Form CMS-10540 QIS Consolidated Plan and Progress Report Form

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
Please retain a copy of the completed Quality Improvement Strategy (QIS) Implementation Plan form so
that it is available for future reference for reporting on activities conducted to implement the QIS. For
detailed instructions, please refer to the QIS Technical Guidance and User Guide for the 20XX Plan Year.

QIS Submission Type
Part A. New, Discontinuing, 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
QIS 1

Instructions

 New
with No Previous
QIS Submission

Complete the Background Information Section (Parts A, 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

Complete a new/separate form to submit the new QIS,
including the Background Information Section (Parts A, B
and C) and the Implementation Plan Section (Parts D and
E). (Must also submit a form to close out the discontinued
QIS; see “Discontinuing a QIS”).

 Discontinuing a QIS Submitted

Complete a form to close out the discontinued QIS,
including the Background Information Section (Parts A, B,
and C) and the Implementation Plan Section (Parts D and
E), with the discontinued QIS information. Include the
Progress Report (Part G) to report on progress of the QIS
up to the point it was discontinued. (Must submit at least
one QIS to cover all eligible QHPs; see “New QIS after
Discontinuing a QIS Submitted during a prior QHP
Application Period”).

during a prior Qualified Health Plan
(QHP) Application Period

 Continuing a QIS with No
Modifications

Complete the Background Information Section (Parts A, B,
and C), Implementation Plan Section (Parts D and E), and
the Progress Report Summary (Part G). Do not complete
the QIS Modification Summary (Part F).

 Continuing a QIS with
Modifications 3

Complete the Background Information Section (Parts A, B,
and C), Implementation Plan Section (Parts D and E);
Modification Section (Part F), and the Progress Report
Section (Part G).

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.
1

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
2. Targets All Health Plans and Product Types Offered Through an Exchange (Must Pass)
Please indicate the number of forms that will be submitted: This is form

of

.

2a. Indicate if this QIS is applicable to all eligible QHPs you offer or are applying to offer through the
Exchanges, or to a subset of eligible QHPs.

 All QHPs
 Subset of QHPs 4*
* 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.
2b.

Select the relevant product types to which the QIS applies. Check all that apply. To update a
prior QIS submission by changing product types, use Criterion 28b in the Modification Summary
section (Part F)

 Health Maintenance Organization (HMO)
 Point of Service (POS)
 Preferred Provider Organization (PPO)
 Exclusive Provider Organization (EPO)
 Indemnity

4

An issuer that previously covered all eligible QHPs with a single QIS may choose to cover a subset of QHPs with its
existing QIS in subsequent years, but must submit an additional QIS form(s) to cover its remaining eligible QHPs.
Similarly, an issuer that previously covered subsets of its eligible QHPs with different quality improvement strategies
may discontinue one or more of its strategies by submitting QIS forms to close them out. The issuer must also ensure
all eligible QHPs are covered by an existing or new QIS.

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF

Background Information
Part B. Issuer Information
These fields are required, but will not be scored as part of the QIS evaluation. Issuers may update the
information in Part B from year to year, as needed.
3. Issuer Legal Name

4. Company Legal Name

5. HIOS Issuer ID

6. Issuer State

7. QIS Primary Contact’s First Name

QIS Primary Contact’s Last Name

8. QIS Primary Contact’s Title

9. QIS Primary Contact’s Phone

Ext.

10. QIS Primary Contact’s Email

11. QIS Secondary Contact’s First Name

QIS Secondary Contact’s Last Name

12. QIS Secondary Contact’s Title

13. QIS Secondary Contact’s Phone

Ext.

14. QIS Secondary Contact’s Email

15. Date Issuer Began Offering Coverage Through the Exchange

/

/

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
16. Current Payment Model(s) Description
Select the category(ies) of payment models that are used by the issuer across its Exchange product
line. Provide the percentage of payments in each payment model category 5 used by the issuer across
its Exchange product line. The total percentage of payments across all four payment model types
should equal approximately 100 percent.6
Payment Model Type

Payment Model Description

 Fee for Service –

Payments are based on volume
of services and not linked to
quality or efficiency.

%

At least a portion of payments
vary based on the quality or
efficiency of health care delivery.

%

Some payment is linked to the
effective management of a
segment of the population or an
episode of care. Payments are
still triggered by delivery of
services, but there are
opportunities for shared savings
or two-sided risk.

%

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).

%

Please confirm the total percentage
of payments across all four
payment model type categories
equals approximately 100%.

%

No Link to Quality and Value

 Fee for Service – Linked
to Quality and Value

 Alternative Payment
Models Built on Fee for
Service Architecture

 Population-based
Payment

Total

Provide Percentage

5

Categories of payment models are defined in the Alternative Payment Model Framework and Progress Tracking
(APM FPT) Work Group – Alternative Payment Model (APM) Framework Final White Paper, available at: https://
hcp-lan.org/workproducts/apm-whitepaper.pdf. See the QIS Technical Guidance and User Guide for the 20XX Plan
Year for examples of payment models within each category.
6

To calculate the percentage of payments for Fee for Service payments linked to quality or value, and/or Alternative
Payment Models tied to quality or 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 (APM Measurement Effort) Final Paper, available at: https://hcp-lan.org/groups/apm-fpt/apm-report/. See
Table 1 (p. 7-10) for instructions to calculate the percentage of payments for these two payment model categories.

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF

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. Issuers may update the
information in Part C from year to year, as needed.
17. 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: Please describe. Do not include company identifying information in your data
source description.
(100 character limit)

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF

QIS Implementation Plan Section
Part D. QIS Summary
These fields are required, but will not be scored as part of the QIS evaluation.
18. QIS Title
Provide a short title for the QIS.
(200 character limit)

19. QIS Description
Provide a brief summary description of the QIS. The description must include the market-based
incentive type and topic area (see Elements 20 and 21).
(1,000 character limit)

Is the QIS described above part of a mandatory State initiative?

 Yes

 No

Is the QIS submission 7 a strategy that the issuer currently has in place for its Exchange product line
and/or for other product lines?

 Yes

 No

7

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. 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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
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: The topic area(s) selected in Element 21 and the measures described in Element 24 should be
linked to these goals.
QIS Goal 1
(500 character limit)

QIS Goal 2
(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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF

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.
20. 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,” “Other provider market-based incentives,” or “Other enrollee 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)

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
21. Topic Area Selection (Must Pass)
Select the topic area(s) this QIS addresses, as defined in the Affordable Care Act. 8 Check each topic
area that applies.

QIS Topic Area

Example Activities Cited in the Affordable Care Act

 Improve health outcomes







 Prevent hospital readmissions



 Improve patient safety and





Appropriate use of best clinical practices
Evidence-based medicine
Health information technology







Smoking cessation
Weight management
Stress management
Healthy lifestyle support
Diabetes prevention





Language services
Community outreach
Cultural competency trainings

reduce medical errors

 Implement wellness and health
promotion activities

 Reduce health and health care
disparities

Quality reporting
Effective case management
Care coordination
Chronic disease management
Medication and care compliance initiatives
Comprehensive program for hospital discharge that
includes:
- Patient-centered education and counseling
- Comprehensive discharge planning
- Post-discharge reinforcement by an appropriate
health care professional

8

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. 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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
22. Rationale for QIS (Must Pass)
Provide a rationale for the QIS that describes the issuer’s current QHP enrollee populations and how
the QIS will address the needs of the current QHP enrollee population(s).
(1,500 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.
(1,500 character limit)

23b. Describe how the activities relate to the selected market-based incentive (see Element 20).
(1,500 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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
23c. Describe how the activities relate to the topic area(s) selected (see Element 21).
(1,500 character limit)

23d. If the issuer did not choose health and health care disparities as a topic area in Element 21, 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 21; OR (2) health and health care disparities are not addressed in this QIS,
check  Not Applicable.
(1,500 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 19).
QIS Goal 1
(500 character limit)

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
For this goal, identify at least one (but no more than two) primary measure(s) used to track
progress toward meeting 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 the 4-digit ID number:
If yes, did the issuer modify the NQF-endorsed measure specification?

 Yes

 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.
Calculated Rate:
Numerator:
Denominator:

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:

24d. Note the performance period (i.e., month and year when data collection began and ended)
covered by the baseline data assessment:

24e. Provide the numerical value performance target for this measure:
24f.

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 the 4-digit ID number:
If yes, did the issuer modify the NQF-endorsed measure specification?

 Yes

 No

24g. 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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
24h. Baseline Assessment. Provide the baseline results by calculating the rate and providing the
associated numerator and denominator, if applicable.
Calculated Rate:
Numerator:
Denominator:
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:
24i.

Note the performance period (i.e., month and year when data collection began and ended)
covered by the baseline data assessment:

24j.

Provide the 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) track progress towards
meeting the goal.
24k. Measure 2a
Measure 2a Name:
Provide a narrative description of the measure numerator and denominator.
(500 character limit)

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
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?

 Yes
24l.

 No

Describe how [Measure 2a] supports the tracking of performance related to [Goal 2].
(1,000 character limit)

24m. Baseline Assessment. Provide the baseline results by calculating the rate and providing the
associated numerator and denominator, if applicable.
Calculated Rate:
Numerator:
Denominator:
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:
24n. Note the performance period (i.e., month and year when data collection began and ended)
covered by the baseline data assessment:
24o. Provide the numerical value performance target for this measure:
24p. Measure 2b
Measure 2b Name:
Provide a narrative description of the measure numerator and denominator.
(500 character limit)

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
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?

 Yes

 No

24q. Describe how [Measure 2b] supports the tracking of performance related to [Goal 2].
(1,000 character limit)

24r.

Baseline Assessment. Provide the baseline results by calculating the rate and providing the
associated numerator and denominator, if applicable.
Calculated Rate:
Numerator:
Denominator:
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:

24s. Note the performance period (i.e., month and year when data collection began and ended)
covered by the baseline data assessment:

24t. Provide the 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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
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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)
Date for
Milestone(s)
Milestone(s)
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
26. Risk Assessment
26a. List all known or anticipated barriers to implementing QIS activities.
(750 character limit)

If no barriers were identified, describe how you assessed risk.
(750 character limit)

26b. Describe the mitigation activities that will be incorporated to address each barrier identified in
Criterion 26a.
(1,500 character limit)

If “New QIS with No Previous QIS submission,” STOP HERE.
If “New QIS after Discontinuing,” STOP HERE.
If “Discontinuing a QIS,” SKIP to page 21 (Part G. Progress Report Summary).
If “Continuing a QIS with Modifications,” continue to next page 19 (Part F. Modification
Summary).
If “Continuing a QIS with No Modifications,” SKIP to page 21 (Part G. Progress Report
Summary).
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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF

QIS Progress Report Section
Part F. QIS Modification Summary
27. Modifying Goals, Measures, and Activities (Must Pass)
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).
27a. QIS Goals: Which Goals, if any, are modified from the most recent QIS submission? Select all
that apply.

 Goal 1

 Goal 2

Describe Modifications to Goals (500 character limit)

27b. QIS Measures: Which Measures, if any, are modified from the most recent QIS submission?
Select all that apply.

 Measure 1a

 Measure 1b

 Measure 2a

 Measure 2b

Describe Modifications to Measures (500 character limit)

27c. QIS Activities: Are Activities modified from the most recent QIS submission?

 Yes

 No

If Yes, describe modifications to activities (500 character limit)

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF

28. Modifying Product Types (500 character limit)
Are the product types modified from the most recent QIS submission? Indicate whether the issuer is
adding and/or removing any product types to the QIS originally listed in Criterion 2b. Select all that
apply.

Health Maintenance Organization (HMO)



Add



Remove

Point of Service (POS)



Add



Remove

Preferred Provider Organization (PPO)



Add



Remove

Exclusive Provider Organization (EPO)



Add



Remove

Indemnity



Add



Remove

Part G. Progress Report Summary
The elements in Part G 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.
29. Analyze Progress Using Baseline Data, as Documented in the Implementation Plan
(Must Pass)
Restate the Goal(s) identified in the most recent Implementation Plan. For each Goal, restate the
Measure(s) information identified in Element 24, and complete the fields below.
QIS Goal 1
(500 character limit)

Measure 1a
29a. Note the baseline performance period (i.e., month and year when data collection began and
ended) covered by the baseline data assessment:

29b. Note the Progress Report performance period (i.e., month and year when data collection began
and ended) covered by the progress update 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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF

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.
Calculated Rate:
Numerator:
Denominator:
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:

29e. Provide the follow-up results by calculating the rate and providing the associated numerator and
denominator, if applicable.
Calculated Rate:
Numerator:
Denominator:
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:
Was the performance target (Criterion 24e) achieved?

 Yes

 No

Measure 1b
29f.

Note the baseline performance period (i.e., month and year when data collection began and
ended) covered by the baseline data assessment:

29g. Note the Progress Report performance period (i.e., month and year when data collection began
and ended) covered by the progress update data assessment:

/

-

/

29h. Measure 1b Name:

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
29i.

Restate the baseline results from Criterion 24h of your most recent QIS submission, including
the rate and associated numerator and denominator, if applicable
Calculated Rate:
Numerator:
Denominator:
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:

29j.

Provide the follow-up results by calculating the rate and providing the associated numerator
and denominator, if applicable.
Calculated Rate:
Numerator:
Denominator:
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:

Was the performance target (Criterion 24j) achieved?

 Yes

 No

QIS Goal 2
(500 character limit)

Measure 2a
29k. Note the baseline performance period (i.e., month and year when data collection began and
ended) covered by the baseline data assessment:

-

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
29l. Note the Progress Report performance period (i.e., month and year when data collection began
and ended) covered by the progress update data assessment:

29m. Measure 2a Name:
29n. Restate the baseline results from Criterion 24m of your most recent QIS submission, including
the rate and associated numerator and denominator, if applicable.
Calculated Rate:
Numerator:
Denominator:
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:

29o. Provide the follow-up results by calculating the rate and providing the associated numerator and
denominator, if applicable.
Calculated Rate:
Numerator:
Denominator:
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:

Was the performance target (Criterion 24o) achieved?

 Yes

 No

Measure 2b
29p. Note the baseline performance period (i.e., month and year when data collection began and
ended) covered by the baseline data assessment:

-

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
29q. Note the Progress Report performance period (i.e., month and year when data collection began
and ended) covered by the progress update data assessment:

29r. Measure 2b Name:

29s. Restate the baseline results from Criterion 24r of your most recent QIS submission, including
the rate and associated numerator and denominator, if applicable.
Calculated Rate:
Numerator:
Denominator:
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:

29t. Provide the follow-up results by calculating the rate and providing the associated numerator and
denominator, if applicable.
Calculated Rate:
Numerator:
Denominator:
If the measure is not a rate, but another data point, enter the number in the space provided.
Data Point:

Was the performance target (Criterion 24t) achieved?

 Yes

 No

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
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, and if applicable, indicate
whether the information provided here affects the decision to modify the QIS (Part F).
If the issuer selected "Discontinuing a QIS Submitted During a Prior QHP Application Period" in
Element 1, provide the rationale for discontinuing the QIS.
If applicable, provide information about changes made based on Post-Certification Assessment
(PCA) Reports from the previous year.
(3,000 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

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.

20XX Plan Year
QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Mockup of Fillable PDF
If “Yes,” describe the problems in meeting timelines.
(1,500 character limit)

32. Mitigation Activities
32a. If “Yes” was selected in 31a, describe the mitigation activities implemented to address each
barrier. Also, describe the result(s) of the mitigation activities. If “No” was selected in 31a,
check
 Not Applicable.
(1,500 character limit)

32b. If “Yes” was selected in 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 31b, check  Not Applicable.
(1,500 character limit)

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.