Form CMS-10540 QIS-Implementation-Plan

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

QIS Implementation Plan
Use this form to provide the baseline details for and to describe your quality improvement strategy (QIS).
Please retain a copy of this completed QIS Implementation Plan form so that it is available for future
reference when reporting on activities conducted to implement the QIS. CMS will also keep each QIS
Implementation Plan form on file as a reference while this particular QIS is in place.
For any fields that do not apply, please simply leave them blank. There is no need to indicate “NA” or “not
applicable” unless specifically instructed to do so for that criterion. For detailed instructions, please refer
to the QIS Technical Guidance and User Guide for the current plan year on the Marketplace Quality
Initiatives website.
PLEASE NOTE: For the 2022 Plan Year, all issuers will need to submit an Implementation Plan
form. If you are an issuer who:
1. Is continuing a current QIS (with or without modifications), select Baseline Implementation Plan
(only for the 2022 Plan Year) and describe the QIS that will be in place for the 2022 Plan Year.
Any modifications made to the QIS from the previous year should be included in this new
Implementation Plan form as the new baseline data. These issuers should also report on
progress achieved on the QIS during the previous year by submitting a separate QIS Progress
Report form.
2. Is discontinuing a current QIS and implementing a new one, select New QIS After
Discontinuing a QIS Submitted During a Prior Qualified Health Plan (QHP) Application
Period and submit the Implementation Plan form to describe the QIS that will be implemented for
the 2022 Plan Year. These issuers should also report on progress to close out the discontinued
QIS by submitting a QIS Progress Report form.
3. Is participating in QIS for the first time, or implementing an additional QIS, select New QIS with
No Previous QIS submission and submit only the Implementation Plan form.

Beginning with the 2023 Plan Year, issuers who are reporting the prior year’s progress on the QIS do not
need to submit an Implementation Plan form each year. Only issuers new to QIS or issuers implementing
a new QIS will need to submit an Implementation Plan form. Future modifications can be reported in a
separate QIS Modification Summary Supplement that will be available for the 2023 Plan Year for issuers
meeting these conditions.

For CMS Use Only

pg. 1
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The time required to complete this information collection is estimated to average 48 hours.
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[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

QIS Submission Type
Part A. New QIS Submission
These fields are 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

Baseline Implementation Plan
(only for the 2022 Plan Year) 1 for
a Continuing QIS

Issuers must complete 2 forms:
1. Complete the Background Information section (Parts A,
B, and C) and the Implementation Plan section (Parts D
and E) of the Implementation Plan form with your
current QIS data. Any modifications from your 2020
Plan Year submission should be reflected in this
Implementation Plan form.
2. Complete a Progress Report form to report progress on
your prior year’s QIS (i.e., Plan Year 2020). See
instructions in the QIS Progress Report form: “Report
on Progress.”

New QIS After Discontinuing a
QIS Submitted During a Prior
Qualified Health Plan (QHP)
Application Period 2

Issuers must complete 2 forms:
1. Complete the Background Information section (Parts A,
B, and C) and the Implementation Plan section (Parts D
and E) of the Implementation Plan form to submit the
new QIS.
2. Complete a Progress Report form to close out the
discontinued QIS. See instructions in the QIS Progress
Report form: “Progress Report Closeout Form.”

New QIS 3 with No Previous
QIS Submission

Complete the Background Information section (Parts A, B,
and C) and the Implementation Plan section (Parts D and E)
of the Implementation Plan form to submit the new QIS.

For the 2022 Plan Year only, all issuers continuing a QIS should select this option to establish baseline
Implementation Plan data
2 A new QIS is required if an issuer: changes its QIS market-based incentive sub-type, changes its QIS topic area,
the QIS is not having the expected impact, or the QIS results in negative outcomes or unintended consequences.
3 A “new QIS” is defined as a QIS that has not been previously submitted to an Exchange.
1

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
2. Targets All QHPs and Product Types Offered Through an Exchange
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*
Note*: If “Subset of QHPs” was selected above, an additional QIS Implementation Plan(s) 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.
Health Maintenance Organization (HMO)
Point of Service (POS)
Preferred Provider Organization (PPO)
Exclusive Provider Organization (EPO)
Indemnity

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 a QIS form(s) to close them out. The issuer must also
ensure all eligible QHPs are covered by an existing or new QIS.

4

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

Background Information
Part B. Issuer Information
These fields are required but will not be scored as part of the QIS evaluation.
3. Issuer Legal Name

4. Company Legal Name

5. HIOS Issuer ID

6. Issuer State

7. QIS Primary Contact’s First Name
8. QIS Primary Contact’s Title

QIS Primary Contact’s Last Name
9. QIS Primary Contact’s Phone

Ext.

10. QIS Primary Contact’s Email
11. QIS Secondary Contact’s First Name
12. QIS Secondary Contact’s Title

QIS Secondary Contact’s Last Name
13. QIS Secondary Contact’s Phone

Ext.

14. QIS Secondary Contact’s Email

15. Date Issuer Began Offering Coverage Through the Exchange
Note: For all date fields in this form, use the down arrow key to activate
the calendar and then use the mouse or arrow keys to navigate to the
correct date.

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
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
Note: These percentages can be estimates and do not need to be exact figures. Issuers may update
this information year to year, as needed.
Payment Model Type

Payment Model Description

Provide Percentage

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 are still 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 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%.

%

Total

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://hcplan.org/workproducts/apm-whitepaper.pdf. See the QIS Technical Guidance and User Guide for the current plan year,
available on the Marketplace Quality Initiatives website, 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.
5

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

Part C. Data Sources Used for Goal Identification and Monitoring Progress
This field is required but will not be scored as part of the QIS evaluation.
17. Data Sources
Indicate the data sources used for identifying QHP enrollee population needs and supporting the QIS
rationale (Element 23). 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. 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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

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
19a. Provide a brief summary description of the QIS. The description must include the market-based
incentive type(s) and topic area(s) selected in Elements 21 and 22.
(1,000 character limit)

19b. Is the QIS described above part of a mandatory state initiative?
Yes

No

19c. 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

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.

7

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
If “yes” was checked for either/both of the above, please describe the state initiative and/or current
issuer strategy.
(1,000 character limit)

20. QIS Goals
Describe the overall goal(s) of the QIS (no more than two).
Note: The topic area(s) selected in Element 22 and the measure(s) described in Element 25 should be
linked to these goals.
QIS Goal 1:
(500 character limit)

QIS Goal 2:
(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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

Part E. QIS Requirements
The Elements in Part E will be scored as part of the QIS evaluation.
21. Market-based Incentive Type(s) (Must Pass)
Select the sub-type of market-based incentive(s) the QIS includes. Check all that apply. If either “Inkind 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. 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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
22. Topic Area Selection (Must Pass)
Select the topic area(s) this QIS addresses, as defined in the Patient Protection and Affordable Care
Act. 8 Check each topic area that applies.
QIS Topic Area

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



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

Implementation of wellness and health promotion activities are cited in Section 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.

8

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
23. Rationale 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).

(1,500 character limit)

24. Activity(ies) that Will Be Conducted to Implement the QIS (Must Pass)
24a. List the activities that will be implemented to achieve the goals described in Element 20.
(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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
24b. Describe how the activities listed in Criterion 24a relate to the market-based incentive(s)
selected in Element 21.
(1,500 character limit)

24c. Describe how the activities listed in Criterion 24a relate to the topic area(s) selected in Element
22.
(1,500 character limit)

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
24d. If health and health care disparities is one of the topic areas selected in Element 22, please
select this box
and move to Element 25.
OR
If health and health care disparities is NOT one of the topic areas selected in Element 22 and
health and health care disparities are not addressed elsewhere in this QIS, please select this
box and move to Element 25.
OR
If health and health care disparities is NOT one of the topic areas selected in Element 22, but
the QIS includes activities related to addressing health and health care disparities, describe the
activities below.
(1,500 character limit)

25. Goal(s), Measure(s), and Performance Target(s) to Monitor QIS Progress (Must Pass)
For Goal 1, identify at least one (but no more than two) primary measure(s) used to track progress
toward meeting the goal.
Measure 1a
25a. Measure 1a Name:
Provide a narrative description of the measure numerator and denominator.
(500 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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

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?
No

Yes

25b. Describe how Measure 1a supports the tracking of performance related to Goal 1.
(1,000 character limit)

25c. Baseline Assessment: Provide the baseline results by either:
• Calculating the rate and providing the associated numerator and denominator (Note: The
numerator and denominator should calculate to the rate provided):
Calculated Rate:
Numerator:
Denominator:
- OR • Indicating the data point if the measure is not a rate:
Data Point:
25d. Provide the baseline performance period (i.e., month and year when data collection began and
ended) covered by the baseline assessment provided in Criterion 25c:

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
25e. Provide the numerical value performance target for this measure (i.e., the target rate or data
point the QIS intends to achieve):
Note: This entry should NOT be a percentage change but a numerical value.

Measure 1b
25f.

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

25g. Describe how Measure 1b supports the tracking of performance related to Goal 1.
(1,000 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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
25h. Baseline Assessment: Provide the baseline results by either:
• Calculating the rate and providing the associated numerator and denominator (Note: The
numerator and denominator should calculate to the rate provided):
Calculated Rate:
Numerator:
Denominator:

- OR • Indicating the data point if the measure is not a rate:
Data Point:
25i.

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

25j.

Provide the numerical value performance target for this measure (i.e., the target rate or data
point the QIS intends to achieve):
Note: This entry should NOT be a percentage change but a numerical value.

QIS Goal 2:
For Goal 2, identify at least one (but no more than two) primary measure(s) used to track
progress toward meeting the goal.
25k. 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 the 4-digit ID number:
If yes, did the issuer modify the NQF-endorsed measure specification?
Yes

No

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
25l.

Describe how Measure 2a supports the tracking of performance related to Goal 2.

(1,000 character limit)

25m. Baseline Assessment: Provide the baseline results by either:
• Calculating the rate and providing the associated numerator and denominator (Note: The
numerator and denominator should calculate to the rate provided):
Calculated Rate:
Numerator:
Denominator:
- OR • Indicating the data point if the measure is not a rate:
Data Point:
25n. Provide the baseline performance period (i.e., month and year when data collection began and
ended) covered by the baseline data assessment:

25o. Provide the numerical value performance target for this measure (i.e., the target rate or data
point the QIS intends to achieve):
Note: This entry should NOT be a percentage change but a numerical value.

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
25p. 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 the 4-digit ID number:
If yes, did the issuer modify the NQF-endorsed measure specification?
No

Yes

25q. Describe how Measure 2b supports the tracking of performance related to Goal 2.
(1,000 character limit)

25r.

Baseline Assessment: Provide the baseline results by either:
• Calculating the rate and providing the associated numerator and denominator (Note: The
numerator and denominator should calculate to the rate provided):
Calculated Rate:
Numerator:
Denominator:
- OR -

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
• Indicating the data point if the measure is not a rate:
Data Point:
25s. Provide the baseline performance period (i.e., month and year when data collection began and
ended) covered by the baseline data assessment:

25t.

Provide the numerical value performance target for this measure (i.e., the target rate or data
point the QIS intends to achieve):
Note: This entry should NOT be a percentage change but a numerical value.

26. Timeline for Implementing the QIS
26a. QIS Initiation/Start Date:
26b. Describe the milestone(s) and provide the date(s) for each milestone (i.e., when activities
described in Element 24 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.

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
27. Risk Assessment
27a. List all known or anticipated barriers to implementing QIS activities.
(750 character limit)

If no barriers were identified, describe how you assessed risk in the box below. If barriers were
identified above, this box should be left blank.
(750 character limit)

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.

[xxxx] Plan Year
QIS Implementation Plan
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
27b. Describe the mitigation activities that will be incorporated to address each barrier identified in
Criterion 27a. If there were no barriers identified, this box should be left blank.
(1,500 character limit)

Optional: If there is any additional information you would like to provide regarding your QIS
Implementation Plan, please do so in the box below.
(1,500 character limit)

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.