Form CMS-10540 QIS Consolidated Plan and Progress Report Form

Q IS Implementation Plan and Progress Report Form

Mockup of Fillable PDF

OMB 0938-XXXX

Please retain a copy of the completed Quality Improvement Strategy (QIS) Implementation Plan form so that it is available for future use for reporting on activities conducted to implement the QIS. For detailed instructions, please refer to the QIS Technical Guidance and User Guide for the 2017 Coverage 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 Submission

Select the option that describes the type of QIS submission, and follow the instructions to complete the submission.

Type of QIS	Instructions
 New QIS1 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 the Qualified Health Plan (QHP) Application Period2	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 Modifications3	Complete the Background Information Section (Parts B and C); Implementation Plan Section (Parts D and E); and the Progress Report Section (Part F).

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	12. QIS Secondary Contact’s Phone	__ Ext.
13. QIS Secondary Contact’s Email

14. Date Issuer Began Offering Coverage Through the Marketplace

__

__

__

/ /

15. Current Payment Model(s) Description

Select the category(ies)⁴ of payment models that are used by the issuer across its Marketplace 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 or Value	Payments are based on volume of services and not linked to quality or efficiency.
 Fee for Service – Linked to Quality or Value	At least a portion of payments vary based on the quality or efficiency of health care delivery.
 Alternative Payment Models Built upon Fee for Service Architecture	Some payment is linked to the effective management of a population or an episode of care. Payments still are triggered by delivery of services, but there are opportunities for shared savings or two-sided risk.
 Population-based Payment	Payment is not directly triggered by service delivery, so volume is not linked to payment. Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., more than one year).

Provide percentage of payments:

Percentage of Fee for Service payments linked to quality or value: %

Percentage of payments tied to quality or value through alternative payment models: %

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. Data Sources

Indicate 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)

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

Provide a short title for the QIS.

(200 character limit)

18. QIS Description

Provide 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 submission⁵ a strategy that the issuer currently has in place for its Marketplace product line and/or for other product lines?

 Yes  No

If “yes” was checked for either/both of the above, please describe the state initiative and/or current issuer strategy.

(1,000 character limit)

Describe the overall goal(s) of the QIS (no more than two).

Note: Measures described in Element 24 should be linked to these goals.

QIS Goal 1:

(500 character limit)

QIS Goal 2:

(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:

 Increased reimbursement

 Bonus payment

 In-kind incentives (Provide a description in the space below.) (500 character limit)

 Other provider market-based incentives (Provide a description in the space below.) (500 character limit)

 Enrollee Market-based Incentives:

 Premium credit

 Co-payment reduction or waiver

 Co-insurance reduction

 Cash or cash equivalents

 Other enrollee market-based incentives (Provide a description in the space below.)
(500 character limit)

20. Topic Area Selection (Must Pass)

Select the topic area(s) this QIS addresses, as defined in the Affordable Care Act.⁶ Check each topic area that applies.

QIS Topic Area	Example Activities Cited in the Affordable Care Act
 Improve health outcomes	Quality reporting Effective case management Care coordination Chronic disease management Medication and care compliance initiatives
 Prevent hospital readmissions	Comprehensive program for hospital discharge that includes: Patient-centered education and counseling Comprehensive 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
 Implement wellness and health promotion activities	Smoking cessation Weight management Stress management Healthy lifestyle support Diabetes prevention
 Reduce health and health care disparities	Language services Community outreach Cultural competency trainings

21. Targets All Health Plans Offered Through a Marketplace (Must Pass)

21a. Indicate if this QIS is applicable to all QHPs you offer or are applying to offer through the Marketplaces, or to a subset of 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 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 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 QHP. Note: Please list additional health plans covered by the QIS on page 24.

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 apply.

 Health Maintenance Organization (HMO)

 Point of Service (POS)

 Preferred Provider Organization (PPO)

 Exclusive Provider Organization (EPO)

 Indemnity

22. Rationale for QIS (Must Pass)

Provide a rationale for the QIS that describes how the QIS will address the needs of the current QHP enrollee population(s).

(1,000 character limit)

23. Activity(ies) that Will Be Conducted to Implement the QIS (Must Pass)

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)

23d. If health and health care disparities was not chosen as a selected topic area in Element 20, does the QIS include any activities related to addressing health and health care disparities? If yes, 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 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 1a

Measure 1a 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 4-digit ID number: If no, check  Not Applicable

Is the NQF-endorsed measure used without modification to the measure specification?

 Yes  No  Not Applicable

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, 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 (e.g., count, ratio, proportion):

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 1b

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 4-digit ID number: If no, check  Not Applicable

Is the NQF-endorsed measure used without modification to the measure specification?

 Yes  No  Not Applicable

24b. Describe how [Measure 1b] supports the tracking of performance related to [Goal 1].

(1,000 character limit)

24c. Baseline Assessment. Provide the baseline results, 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 (e.g., count, ratio, proportion):

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:

QIS Goal 2:

(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

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 4-digit ID number: If no, check  Not Applicable

Is the NQF-endorsed measure used without modification to the measure specification?

 Yes  No  Not Applicable

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, 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 (e.g., count, ratio, proportion):

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

Measure 2b 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 4-digit ID number: If no, check  Not Applicable

Is the NQF-endorsed measure used without modification to the measure specification?

 Yes  No  Not Applicable

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, 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 (e.g., count, ratio, proportion):

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:

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)	Date for Milestone(s)
1.	__ __ /
2.	__ __ /
3.	__ __ /
4.	__ __ /
5.	__ __ /
6.	__ __ /
7.	__ __ /
8.	__ __ /
9.	__ __ /
10.	__ __ /

26. Risk Assessment

26a. List any known or anticipated barriers to implementing QIS activities.

(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)

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.

27. Addition of QHPs to the Issuer’s QIS

27a. Indicate if the issuer is adding any QHPs to the QIS originally listed in 21b.

 Add QHP(s)

 No additional QHP(s)

27b. If “Add QHP(s)” was selected, list all new QHPs and provide each plan’s unique 14-digit HIOS Plan ID (SCID). If no additional QHPs were included, check  Not Applicable.

Note: Please list additional health plans covered by the QIS on page 25.

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)

28. QIS Modifications

28a. If “Continuing a QIS with Modifications” was selected in Part A, Element 1, please indicate what type of modification the issuer is making to its QIS. Check all that apply. Note that modifications only apply to elements in Part D (Implementation Plan). If no modifications are being made, check  Not Applicable.

Element Being Modified

 Goals

 Performance measure(s)

 Activities

28b. Provide a justification and brief description of the modification(s) selected in Criterion 28a. If “Continuing a QIS with Modifications” was NOT checked in Part A, Element 1, check  Not Applicable.

(500 character limit)

29. Analyze Progress Using Baseline Data, as Documented in the Implementation Plan (Must Pass)

Restate the goals identified in the Implementation Plan (see Elements 18 and 24). For each goal, restate the measure(s) information identified in Element 24, and complete the tables 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:

__

__

__

__

/ - /

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, 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 (e.g., count, ratio, proportion):

Numerator:

Denominator:

29e. Provide the follow-up results. 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 (e.g., count, ratio, proportion):

Numerator:

Denominator:

Was the performance target (Criterion 24e) achieved?

 Yes  No

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, 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 (e.g., count, ratio, proportion):

Numerator:

Denominator:

29e. Provide the follow-up results. 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 (e.g., count, ratio, proportion):

Numerator:

Denominator:

Was the performance target (Criterion 24e) achieved?

 Yes  No

QIS Goal 2:

(500 character limit)

Measure 2a:

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, 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 (e.g., count, ratio, proportion):

Numerator:

Denominator:

29e. Provide the follow-up results. 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 (e.g., count, ratio, proportion):

Numerator:

Denominator:

Was the performance target (Criterion 24e) achieved?

 Yes  No

Measure 2b:

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 2b Name:

29d. Restate the baseline results, 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 (e.g., count, ratio, proportion):

Numerator:

Denominator:

29e. Provide the follow-up results. 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 (e.g., count, ratio, proportion):

Numerator:

Denominator:

Was the performance target (Criterion 24e) achieved?

 Yes  No

30. Summary of Progress (Must Pass)

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 Criterion 28a, indicate whether the information provided here affects the decision to modify or change the QIS:

(1,500 character limit)

31. Barriers

31a. Were barriers encountered in implementing the QIS?

 Yes  No

If “Yes,” describe the barriers.

(1,500 character limit)

31b. Were there problems meeting timelines as indicated in Element 25?

 Yes  No

If “Yes,” describe the problems in meeting timelines.

(1,500 character limit)

32. Mitigation Activities

If “Yes” was selected in 31a or 31b, describe the mitigation activities implemented to address each barrier or problem in meeting the timeline. Also, describe the result(s) of the mitigation activities.

If “No” was selected in 31a and 31b, check  Not Applicable.

(1,500 character limit)

Criterion 21b continued

In the space provided, place 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.

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

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

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

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

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

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

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

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

HIOS Plan ID (SCID)  New Health Plan  Existing Health Plan

Criterion 27b continued

In the space provided, place specify any additional health plans (outside of those already listed in Criterion 27b) covered by the QIS by listing each plan’s unique 14-digit HIOS Plan ID (Standard Component 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)

1 A “new QIS” is defined as a QIS that has not been previously submitted to a Marketplace, 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: QIS activities, QIS goals, and/or QIS measures.

4 Categories of payment models are defined in Rajkumar R, Conway PH, and Tavenner M. CMS— Engaging Multiple Payers in Payment Reform. JAMA. 311:19. See the QIS Technical Guidance and User Guide for the 2017 Coverage Year for examples of payment models within each category.

5 Issuers may use existing strategies employed in non-Marketplace product lines (e.g., Medicaid, commercial) if the existing strategies are relevant to their QHP enrollee populations and meet the QIS requirements and criteria.

6 Implementation of wellness and health promotion activities are cited in Section 2717(b) of the Affordable Care Act. All other activities are cited in Section 1311(g)(1) of the Affordable Care Act.

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-XXXX. 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.

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Author	Poland, Josh [USA]
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File Created	2021-01-24