Qis Implementation Plan And Progress Report Form

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QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Please retain a copy of the completed Quality Improvement Strategy (QIS) form so that it is available for
future reference for reporting on activities conducted to implement the QIS. For detailed instructions,
please refer to the QIS Technical Guidance and User Guide for the 2018 Plan Year.
QIS Submission Type
Part A. New or Continuing 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
Complete the Background Information Section (Parts
1
New QIS
with No Previous
B and C) and the Implementation Plan Section (Parts
QIS submission
D and E).
Must complete two forms:
New QIS after Discontinuing
1. Complete a form to close out the discontinued QIS,
a QIS Submitted during a
including the Background Information Section (Parts B
prior Qualified Health
and C); Implementation Plan Section (Parts D and E),
Plan (QHP) Application
with the discontinued QIS information; and Progress
2
Period
Report Section (Part F); AND
2. Complete a new/separate form to submit the new
QIS, including the Background Information Section
(Parts B and C) and the Implementation Plan Section
(Parts D and E).
Complete the Background Information Section (Parts
Continuing a QIS with No
B and C), Implementation Plan Section (Parts D and
Modifications
E), and the Progress Report Section (Part F).
Complete the Background Information Section (Parts
Continuing a QIS with
3
B and C); Implementation Plan Section (Parts D and
Modifications
E); and the Progress Report Section (Part F).
1
A “new QIS” is defined as a QIS that has not been previously submitted to a Marketplace, or is a QIS that is based
upon a different market-based incentive(s) and/or topic area(s) than the issuer’s previous QIS.
2
A new QIS is required if an issuer: changes its QIS market-based incentive type or sub-type, changes its QIS topic
area, reaches one or more of its QIS performance targets, the QIS is not having the expected impact, or the QIS
results in negative outcomes or unintended consequences.
3
An issuer may continue with an existing QIS even if it changes the following: activities, goals, and/or performance
measures.
pg. 1
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.

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