Alternative MAC QRS Methodology Request Template

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Alternative MAC QRS Methodology Request Template
OVERVIEW
Under 42 C.F.R. § 438.505(a)(1)(i), States must calculate quality ratings for the Medicaid and Children’s Health Insurance Program (CHIP) Quality Rating System (MAC QRS) mandatory measure set using either the standard MAC QRS methodology described in § 438.515(b)(1) and (2), and applicable to separate CHIP by cross-reference through § 457.1240(d), or an alternative MAC QRS methodology approved by CMS. This template has been developed to assist states who wish to use an alternative MAC QRS methodology to calculate quality ratings for MAC QRS performance measures and should be used when a State is applying for a new alternative QRS methodology or modifying an existing alternative QRS methodology. A complete template must be submitted to CMS no later than 6 months prior to the State’s proposed implementation date for the alternative methodology.   
States must use this template if they wish to submit a request for an alternative QRS methodology. CMS will review the request and, if approved, the State may apply the alternative MAC QRS methodology to calculate quality ratings for MAC QRS performance measures. To be approved, an alternative methodology must produce substantially comparable information about plan performance and meet other requirements described in § 438.515(c). Once approved, a State may request modification of the approved alternative QRS methodology at a future date. 
CMS will only review complete submissions which must include:
    • The alternative QRS methodology to be used in generating plan ratings. 
    • Information or documentation specified by CMS to demonstrate compliance with the quality rating requirements, which is described in § 438.515(a); and
    • Supporting documents and evidence that the State believes demonstrates compliance with the requirements specific to sources of Medicare data, the State’s Medicaid fee-for-service providers, or both if all data necessary to calculate a MAC QRS performance measure cannot be provided by the managed care plans per § 438.515(a)(1)(ii).
CMS will not review or approve an alternative methodology request to implement a MAC QRS that does not comply with:
    • The requirement to include mandatory MAC QRS performance measures established in § 438.510(a)(1);
    • The general requirements for calculating quality ratings established in § 438.515(a)(1) through (4);
    • The requirement to include the website features established and identified in § 438.520(a)(1) through (6); 
    • Requests to include plans that do not meet the 500-enrollee minimum threshold established in § 438.515(a)(1)(i), which is permitted without CMS review or approval; or
    • Requests to implement additional measures or website features, which are permitted, without CMS review or approval, as described in § 438.520(c). 

INSTRUCTIONS
Complete the fields below to describe the alternative MAC QRS methodology or modification to an existing alternative methodology previously approved by CMS and provide supporting information and evidence that the alternative methodology will produce quality ratings that yield information regarding managed care plan performance that, to the extent feasible, is substantially comparable to that yielded by the CMS-developed methodology.
Submission of Request and Timing:
    • Optional technical assistance - States may schedule technical assistance to help them draft an alternative QRS request at any time. 
    • Required pre-review for new alternative methodology requests – States must request a CMS pre-review for new alternative methodology requests. The pre-review request must be submitted no later than 1 month prior to the state’s intended submission date and must include a draft Alternative QRS request. Pre-reviews are not required for modifications to alternative methodologies previously approved by CMS.
    • Submission due date – Both new and modification requests for an alternative methodology must be completed and received no later than 6 months prior to when the state wishes to implement the alternative methodology. As examples, the implementation date could be when the state wishes to begin calculating quality ratings for MAC QRS performance measures using the alternative methodology or could be when the state must begin to implement system changes to be able to apply the methodology to calculate quality ratings. The implementation date should not be when quality ratings calculated using the alternative methodology will be posted.
CMS contact information 
    • Submit all completed alternative MAC QRS methodology requests for approval and all requests for technical assistance and pre-reviews to: [email protected] with the subject line “Alternative QRS Request – [State Name]”.
    • If you need assistance with this template, please contact [email protected]. The request should include a general description of the technical assistance requested by the State.
SECTION 1: State and request information
State name: 
Insert text here.
State contact:
Insert text here.
State contact title:
Insert text here.
State contact phone #:
Insert text here.
State contact email address:
Insert text here.

Date of Alternative MAC QRS Methodology Submission:
Insert text here.

Type of Request: Is this a request for a new alternative methodology approval or modification of an alternative methodology previously approved by CMS?
    • New alternative methodology
    • Modification of existing alternative methodology previously approved by CMS. If submitting a modification request, please include as an attachment the original alternative methodology submission that was approved by CMS, and which you are opting to modify.
Expected date of implementation, if approved. (May provide more than one implementation date if applicable.):
Insert text here.

SECTION 2: In Table 1 below, provide an overview of the state’s managed care landscape. If the state operates more than one Medicaid managed care program, additional tables are available in Appendix A.1 
Table 1. State managed care landscape
Managed care program name: Insert text here.
Program covered
Choose an item.
Population(s) covered. More than one can be selected.
Choose an item.
Managed care plans offered through the program* 
List plans
Does the program cover dental benefits? 
Choose an item.
Does the program cover Long Term Services and Supports (LTSS) benefits?
Choose an item.
Does the program cover behavioral health (BH) benefits?
Choose an item.
Does the program cover pharmacy benefits?
Choose an item.
Specify other benefits coverage.
Insert text here.
Additional information about this program.
Insert text here.
*The MAC QRS requirements only apply to a managed care organization (MCO), prepaid inpatient health plan (PIHP), or prepaid ambulatory health plan (PAHP) as identified in § 438.505(b). 
Any additional comments on your managed care program(s) can be included below:


SECTION 3: ALTERNATIVE MAC QRS METHODOLOGY INFORMATION
    1. Select the methodology requirement(s) for which the state is requesting to apply an alternative methodology or modify an existing alternative methodology approved by CMS. The State may select more than one requirement. Please provide additional information in response to the supporting question for any methodology requirement selected.
            ▪ Inclusion of all necessary data sources, § 438.515(b)(1): The State must ensure that the quality ratings issued under § 438.515(a)(4) include data for all enrollees who receive coverage through the managed care plan for a service or action for which data are necessary to calculate the quality rating for the managed care plan including, to the extent feasible without undue burden, Medicaid FFS and Medicare data for enrollees who receive Medicaid benefits through FFS and managed care, or are dually eligible for both Medicare and Medicaid, and receive full benefits from Medicaid, or both.
A. Describe in detail the alternative methodology or modification to an existing alternative methodology that the state wishes to apply and why this methodology or modification is being requested. For new requests, describe how the state’s alternative MAC QRS methodology deviates from the CMS requirement. For modifications, describe how the modification deviates from both the existing alternative QRS approved by CMS and the CMS requirement. If additional documentation is necessary, please submit it as an attachment in your submission email and reference the file name below. 


B. Will the alternative methodology or modification be applied to produce quality ratings for all programs, managed care plans, and populations of enrollees or only a subset? Please note this below, and if a subset, describe in detail the quality ratings to which the alternative methodology or modification will be applied.



        ◦ Issuance of quality ratings for each managed care plan at the plan level, § 438.515(b)(2): The State must ensure that the quality ratings issued under § 438.515(a)(4) are issued to each managed care plan at the plan level and, by managed care program, so that a plan participating in multiple managed care programs is issued distinct ratings for each program in which it participates, resulting in quality ratings that are representative of services provided only to those beneficiaries enrolled in the plan through the rated program. 
A. Describe in detail the alternative methodology or modification to an existing alternative methodology that the state wishes to apply and why the methodology or modification is being requested. For new requests, describe how the state’s alternative MAC QRS methodology deviates from the CMS requirement. For modifications, describe how the modification deviates from both the existing alternative QRS approved by CMS and the CMS requirement. If additional documentation is necessary, please submit it as an attachment in your submission email and reference the file name below.



    B. Will the methodology or modification be applied to produce plan-level quality ratings for all programs, or only a subset? Please note that below, and if a subset, describe in detail the quality ratings to which the alternative methodology or modification will be applied.




    C. Identify the measurement year during which the alternative MAC QRS methodology or modification will first be applied to produce MAC QRS quality ratings and the duration for which the state intends to apply the methodology. If the state is requesting multiple alternative methodologies, modifications, or both list each alternative methodology and dates individually. If additional documentation is necessary, please submit it as an attachment in your submission email and reference the file name below.


    D. Describe how the quality ratings produced by the alternative methodology or modified alternative methodology would yield information regarding managed care plan performance which, to the extent feasible, will be substantially comparable to that yielded by the applicable CMS methodology described in § 438.515(b), taking into account such factors as differences in covered populations, benefits, and stage of delivery system transformation, to enable meaningful comparison of performance across States. If the state is requesting multiple alternative methodologies, modifications, or both provide this information for each alternative methodology individually. 
Supporting Evidence: States are encouraged to attach supporting documents and qualitative and/or quantitative evidence to support the substantial comparability of ratings generated by the requested alternative methodology. Please submit supporting documentation as an attachment in your submission email and reference the file name below.