMS guidance. An internal build uses your team's writing capacity; IHS adds drafting and gap-assessment support while your clinical leaders approve the content. For a general compliance program build under OIG guidance, a different service, see our compliance program development page.
What does it cost?
The reviewed regulation does not state a fee; this does not establish that submission is free. IHS scopes each engagement after a free introductory call. What moves the scope is the number of SNP plan types and populations, your provider network and staffing structure, and how far your current model of care is from paragraphs (f)(1) and (f)(2).
Your own staff time is the third cost. Your clinical, quality and care management leaders supply data, review drafts and approve every care process, and that time is yours whichever route you take.
What this is not
This is not legal advice. IHS is a consulting firm, not a law firm, and your counsel confirms regulatory questions. It is not a guarantee of any score or approval period. IHS does not submit the model of care to CMS or NCQA; the plan does.
Frequently asked questions
What is a special needs plan model of care?
It is an evidence-based model of care with appropriate networks of providers and specialists, designed to meet the specialized needs of the plan's targeted enrollees. Paragraph (f)(1) requires every MA organization offering a special needs plan to implement one. IHS drafts the narrative and structure.
What must a model of care contain under 42 CFR 422.101(f)?
Paragraph (f)(1) sets duties such as the initial health risk assessment, outreach attempts and an individualized plan of care. Paragraph (f)(2) requires the plan to target one of the three SNP populations defined in section 422.2 and to have appropriate staff trained on the model of care. IHS organizes the narrative to those duties.
What score does a model of care need to be approved?
Each element must meet a minimum benchmark score of 50 percent and the model of care an aggregate minimum benchmark of 70 percent, and a model of care is approved only if it meets both, under paragraph (f)(3)(iii). IHS drafts a self-scoring step against those benchmarks. The plan's clinical leaders approve the content, and IHS does not guarantee a score.
How long is a model of care approved for?
Under paragraph (f)(3)(iii), approval requires at least 50 percent on every element and 70 percent overall. A passing C-SNP model is approved for 1 year; I-SNP and D-SNP models receive 3 years at 85 percent or greater, 2 years at 75-84 percent and 1 year at 70-74 percent. A model approved through the one-time cure receives only 1 year. IHS drafts the renewal calendar.
What happens if the model of care misses an element?
If a model of care fails the 50 percent element benchmark or the 70 percent aggregate benchmark, paragraph (f)(3)(iii)(C) gives a one-time opportunity to resubmit the corrected model of care for reevaluation. A model of care corrected and resubmitted under this cure period is approved for only 1 year. IHS drafts a cure plan so the correction is ready if it is needed.
What are the HRA timing and outreach requirements?
New enrollees receive a comprehensive initial HRA within 90 days before or after enrollment takes effect; a comprehensive HRA is also required annually. To schedule either assessment, make at least three attempts on different days at different times of day, excluding automated calls, unless the enrollee agrees or declines before three attempts. If there is no response, send a follow-up letter; document contact attempts and, where applicable, refusal for enrollees who cannot be reached or decline. IHS drafts the timeline and outreach log.
How is the individualized plan of care developed?
Within 90 days of conducting the initial HRA or 90 days after the effective date of enrollment, whichever is later, the plan develops a comprehensive individualized plan of care. It is developed through an interdisciplinary care team with active participation of the enrollee (or the enrollee's representative, as applicable), as feasible. IHS drafts the care team description and the plan timeline.
What does model of care development cost?
The reviewed regulation does not state a fee; this does not establish that submission is free. IHS scopes each engagement after a free introductory call. Allow for your clinical leaders' time to review and approve drafts.