cms-10540 2022 Modification Summary Supplement

[xxxx] Plan Year
QIS Modification Summary Supplement
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

QIS Modification Summary Supplement
Use this form to indicate any modifications to an existing quality improvement strategy (QIS)
Implementation Plan on file for the upcoming plan year (making changes to goals, activities, measures,
performance targets, and/or the product types). You must also report progress on your current QIS using
the separate QIS Progress Report form.
For detailed instructions, please refer to the QIS Technical Guidance and User Guide for the current plan
year on the Marketplace Quality Initiatives website.

QIS Submission Type
Part A. 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
Continuing QIS with
Modifications

Instructions
Issuers must complete 2 forms:
1. Complete the Background Information section (Parts A and B) and
the QIS Modification Summary (Part C) of the Modification
Summary Supplement to reflect modifications for the upcoming
year.
2. Complete the QIS Progress Report form to report on progress
achieved on your QIS during the previous year over the past plan
year. See instructions in the QIS Progress Report form: Report on
Progress.

For CMS Use Only

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.

[xxxx] Plan Year
QIS Modification Summary Supplement
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. Issuers may update the
information in Part B from year to year, as needed.
2. Issuer Legal Name
3. HIOS Issuer ID
5. QIS Primary Contact’s First Name
6. QIS Primary Contact’s Email

4. Issuer State
QIS Primary Contact’s Last Name
7. QIS Primary Contact’s Phone

Ext.

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 Modification Summary Supplement
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

Part C. QIS Modification Summary
Complete the following section regarding modifications to the QIS for the upcoming plan year.
8. Modifying Product Types, Goals, Activities, and Measures or Associated Performance Targets
(Must Pass)
8a. Which component(s) of your QIS are you modifying for the upcoming plan year? (check boxes for
product types, goals, activities, measures, and performance targets)
Product Types (complete 8b)
Goals (complete 8c)
Activities (complete 8d)
Measures (complete 8e)
Performance Targets (complete 8e)
Note: ONLY enter information in the fields below for the components you have indicated above.
8b. Modifying QIS Product Types: For product type changes, indicate whether you are adding
and/or removing any product types to the QIS originally listed in Criterion 2b of your Implementation
Plan on file. 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

8c.

Modifying QIS Goals: For modified Goal(s), indicate which Goal(s) you are modifying and
state the new Goal(s) in the space provided below:
Goal 1

Goal 2

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 Modification Summary Supplement
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
Provide a rationale for the modification(s).
(500 character limit)

8d.

Modifying QIS Activities: If the activities (that will be implemented to achieve the identified
Goals) are modified, include the modified activities here.
(500 character limit)

Provide a rationale for the modification(s).
(500 character limit)

8e.

Modifying QIS Measures or Associated Performance Targets: For modified Measures or
Associated Performance Targets, indicate which Measure(s) you are modifying and state the
new Measure(s) and Performance Target(s).
Please select and provide all information for each measure which is being changed.
Measure 1a name:
Is this a National Quality Forum (NQF)-endorsed measure?

Yes

No

If yes, provide the 4-digit ID number:

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 Modification Summary Supplement
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
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:

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

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.

Provide a rationale for the modifications.
(500 character limit)

Measure 1b name:
Is this a National Quality Forum (NQF)-endorsed measure?

Yes

No

If yes, provide the 4-digit ID number:

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 Modification Summary Supplement
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
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:

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

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.

Provide a rationale for the modifications.
(500 character limit)

Measure 2a name:
Is this a National Quality Forum (NQF)-endorsed measure?

Yes

No

If yes, provide the 4-digit ID number:

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 Modification Summary Supplement
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
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:

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

Provide the numerical value performance target for this measure (Note: This entry should NOT
be a percentage change but a numerical value):

Provide a rationale for the modifications.
(500 character limit)

Measure 2b name:
Is this a National Quality Forum (NQF)-endorsed measure?

Yes

No

If yes, provide the 4-digit ID number:

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 Modification Summary Supplement
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
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:

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

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.

Provide a rationale for the modifications.
(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.