CMS-10540 QIS-Implementation-Plan

2025 Plan Year

Draft QIS Implementation Plan

OMB 0938-1286

Expiration Date: XX/XX/20XX

Submission date (please indicate the date you are
submitting this QIS form via HIOS or SERFF)

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 Quality Improvement Strategy: Technical Guidance and User Guide for the current plan year on the Marketplace Quality Initiatives website.

If you are an issuer that:

1. 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 2025 Plan Year. These issuers should also report on progress to close out the discontinued QIS by submitting a QIS Progress Report form.

2. 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 QIS Implementation Plan form.

For CMS Use Only

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
New QIS After Discontinuing a QIS Submitted During a Prior Qualified Health Plan (QHP) Application Period1	Issuers must complete 2 forms: 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. Complete a Progress Report form to close out the discontinued QIS. See instructions in the QIS Progress Report form: “Progress Report Closeout Form.”
New QIS2 with No QIS on file	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. 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 QHPs³*

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)

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	QIS Primary Contact’s Last Name
8. QIS Primary Contact’s Title	9. QIS Primary Contact’s Phone	Ext.
10. QIS Primary Contact’s Email
11. QIS Secondary Contact’s First Name	QIS Secondary Contact’s Last Name
12. QIS Secondary Contact’s Title	13. QIS Secondary Contact’s Phone		Ext.
14. QIS Secondary Contact’s Email
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. 15. Date Issuer Began Offering Coverage Through the Exchange

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 category⁴ 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.⁵

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).	%
Total	Please confirm the total percentage of payments across all four payment model type categories equals approximately 100%.	%

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)

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 submission⁶ a strategy that the issuer currently has in place for its Exchange product line and/or for other product lines?

Yes No

If “Yes” was checked for either/both of the above, please describe the state initiative and/or current issuer strategy.

(1,000 character limit)

Part E. QIS Requirements

The Elements in Part E will be scored as part of the QIS evaluation.

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. Please do not include specific performance targets or timelines to the goals because this Implementation Plan Form will remain on file, and references to specific years or performance targets will become outdated over time.

QIS Goal 1:

(500 character limit)

QIS Goal 2:

(500 character limit)

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 “In- kind 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)

22. Topic Area Selection (Must Pass)

Select the topic area(s) this QIS addresses, as defined in the Patient Protection and Affordable Care Act.⁷ Issuers are required to select the “Reduce health and health care disparities” topic area within at least one of their quality improvement strategies on file.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

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

(500 character limit)

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)

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)

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 or data point calculation method.

(500 character limit)

Is this a consensus-based entity (CBE)-endorsed measure?⁹ Yes No

If yes, provide the 4-digit ID number:

If yes, did the issuer modify the CBE-endorsed measure specification?

Yes No

25b. Describe how Measure 1a supports the tracking of performance related to Goal 1.

(1,000 character limit)

25c. Baseline Assessment:¹⁰ 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:

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 be a rate (%) or a data point target, NOT a percentage change.)

Measure 1b

25f. Measure 1b Name:

Provide a narrative description of the measure numerator and denominator or data point calculation method.

(500 character limit)

Is this a consensus-based entity (CBE)-endorsed measure? Yes No

If yes, provide the 4-digit ID number:

If yes, did the issuer modify the CBE-endorsed measure specification?

Yes No

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

(1,000 character limit)

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 covered by the baseline assessment provided in Criterion 25h:

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 be a rate (%) or a data point target, NOT a percentage change.)

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 or data point calculation method.

(500 character limit)

Is this a consensus-based entity (CBE)-endorsed measure? Yes No

If yes, provide the 4-digit ID number:

If yes, did the issuer modify the CBE-endorsed measure specification?

Yes No

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 assessment provided in Criterion 25m:

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 be a rate (%) or a data point target, NOT a percentage change.)

25p. Measure 2b

Measure 2b Name:

Provide a narrative description of the measure numerator and denominator or data point calculation method.

(500 character limit)

Is this a consensus-based entity (CBE)-endorsed measure? Yes No

If yes, provide the 4-digit ID number:

If yes, did the issuer modify the CBE-endorsed measure specification?

Yes No

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 -

• 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 assessment provided in Criterion 25r:

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 be a rate (%) or a data point target, NOT a percentage change.)

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)

27. Risk Assessment (Must Pass)

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)

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)

1 A new QIS is required if an issuer changes its QIS market-based incentive sub-type, the QIS is not having the expected impact, or the QIS results in negative outcomes or unintended consequences.

2 A “new QIS” is defined as a QIS that has not been previously submitted to an Exchange.

3 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 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://hcp-lan.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.

5 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: http://hcp-lan.org/workproducts/apm-measurement-final.pdf. See Table 1 (p. 7-10) for instructions to calculate the percentage of payments for these two payment model categories.

6 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 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 Beginning with the 2024 Plan Year, issuers are required to address at least two topic areas in their quality improvement strategies on file with “Reduce health and health care disparities” as one of the topic areas, as cited in the Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2023 (87 FR 27208).

9 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.p4qm.org/measures).

10 Baseline assessment results should report performance before implementation of the QIS.

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 OMB control number. The valid OMB control number for this information collection is 0938-1286. This information collection is mandatory for issuers applying for QHP certification in applicable Exchanges that meet the QIS participation criteria, in accordance with section 1311(g) of the PPACA. CMS will assess responses for completeness, evaluate them against QIS requirements, and confidentially report results to issuers.

The time required to complete this information collection is estimated to average 44 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. The information will remain confidential to the extent permitted by law. 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, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850 Attn: PRA Reports Clearance Officer.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Subject	QIS Implementation Plan
Author	Centers for Medicare & Medicaid Services
File Modified	0000-00-00
File Created	2024-12-02