cms-10540 Modification Summary Supplement

2025 Plan Year

Draft QIS Modification Summary Supplement

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 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 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	Instructions
Continuing QIS with Modifications	Issuers must complete 2 forms: 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. 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

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	4. Issuer State
5. QIS Primary Contact’s First Name	QIS Primary Contact’s Last Name
6. QIS Primary Contact’s Email	7. QIS Primary Contact’s Phone	Ext.

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

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)

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)

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:

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.)

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.)

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.)

Provide a rationale for the modifications.

(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.

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.p4qm.org/measures).

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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 18 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 Modification Summary Supplement
Author	Centers for Medicare & Medicaid Services
File Modified	0000-00-00
File Created	2024-12-01