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2019 QIS Implementation Plan and Progress Report F orm
OMB 0938-1286
Expiration Date: 10/31/2018
Please retain a copy
of the completed
Quality Improvement
Strategy
(QIS)
form so that it is available for
future referenc
e for reporting on
activities
conducted to implement the QIS. For detailed
instructions,
please refer to the QIS Technical Guidance and User Guide for the 2019 Plan Year
.
QIS Submission Type
Part A. New or Continuing QIS Submission
This field is required, but will not be scored as part of the QIS evaluation.
1. Type of QIS Su
bmission
Select the option that describes the type of QIS submission, and follow the instructions to complete
the submission.
Type of QIS
Instructions
New QIS
1
with No Previous
QIS submission
Complete the Background Information Section (Parts
B and C) and the Implementation Plan Section (Parts
D and E).
New QIS after Discontinuing
a QIS Submitted during a
prior Qualified Health
Plan (QHP) Application
Period
2
Must complete two forms:
1. Complete a form to close out the discontinued QIS,
including the Background Information Section (Parts B
and C); Implementation Plan Section (Parts D and E),
with the discontinued QIS information; and Progress
Report Section (Part F); AND
2. Complete a new/separate form to submit the new
QIS, including the Background Information Section
(Parts B and C) and the Implementation Plan Section
(Parts D and E).
Continuing a QIS with No
Modifications
Complete the Background Information Section (Parts
B and C), Implementation Plan Section (Parts D and
E), and the Progress Report Section (Part F).
Continuing a QIS with
Modifications
3
Complete the Background Information Section (Parts
B and C); Implementation Plan Section (Parts D and
E); and the Progress Report Section (Part F).
1
A “new QIS” is defined as a QIS that has not been previously submitted to an Exchange, or is a QIS that is based
upon a different market-based incentive(s) and/or topic area(s) than the issuer’s previous QIS.
2
A new QIS is required if
an issuer: changes
its
QIS market-based incentive type or sub-type, changes
its QIS topic
area, reaches
one or
more of
its
QIS performance targets, the QIS is
not
having the expected impact, or the QIS
results
in negative outcomes or unintended consequences.
3
An issuer may continue with an existing QIS even if it changes the following: activities, goals, and/or performance
measures.
pg. 1
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
14. Date Issuer Began Offering Coverage Through the Exchange
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Background Information
Part B. Issuer Information
These fields are required, but will not be scored as part of the QIS evaluation.
2. Issuer Legal Name
3. Company Legal Name
4. HIOS Issuer ID
5. Issuer State
6. QIS Primary Contact’s First Name
QIS Primary Contact’s Last Name
7. QIS Primary Contact’s Title
8. QIS Primary Contact’s Phone
Ext.
9. QIS Primary Contact’s Email
10. QIS Secondary Contact’s First Name
QIS Secondary Contact’s Last Name
11. QIS Secondary Contact’s Title
Ext.
13. QIS Secondary Contact’s Email
/ /
pg. 2
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
Percentage of Fee for Service payments linked to quality and value:
%
4
Categories of payment models are defined in Alternative Payment Model Framework and Progress Tracking (APM
FPT) Work Group – Alternative Payment Model (APM) Framework Final White Paper.
Plan Year for examples of payment models within each category.
5
To calculate the percentage of payments for Fee for Service payments linked to quality and value, and/or Alternative
Payment Models tied to quality and value, issuers should use the calculation methodologies defined in the Measuring
Progress: Adoption of Alternative Payment Models in Commercial, Medicare Advantage, and State Medicaid Programs
instructions to calculate the percentage of payments for these two payment model categories.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
15. Current Payment Model(s) Description
Select the category(ies)
4
of payment models that are used by the issuer across its Exchange
product line. If “Fee for
Service – Linked to Quality or Value” AND/OR “Alternative Payment Models
Built upon Fee for Service Architecture” is checked, provide the percentage of payments tied to
quality or value.
Payment Model Type
Payment Model Description
Fee for Service – No Link to
Quality and Value
Payments are based on volume of services
and not linked to quality or efficiency.
Fee for Service – Linked to Quality
and Value
At least a portion of payments vary based on
the quality or efficiency of health care delivery.
Alternative Payment Models Built
on Fee for Service Architecture
Some payment is linked to the effective
management of a segment of the population
or an episode of care. Payments still triggered
by delivery of services, but opportunities for
shared savings or two-sided risk.
Population-based Payment
Payment is not directly triggered by service
delivery so payment is not linked to volume.
Clinicians and organizations are paid and
responsible for the care of a beneficiary for a
long period (e.g., more than one year).
5
Percentage of payments tied to quality and
value through alternative payment models:
Provide percentage of payments:
%
https://hcp-lan.org/workproducts/apm-whitepaper.pdf. See the QIS Technical Guidance and User Guide for the 2019
(APM Measurement Effort) Final Paper. https://hcp
-lan.org/groups/apm-fpt/apm-report/. See Table 1 (p. 7-10) for
pg. 3
According to the Paperwork
Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget
(OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Part C. Data Sources Used for Goal Identification and Monitoring Progress
These fields are required, but will not be scored as part of the QIS evaluation.
16. Dat
a Sources
Indi
cate the data sources used for identifying QHP enrollee population needs and supporting the QIS
rationale (Element 22). Check all that apply.
Data Sources
Internal issuer enrollee data
Medical records
Claim files
Surveys (enrollee, beneficiary satisfaction, other)
Plan data (complaints, appeals, customer service, other)
Registries
Census data
Specify Type [e.g., block, tract, ZIP Code]:
Area Health Resource File (AHRF)
All-payer claims data
State health department population data
Regional collaborative health data
Other
If you checked “Other,” please describe. Do not include company identifying information in your data
source description.
(100 character limit)
pg. 4
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
QIS Implementation Plan Section
Part D. QIS Summary
These fields are required, but will not be scored as part of the QIS evaluation.
17. QIS Title
Prov
id
e a short title for the QIS.
(200 character limit)
18. QIS Description
Prov
id
e a brief summary description of the QIS. The description must include the market-based
incentive type and topic area.
(1,000 character limit)
Is the QIS described above part of a mandatory State initiative?
Yes No
Is the QIS submission
6
a strategy t
hat the issuer currently has in place for its Exchange product line
and/or for other product lines?
Yes
No
6
Issuers may use existing strategies employed in non-Exchange product lines (e.g., Medicaid, commercial) if the
existing strategies are relevant to their QHP enrollee populations and meet the QIS requirements and criteria.
pg. 5
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
Yes
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
If “yes” was checked for either/both of the above, please describe the State initiative and/or current
issuer strategy.
(1,000 character limit)
Desc
ribe the overall goal(s) of the QIS (no more than two).
Note: The topic area(s) selected in Element 20 and the measures described in Element 24 should be
linked to these goals.
QIS Goal 1:
Is Goal 1 modified from the most recent QIS submission?
Yes
No Not Applicable
(500 character limit)
QIS Goal 2: Is Goal 2 modified from the most recent QIS submission?
Not Applicable
(500 character limit)
pg. 6
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
No
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Premium credit
Co-payment reduction or waiver
Co-insurance reduction
Cash or c
ash equivalents
Increased reimbursement
Bonus payment
In-kind incentives (Provide a description in the space below.) (500 character limit)
Part E.
QIS Requirements
The elements in Part E will be scored as part of the QIS evaluation. All elements must receive a
“meets” score during the QIS evaluation. If any elements are scored as “does not meet” in the QIS
evaluation, the issuer must revise those elements and resubmit its Implementation Plan for re-review.
19. Market-based Incentive Type(s) (Must Pass)
Select
the type and sub-type of market-based incentive(s) the QIS includes. Check all that apply. If
either “In-kind incentives” or “Other provider market-based incentives” is selected, provide a brief
description in the space provided.
Provider Market-based
Incentives:
Other provider market-based incentives (Provide a description in the space below.) (500
character limit)
Enrolle
e Market-based Incentives:
Other
enrollee market-based incentives (Provide a description in the space below.) (500 character
limit)
pg. 7
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
20. Topic Area Selection (Must Pass)
Comprehensive program for hospital discharge that
includes:
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Select the topic area(s) this QIS addresses, as defined in the Patient Protection and Affordable Care
Act.
7
Check each topic area that applies.
Example Activities Cited in the Patient Protection
and Affordable Care Act
Improve health outcomes
Quality reporting
Effective case management
Care coordination
Chronic disease management
Medication and care compliance initiatives
Prevent hospital readmissions
- Patient-c
entered education and counseling
- C
omprehensive discharge planning
- Post-discharge reinforcement by an appropriate
health care professional
Improve patient
safety and
reduce medical errors
Appropriate use of best clinical practices
Evidence-based medicine
Health information technology
Smoking cessation
Implement wellness and health
promotion activities
Weight management
Stress management
Healt
hy lifestyle support
Diabetes prevention
Reduce health and health care
disparities
Language services
Community outreach
Cultural competency trainings
7
Implementation of wellness and health promotion activities are cited in Secti
on 2717(b) of the Patient Protection and Affordable Care Act.
All other activities are cited in Section 1311(g)(1) of the Patient Protection and Affordable Care Act.
pg. 8
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
QIS Topic Area
21. Targets All Health Plans Offered Through an Exchange (Must Pass)
pg. 9
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
21a. Indicate if this QIS is applicable to all eligible
QHPs you offer or are applying to offer through
the Exchange, or to a subset of eligible QHPs.
All QHPs
Subset of QHPs*
* If “Subset of QHPs” was selected above, an additional QIS Implementation Plan(s) (Parts D
and E of this form) must be submitted for eligible QHPs not covered by this QIS.
If “Subset of QHPs” was selected above, please indicate the number of forms that will be
submitted: This is form
.
of
21b. In the space provided, specify all eligible QHPs covered by the QIS by listing each plan’s
unique 14-digit HIOS Plan ID (Standard Component ID [SCID]). Indicate if each one is a new or
existing eligible QHP. For initial s
ubmissions, specify all eligible QHPs covered by the QIS. To
update a prior QIS submission by adding or removing SCIDs, use Element 27. Note: Please list
additional health plans covered by the QIS on pages 26 and 27.
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health
Plan
Existing Health Plan
21c. Select the relevant product types to which the QIS applies. Check all that a pply.
Health Maintenance Organization (HMO)
Point of Service (POS)
Preferred Provider Organization (PPO)
Exclusive Provider Organization (EPO)
Indemnity
22. R
ationale for QIS (Must Pass)
Provide a rationale for the QIS that describes the issuer’s current QHP enrollee population(s) and
how the QIS will address the needs of the current QHP enrollee population(s).
(1,000 character limit)
pg. 10
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
Q
IS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
23. Activity(ies) that Will Be Conducted to Implement the QIS (Must Pass)
Is the activity(ies) modified from the most recent QIS submission?
Yes No Not Applicable
23a. List the activities that will be implemented to achieve the identified goals.
(1,000 character limit)
23b. Describe how the activities relate to the selected market-based incentive (see Element 19).
(1,000 character limit)
23c. Describe how the activities relate to the topic area(s) selected (see Element 20).
(1,000 character limit)
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
23d. If the issuer did not choose health and health care disparities as a topic area in Element 20, but
the QIS does include activities related to addressing health and health care disparities, describe
the activities below. If (1) health and health care disparities is one of the topic areas selected in
Element 20; OR (2) health and health care disparities are not addressed in this QIS,
check
Not Applicable.
(1,000 character limit)
24. Goal(s), Measure(s), and Performance Target(s) to Monitor QIS Progress (Must Pass)
Restate the goal(s) identified in the QIS description (see Element 18).
QIS Goal 1:
(
500 char
acter limit)
For this goal, identify at least one (but no more than two) primary measure(s) used to track progress
against the goal.
24a. Measure 1a
Is Measure 1a modified from the most recent QIS submission?
Yes No Not Applicable
pg. 11
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Yes
Measure 1a Name:
Provide a narrative description of the measure numerator and denominator.
(500 character limit)
No
Is this a National Quality Forum (NQF)-endorsed measure? Yes
If yes, provid
e the 4-digit ID number:
If yes, did the issuer modify the NQF-endorsed measure specification?
No
24b. Describe how [Measure 1a] supports the tracking of performance related to [Goal 1].
(1,000 character
limit)
24c. Baseline Assessment. Provide the baseline results by calculating the rate and providing the
associated numerator and denominator, if applicable. If the measure is not a rate but another
data point, enter the number in the space provided for numerator and enter “1” in the space for
denominator.
Rate or other data point:
Numerator:
Denominator:
24d. Performance period (i.e., month and year when data collection began and ended) covered by
the baseline data assessment:
-
pg. 12
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
24e. Provide numerical value performance target for this measure:
24a. Measure 1b
Is Measure 1b modified from the most recent QIS submission?
No Not Applicable
Measure 1b Name:
Provide a narrative description of the measure numerator and denominator.
(500 character limit)
Is this a National Quality Forum (NQF)-endorsed measure? Yes No
If yes, provide the 4-digit ID number:
If yes, did the issuer modify the NQF-endorsed measure specification?
24b. Describe how [Measure 1b] supports the tracking of performance related to [Goal 1].
(1,000 character limit)
pg. 13
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
Yes
No
Yes
QIS Goal 2:
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
24c. Baseline Assessment. Provide the baseline results by calculating the rate and providing the
associated numerator and denominator, if applicable. If the measure is not a rate but another
data point, enter the number in the space provided for numerator and enter “1” in the space for
denominator.
Rate or other data point:
Numerator:
Denominator:
24d. Performance period (i.e., month and year when data collection began and ended) covered by
the baseline data assessment:
-
24e. Provide numerical value performance target for this measure:
(500 character limit)
For this goal, identify at least one (but no more than two) primary measure(s) used to track progress
against the goal.
24a. Measure 2a
Is Measure 2a modified from the most recent QIS submission?
Yes No Not Applicable
Measure 2a Name:
Provide a narrative description of the measure numerator and denominator.
(500 character limit)
Is this a National Quality Forum
(NQF)-endorsed measure? Yes No
If yes, provide the 4-digit ID number:
pg. 14
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
If yes, did the issuer modify the NQF-endorsed measure specification?
Yes No
24b. Describe how [Measure 2a] supports the tracking of performance related to [Goal 2].
(1,000 character limit)
24c. Baseline Assessment. Provide the baseline results by calculating the rate and providing the
associated numerator and denominator, if applicable. If the measure is not a rate but another
data point, enter the number in the space provided for numerator and enter “1” in the space for
denominator.
Rate or other data point:
Numerator:
Denominator:
24d. Performance period (i.e., month and year when data collection began and ended) covered by
the baseline data assessment:
-
24e. Provide numerical value performance target for this measure:
24a. Measure 2b
Is Measure 2b modified from the most recent QIS submission?
Yes No Not Applicable
Measure 2b Name:
pg. 15
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Provide a narrative description of the measure numerator and denominator.
(500 character limit)
Is this a National Quality F
orum (NQF)-endorsed measure? Yes No
If yes, provide the 4-digit ID number:
If yes, did the issuer modify the NQF-endorsed measure specification?
Yes No
24b. Describe how [Measure 2b] supports the tracking of performance related to [Goal 2].
(1,000 character limit)
24c. Baseline Assessment. Provide the baseline results by calculating the rate and providing the
associated numerator and denominator, if applicable. If the measure is not a rate but another
data point, enter the number in the space provided for numerator and enter “1” in the space for
denominator.
Rate or other data point:
Numerator:
Denominator:
24d. Performance period (i.e., month and year when data collection began and ended) covered by
the baseline data assessment:
-
24e. Provide numerical value performance target for this measure:
pg. 16
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
25. Timeline for Implementing the QIS
25a. QIS Initiation/Start Date:
25b. Describe the milestone(s) and provide the date(s) for each milestone (e.g., when activities
described in Element 23 will be implemented). At least one milestone is required. (100
character limit per milestone)
Milestone(s)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Date for
Milestone(s)
pg. 17
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
26. Risk Assessment
26a
. L
ist all known or anticipated barriers to implementing QIS activities. If no barriers were
identified, describe how you assessed barriers.
(1,500 character limit)
26b. Describe the mitigation activities that will be incorporated to address each barrier identified in
Criterion 26a.
(1,500 character limit)
pg. 18
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
27. Addition/Removal of QHPs and product types to the Issuer’s QIS
(SCID). If “No additions or removals” was selected, check
Not Applicable.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
QIS Progress Report Section
Part F. Progress Report Summary
The elements in Part F will be scored as part of the QIS evaluation. All elements must receive a
“meets” during the QIS evaluation. If any elements are scored as “does not meet” in the QIS evaluation,
the issuer must revise its Progress Report and submit it for re-review.
27a. Indicate if the issuer is adding or removing any QHPs to the QIS originally listed in Criterion 21b.
Add QHP(s)
Remove QHP(s)
No additions or removals
27b. If “Add QHP(s)” or “Remove QHP(s)” was selected, list the QHPs that were added or removed
(all newly QIS-eligible QHPs should be listed) and provide each plan’s unique 14-digit HIOS Plan ID
Note:
To list more than three SCIDs, please use page 28.
HIOS Plan ID (SCID) Add QHP Remove QHP
HIOS Plan ID (SCID) Add QHP Remove QHP
HIOS Plan ID (SCID) Add QHP Remove QHP
27c. Indicate if the issuer is adding or removing any product types to the QIS originally listed in Criterion 21c.
Check all that apply.
If there are no additions or removals, check Not Applicable.
Add
Health Maintenance Organization (HMO)
Remove
Add
Remove
Point of Service (POS)
Add
Remove
Preferred Provider Organization (PPO)
Add
Remove
Exclusive Provider Organization (EPO)
Add
Remove
Indemnity
28. QIS Modifications
If “Continuing a QIS with Modifications” was selected in Part A, Element 1, please indicate what
type of modification(s) the issuer is making to its QIS and provide a rationale for the modification(s).
Note that modifications only apply to elements in Part D (Implementation Plan). If no modifications are
being made, select “Not Applicable”
for each criterion.
pg. 19
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
28a. Modifying the activities of the QIS (Element 23)? If no, check Not Applicable.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
(500 character limit)
28b. Modifying the goals of the QIS? If no, check Not Applicable.
(500 character limit)
28c. Modifying the measure(s) of the QIS? If no, check
Not Applicable.
(500 character limit)
29. Analyze Progress Using Baseline Data, as Documented in th
e Implementation Plan
(Must Pass)
Rest
ate the goals identified in the most recent Implementation Plan. For each goal, restate the
measure(s) information identified in the most recent Implementation Plan, and complete the fields
below.
QIS Goal 1:
(500 character limit)
Measure 1a:
29a. Baseline performance period (i.e., month and year when data collection began and ended)
covered by the baseline data assessment:
-
pg. 20
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
29b. Progress Report performance period (i.e., month and year when data collection began and
ended) covered by the progress update data assessment:
-
29c. Measure 1a name:
29d. Restate the baseline results from Criterion 24c of your most recent QIS submission, including
the rate and associated numerator and denominator, if applicable. If the measure is not a rate
but another data point, enter the number in the space provided for numerator and enter “1” in
the space for denominator.
Rate or other data point:
Numerator:
Denominator:
29e. Provide the follow-up results by calculating the rate and providing the associated numerator
and denominator, if applicable. If the measure is not a rate, but another data point, enter the
number in the space provided for numerator and enter “1” in the space for denominator.
Rate or other data point:
Numerator:
Denominator:
Yes No
Was the performance target (Criterion 24e) achieved?
Measure 1b:
29a. Baseline performance period (i.e., month and year when data collection began and ended)
covered by the baseline data assessment:
-
29b. Progress Report performance period (i.e., month and year when data collection began and
ended) covered by the progress update data assessment:
-
29c. Measure 1b name:
29d. Restate the baseline results from Criterion 24c of your most recent QIS submission, including
the rate and associated numerator and denominator, if applicable. If the measure is not a rate
but another data point, enter the number in the space provided for numerator and enter “1” in
the space for denominator.
Rate or other data point:
pg. 21
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Measure 2a:
Numerator:
Denominator:
29e. Provide the follow-up results by calculating the rate and providing the associated numerator
and denominator, if applicable. If the measure is not a rate, but another data point, enter the
number in the space provided for numerator and enter “1” in the space for denominator.
Rate or oth
er data point:
Numerator:
Denominator:
Was the performance target (Criterion 24e) achieved?
Yes No
QIS Goal 2:
(500 character limit)
29a. Baseline performance period (i.e., month and year when data collection began and ended)
covered by the baseline data assessment:
-
29b. Progress Report performance period (i.e., month and year when data collection began and
ended) covered by the progress update data assessment:
-
29c. Measure 2a name:
29d. Restate the baseline results from Criterion 24c of your most recent QIS submission, including
the rate and associated numerator and denominator, if applicable. If the measure is not a rate
but another data point, enter the number in the space provided for numerator and enter “1” in
the space for denominator.
Rate or other data point:
Numerator:
Denominator:
pg. 22
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
Provide the follow-up results by calculating the rate and providing the associated numerator
and denominator, if applicable. If the measure is not a rate, but another data point, enter the
number in the space provided for numerator and enter “1” in the space for denominator.
Rate or other data point:
Numerator:
Denominator:
Was the performance target (Criterion 24e) achieved?
No
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
29e.
29a.
29b.
29c.
29d.
29e.
Yes
-
Progress Report performance period (i.e., month and year when data collection began and
ended) covered by the progress update data assessment:
-
Measure 2b Name:
Restate the baseline results from Criterion 24c of your most recent QIS submission, including
the rate and associated numerator and denominator, if applicable. If the measure is not a rate
but another data point, enter the number in the space provided for numerator and enter “1” in
the space for denominator.
Rate or other data point:
Numerator:
Denominator:
Provide the follow-up results by calculating the rate and providing the associated numerator
and denominator, if applicable. If the measure is not a rate, but another data point, enter the
number in the space provided for numerator and enter “1” in the space for denominator.
Rate or other data point:
Numerator:
Denominator:
W
as the performance target (Criterion 24e) achieved?
Yes No
pg. 23
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
Measure 2b:
Baseline performance period (i.e., month and year when data collection began and ended)
covered by the baseline data assessment:
30. Summary of Progress (Must Pass)
31a. Were barriers encountered in implementing the QIS?
Yes
No
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Indicate why progress was or was not made toward the performance target(s) documented in
Element 24. Include a description
of activities that led to the outcome.
If modifications were checked in Element 28, indicate whether the information provided here affects
the decision to modify or change the QIS.
(1,500 character limit)
31. Barriers
If “Yes,” describe the barriers.
(1,500 c
haracter limit)
pg. 24
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
31b. Were there problems meeting timelines as indicated in Element 25?
If “Yes,” describe the problems in meeting timelines.
(1,500 character limit)
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Yes No
32. Mitigation Activities
32a. If “Yes” was selected in Criterion 31a, describe the mitigation activities implemented to address each
barrier. Also, describe the result(s) of the mitigation activities. If “No” was selected in Criterion 31a, check
Not Applicable.
(750 character limit)
32b. If “Yes” was selected in Criterion 31b, describe the mitigation activities implemented to address each
problem in meeting the timeline. Also, describe the result(s) of the mitigation activities. If “No” was selected
in Criterion 31b, check
Not Applicable.
(750 character limit)
pg. 25
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
Criterion 21b continued
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing
Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
In the space provided, please specify any additional health plans (outside of those already listed in
Criterion 21b) covered by the QIS by listing each plan’s unique 14-digit HIOS Plan ID (Standard
Component ID [SCID]). Indicate if each one is a new or existing health plan.
pg. 26
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office
of Management
and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time required to
complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.
pg. 27
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
Existing Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
New Health Plan
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Criterion 21b continued
In the spac
e provided, please specify any additional health plans (outside of those already listed in
Criterion 21b) covered by the QIS by listing each plan’s unique 14-digit HIOS Plan ID (Standard
Component ID [SCID]). Indicate if each one is a new or existing health plan.
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Remove QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
Add QHP
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
HIOS Plan ID (SCID)
pg. 28
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286.
The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850.
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Criterion 27b continued
In the space provided, please specify any health plans (outside of those already listed in Criterion
27b) that were added to or removed from the QIS by listing each plan’s unique 14-digit HIOS Plan
ID (Standard Component ID [SCID]).
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