cms-10540 Modification Summary Supplement

XXXX Plan Year
QIS Modification Summary Supplement
OMB 0938-1286
Expiration Date: XX/XX/XXXX

QIS Modification Summary Supplement
Submission date (please indicate the date you are
submitting this QIS form via HIOS or SERFF)
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 topic areas, goals, activities,
measures, performance targets, and/or the product types). Issuers who have previously submitted two
(2) Modification Summary Supplement forms for a QIS on file, must submit a QIS Implementation
Plan form to replace that QIS. You must also report progress on your current QIS using the separate
QIS Progress Report form.
For detailed instructions, please refer to the Quality Improvement Strategy: 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 over the past plan year. See instructions in
the QIS Progress Report form: Report on Progress.

QIS Title
Restate the short title for the QIS being modified. (200 character limit)

For CMS Use Only

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.

pg. 1

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.

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.

pg. 2

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, Topic Areas, 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? Changes in one
component may necessitate modifications to other components. (Check boxes for product types,
goals, activities, measures, and performance targets.)
Product Types (complete 8b)
Topic Areas (complete 8c)
Goals (complete 8d)
Activities (complete 8e)
Measures (complete 8f)
Performance Targets (complete 8f)
Note: ONLY enter information in the fields below for the components you have indicated above.
Please provide a high-level description of the modifications described below.
(500 character limit)

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 your Implementation Plan or
Modification Summary Supplement 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

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.

pg. 3

XXXX Plan Year
QIS Modification Summary Supplement
OMB 0938-1286
Expiration Date: XX/XX/XXXX
8c. Modifying QIS Topic Areas: For Topic Area changes, indicate whether you are adding and/or
removing any Topic Areas to the Implementation Plan or Modification Summary Supplement on
file. Select all that apply. 1
Note that if you are modifying the QIS Topic Areas for your existing QIS, you must also use this
form to modify the QIS Goals and Activities listed in the Implementation Plan or Modification
Summary Supplement on file, if applicable, by completing Criteria 8d and 8e. You may also need
to update the QIS Measures and Performance Targets listed in the Implementation Plan or
Modification Summary Supplement on file, if applicable, by completing Criterion 8f.
Improve health outcomes

Add

Remove

Prevent hospital readmissions

Add

Remove

Improve patient safety and reduce medical errors

Add

Remove

Implement wellness and health promotion activities

Add

Remove

Reduce health and health care disparities

Add

Remove

If you have added a topic area(s), please describe how that topic area(s) will be addressed within
your existing QIS. If you removed a topic area, please describe the rationale or reason for
removing.
(500 character limit)

If the “Reduce health and health care disparities” Topic Area is selected, what population(s)
does(do) the QIS address?
(500 character limit)

1
Issuers with a current QIS on file should review the information they included in criterion 24d of their QIS
Implementation Plan.

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.

pg. 4

XXXX Plan Year
QIS Modification Summary Supplement
OMB 0938-1286
Expiration Date: XX/XX/XXXX
8d. 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. Please do not include specific performance targets
or goals tied to a specific calendar year or plan year because this Modification Summary
Supplement will remain on file, and references to specific years or performance targets will
become outdated over time:
Goal 1

Goal 2

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

8e. Modifying QIS Activities: If you are modifying Activities, describe them here.
(500 character limit)

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

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.

pg. 5

XXXX Plan Year
QIS Modification Summary Supplement
OMB 0938-1286
Expiration Date: XX/XX/XXXX
8f. Modifying QIS Measures or Associated Performance Targets: For modified or new Measures
or Associated Performance Targets, select the checkbox for the measure and provide all
information. Note: Please refer to your QIS on file to verify measure number and to replicate
unchanged information. If you are removing a measure, you just need to state which measure
you are removing in the space below (Description of modification) and you do NOT need to fill out
any further information for the measure.
Description of modification (e.g., remove measure, change measure or measure specifications,
change target, add new measure).
(500 character limit)

Measure 1a name:
Please select and provide all information for each measure criterion.
Is this a consensus-based entity (CBE)-endorsed measure? 2

Yes

No

If yes, provide the 4-digit ID number:
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:

2 The CBE sets measure evaluation criteria through experts and multi-stakeholder groups involved in the evaluation
process. For further details regarding CBE endorsed quality measures, please visit the CBE measure database
(http://www.p4qum.org/measures).

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.

pg. 6

XXXX Plan Year
QIS Modification Summary Supplement
OMB 0938-1286
Expiration Date: XX/XX/XXXX
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 be a rate (%) or a data point target, NOT a percentage change.)

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

Measure 1b name:
Please select and provide all information for each measure criterion.
Is this a consensus-based entity (CBE)-endorsed measure?

Yes

No

If yes, provide the 4-digit ID number:
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 be a rate (%) or a data point target, NOT a percentage change.)

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.

pg. 7

XXXX Plan Year
QIS Modification Summary Supplement
OMB 0938-1286
Expiration Date: XX/XX/XXXX

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

Measure 2a name:
Please select and provide all information for each measure criterion.
Is this a consensus-based entity (CBE)-endorsed measure?

Yes

No

If yes, provide the 4-digit ID number:
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 be a rate (%) or a data point target, NOT a percentage change.)

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.

pg. 8

XXXX Plan Year
QIS Modification Summary Supplement
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Provide a rationale for the modifications.
(500 character limit)

Measure 2b name:
Please select and provide all information for each measure criterion.
Is this a consensus-based entity (CBE)-endorsed measure?

Yes

No

If yes, provide the 4-digit ID number:
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 be a rate (%) or a data point target, NOT a percentage change.)

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.

pg. 9

XXXX Plan Year
QIS Modification Summary Supplement
OMB 0938-1286
Expiration Date: XX/XX/XXXX
Provide a rationale for the modifications.
(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.