Form CMS-10398 #72 CMS-10398 #72 Expression of Interest Form

Maternal and Infant Health Initiative
Infant Well-Child Visit Learning Collaborative Affinity Group
Expression of Interest Form

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the Infant WellChild Visit Learning Collaborative Affinity Group opportunity, which will support state
efforts to improve the use and quality of well-child visits among Medicaid and Children’s Health
Insurance Program (CHIP) beneficiaries ages 0 to 12 months. Through this affinity group,
quality improvement (QI) advisors and subject matter experts will provide technical assistance to
Medicaid- and CHIP-led state QI teams with individualized and group meetings. State teams will
use QI tools to identify, implement, and test change ideas for improving infant well-child visit
rates and quality. Participating state teams will meet monthly from October 2021 to October
2022 (with additional technical assistance available until October 2023). For more information
on the affinity group, please see the fact sheet available here.
To participate in the affinity group, please submit the Expression of Interest form, found here, by
Thursday, September 30, 2021, 8 p.m. ET. In addition to the state Medicaid and CHIP staff,
state Medicaid and CHIP agencies are encouraged to include representatives from managed care
plans, state health departments, other public entities, providers, and other relevant partners as
part of the affinity group team. Upon receiving the form, CMS and the QI technical assistance
team will contact the proposed state QI team leader to discuss the state’s infant well-child visit
improvement goals.
We will consider the following information from states to help us prepare for the affinity group:
•
•
•
•
•

1

Goals for improving infant well-child visit rates and quality
Challenges and opportunities related to infant well-child visits
Access to infant well-child visit data, including the ability to report the Core Set measure
Well-Child Visits in the First 30 Months of Life (W30-CH)
Identification of the state team willing to work about 10 to 15 hours each month
(depending on role, project, and team size) on the state QI project
Commitment to action with support from Medicaid and/or CHIP leadership

Please complete the following:
Contact Information
Team leader name:

Title:

Agency name:
Mailing address:
Phone:

Email:

1. Participation goals: Briefly share your goals for participating in the affinity group. What

outcomes do you hope to improve by participating (for example, improve performance in
attendance at well-child visits for infants ages 0 to 12 months, improve the percentage of
infants receiving recommended care, and/or reduce disparities in infant well-child visit rates)?

2. State needs assessment: CMS wants to understand your state’s challenges and opportunities

related to infant well-child visits for Medicaid and CHIP beneficiaries.

a. What are the key challenges and opportunities related to quality well-child visits for infants
ages 0 to 12 months in your state? If available, please use data to describe the opportunities
for improvement in your state.
b. Are you aware of any disparities in infant well-child visit rates in your state? If available,
please use data to describe the disparities.
c. Briefly describe the infant well-child-visit-related initiatives you have implemented or that
are underway in your state.
d. In what ways has your state employed quality tools to help increase the infant well-child
visit rate for beneficiaries enrolled in Medicaid/CHIP managed care (for example,
conducted performance improvement projects or included W30-CH as part of your state’s
quality strategy)?
e. What models of care related to infant well-child visits do you cover in your state (for
example, medical home models or home visiting)?
3. Early project ideas: Please describe any project ideas that you are considering that you

anticipate will improve infant well-child visit rates among Medicaid and CHIP beneficiaries
in your state. (Note: identifying an intervention or a strategy is not a requirement to participate
in the affinity group. A state can begin to develop QI project as part of the affinity group.)

4. What data does your state use to track the rates and quality of well-child visits for Medicaid

and CHIP beneficiaries?

2

5. Your team: In the table below, provide the names, titles, and affiliations of your proposed

team members. The team lead or co-lead must be a staff member from the Medicaid or CHIP
program. Please include someone to help gather and understand your data. Add more rows if
necessary.

Name

Title

Organizational
Affiliation

Email

Confirmed
(Yes or No)

6. Senior leadership support: State teams should have the support of the Medicaid or CHIP

Director, Medical Director, or other senior leadership in the agency to demonstrate the state’s
interest in achieving the project’s goals. Please indicate the name and contact information of
the senior Medicaid or CHIP official supporting your state’s participation.

State Medicaid or CHIP senior official
Name:
Title:
Email:
Phone:
7. Is there any other information you would like to provide?

Thank you for your interest!
If you have questions, please submit them to
[email protected].

3

PRA Disclosure Statement The purpose of this PRA package is to collect information that is
voluntarily submitted by state Medicaid and CHIP agencies regarding participation in the Infant
Well-Child Visit Affinity Group. Under the Privacy Act of 1974 any personally identifying
information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-1148 (CMS-10398 #72). The time required to
complete this information collection is estimated to average seven hours per response, including
the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. 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.

4