CMS-10540 2020 QIS Progress Report

[xxxx] Plan Year
QIS Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

QIS Progress Report Form
Use this form to report on progress made during the previous year of your quality improvement strategy
(QIS). Please refer to your most recent QIS Implementation Plan and any subsequent modifications for
baseline data.
Confirm you have reviewed your most recent QIS Implementation Plan in preparing this
submission.
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: Only issuers who are continuing a QIS 1 need to submit a Progress Report form.
There are two scenarios for issuers:
1. Progress Report: Issuers who are continuing their current QIS (with or without modifications)
should select Report on Progress and report progress on their prior year’s QIS (i.e., the 2020
Plan Year Implementation Plan form). These issuers should also describe the QIS that will be in
place for the 2022 Plan Year by submitting a QIS Implementation Plan.
2. Progress Report Closeout Form: Issuers discontinuing their current QIS and implementing a
new one should select Progress Report Closeout Form and submit the Progress Report form to
close out the discontinued QIS. These issuers should also describe the QIS that will be in place
for the 2022 Plan Year by submitting a QIS Implementation Plan for the new QIS.

For CMS Use Only

This includes issuers who selected 1) Baseline Implementation Plan (only for the 2022 Plan Year) or 2) New QIS
After Discontinuing a QIS in the QIS Implementation Plan Form for the 2022 Plan Year.

1

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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

QIS Submission Type
Part A. Progress Report or Closeout 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

Progress Report

Issuers must complete 2 forms:
1. Complete the Background Information section (Parts A and B), and
the Progress Report Summary section (Part C) of the Progress
Report form to report progress on your prior year’s QIS (i.e., 2020
Plan Year Implementation Plan form).
2. Complete an Implementation Plan form to submit the baseline
Implementation Plan. See instructions in the QIS Implementation
Plan form: “Baseline Implementation Plan (only for the 2022 Plan
Year)”.

Progress Report Closeout
Form

Issuers must complete 2 forms:
1. Complete the Background Information section (Parts A and B) and
the Progress Report Summary section (Part C) of the Progress
Report form to close out the discontinued QIS, reporting on progress
up until the strategy was discontinued.
2. Complete a new Implementation Plan form. See instructions in the
QIS Implementation Plan form: New QIS after Discontinuing a QIS
Submitted During a Prior QHP Application Period”.

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 Progress Report Form
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. Company Legal Name

4. HIOS Issuer ID

5. Issuer State

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

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

Ext.

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

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

Ext.

13. QIS Secondary Contact’s Email

14. 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. 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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
15. 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 2 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. 3
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.
3 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.
2

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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

QIS Progress Report Section
Part C. QIS Progress Report Summary
The Elements in Part C will be scored as part of the QIS evaluation.
Note: The Goal(s) and Measure(s) identified in this section (Part C: Progress Report Summary) are the
Goal(s) and Measure(s) from the Implementation Plan form on file against which QIS progress is
measured.
Note: All references to Implementation Plan form elements and criteria in this form refer to the 2020 Plan
Year Implementation Plan.
16. Analyze Progress Using Baseline Data, as Documented in the Implementation Plan
(Must Pass)
Restate Goal 1 identified in Element 24 of the Implementation Plan on file.
QIS Goal 1:
(500 character limit)

Measure 1a:
16a. Restate Measure 1a name from Criterion 24a of the Implementation Plan on file:

16b. Baseline Assessment: Restate the baseline results from Criterion 24c of the Implementation
Plan on file 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:

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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

16c. Provide the baseline performance period (i.e., month and year when data collection began and
ended) covered by the baseline assessment provided in Criterion 24c:

16d. Provide the Progress Report 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:

16e. Provide the Progress Report performance period (i.e., month and year when data collection
began and ended) covered by the progress report assessment:

16f.

Restate 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.

16g. Was the performance target achieved?
Yes

No

Measure 1b:
16h. Restate Measure 1b name from Criterion 24f of the Implementation Plan on file:

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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
16i.

Baseline Assessment: Restate the baseline results from Criterion 24h of the Implementation
Plan on file 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:

16j.

Provide the baseline performance period (i.e., month and year when data collection began and
ended) covered by the baseline assessment provided in Criterion 24h:

16k. Provide the Progress Report 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:

16l.

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

16m. Restate 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.

16n. Was the performance target achieved?
Yes

No

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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]

QIS Goal 2
Restate Goal 2 identified in Element 24 of the Implementation Plan on file.
QIS Goal 2:
(500 character limit)

Measure 2a:
16o. Restate Measure 2a name from Criterion 24k of the Implementation Plan on file:

16p. Baseline Assessment: Restate the baseline results from Criterion 24m of the Implementation
Plan on file 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:

16q. Provide the baseline performance period (i.e., month and year when data collection began and
ended) covered by the baseline assessment provided in Criterion 24h:

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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
16r.

Provide the Progress Report 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:

16s. Provide the Progress Report performance period (i.e., month and year when data collection
began and ended) covered by the progress report assessment:

16t.

Restate 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.

16u. Was the performance target achieved?
Yes

No

Measure 2b:
16v. Restate Measure 2b name from Criterion 24p of the Implementation Plan on file:

16w. Baseline Assessment: Restate the baseline results from Criterion 24r of the Implementation
Plan on file 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:

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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
16x. Provide the baseline performance period (i.e., month and year when data collection began and
ended) covered by the baseline assessment provided in Criterion 24h:

16y. Provide the Progress Report 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:
16z. Provide the Progress Report performance period (i.e., month and year when data collection
began and ended) covered by the progress report assessment:

16aa. Restate 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.

16bb. Was the performance target achieved?
Yes

No

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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
17. Summary of Progress (Must Pass)
17a. Please provide a summary of progress covering the following details:
•
•

Indicate why progress was or was not made toward the performance target(s)
documented in Element 24 of your QIS Implementation Plan on file, and
Include a description of activities that led to the outcome.

(1,000 character limit)

17b. If the issuer selected "Progress Report Closeout Form" in Element 1 of this Progress Report
form, provide the rationale for discontinuing the QIS.
(1,000 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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
17c. If the issuer received an “Interim Meets” determination during the previous Post-certification
Assessment (PCA) period and was instructed to address the deficiencies in their subsequent
Plan Year submission, please indicate which elements and/or criteria you updated based on
PCA Notices and describe the changes.
(1,000 character limit)

18. Barriers and Mitigation Activities
18a. Were barriers encountered in implementing the QIS?
No

Yes
If “Yes,” describe:
•

The barriers, and

•

The mitigation activities implemented to address each barrier.

(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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
18b. Were there problems meeting timelines as indicated in Element 25 of the QIS Implementation
Plan on file?
No

Yes
If “Yes,” describe:
•

The problems in meeting timelines, and

•

The mitigation activities implemented to address each problem in meeting the timeline.

(1,500 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 Progress Report Form
OMB 0938-1286
Expiration Date: [xx/xx/xxxx]
Optional: If there is any additional information you would like to provide regarding your QIS Progress
Report, please do so in the box below.
(1,500 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.