Form CMS-10209 CCIP CMS-10209 CCIP Chronic Care Improvement Program Reporting Template

Medicare Advantage Chronic Care Improvement Program Reporting Template.

OMB #0938 - Pending Approval.

This form is currently available for informational purposes. Use of this form is not required until OMB approval is obtained. This form is subject to change.

Chronic Care Improvement Program Reporting Template

Instructions:

Beginning January 1, 2006, all Medicare Advantage Organizations (MAOs), except for private-fee-for-service and medical savings account plans, are required to implement a chronic care improvement program (CCIP) and report on the ongoing activity of these programs in advance of routine CMS Audits. MAOs must use this template to report CCIP activity.

• MAOs will submit a report for each year of CCIP activity occurring since their last prior routine CMS audit, or January 1, 2006 – whichever occurs later.

• Provide information for all items under Parts A through I using as much space as is necessary to provide complete information.

• MAOs may submit additional supporting documentation along with the information in the reporting template.

• Questions about Medicare Advantage CCIP reporting can be submitted to Shaheen Halim, Ph.D. at:

QIP-CCIP@cms.hhs.gov or 410-786-0641.

A. Medicare Advantage Organization Information :

1. Organization Name:

2. CMS Contract Number:

3. Reporting Year:

4. Date of CCIP Implementation:

5. First Name of CCIP contact:

6. Last Name of CCIP contact:

7. CCIP contact direct phone number:

8. CCIP contact Fax Number:

9. CCIP contact Email Address:

B. Target Population(s) for CCIP:

1. Please define the Medicare Advantage population that your organization is attempting to target with this CCIP. Include all chronic diseases/conditions your organization is attempting to target with the program:

C. Methodology for identifying eligible MA enrollees:

1. Please state all criteria for inclusion of Medicare Advantage enrollees in the chronic care improvement program (including diagnoses codes, number of coexisting diseases/conditions, diagnosis timeframes, risk factors, medication criteria).

2. List the data and information sources from which data to determine eligibility for inclusion are obtained.

3. Provide the number of Medicare Advantage enrollees that your organization has identified as eligible for inclusion in the CCIP. Specify numbers (including percentage of population) for each of your targeted chronic diseases/conditions. Also specify whether these numbers reflect unique enrollees, or whether enrollees with multiple conditions may be counted more than once.

4. Provide the number of Medicare Advantage enrollees identified in C.3. above that are actually participating in the CCIP. Specify numbers (including percentage of population) for each of your targeted chronic diseases/conditions. Also specify whether these numbers reflect unique enrollees, or whether enrollees with multiple conditions may be counted more than once.

5. Please explain the process that your organization uses to inform new and existing Medicare Advantage members that they are eligible for inclusion in the CCIP.

6. Are eligible Medicare Advantage enrollees automatically included in the CCIP or must they elect to participate? Explain how this occurs:

7. Describe how this CCIP improves health outcomes for your organization’s MA beneficiaries. Complete the table below for each of your targeted chronic diseases/conditions.

Chronic Disease/Condition	Prevalence Rate in your MA population	Brief rationale for targeting the Chronic Disease/Condition

8. List and Describe the data sources used to determine that a CCIP was needed for the conditions selected (e.g., rates of inpatient utilization, ER utilization, clinical performance measures such as HbA1c levels , etc.).

D. Interventions

1. Describe each intervention/strategy used in this program to improve the coordination of care of participants. Indicate dates of initiation and completion/expected completion for each intervention or whether the intervention is ongoing. Describe any barriers that the interventions are meant to address.

2. Describe each intervention/strategy used in this program to improve the health status of participants. Indicate dates of initiation and completion/expected completion for each intervention or whether the intervention is ongoing. Describe any barriers that the interventions are meant to address.

3. Provide the number and type/roles of staff involved in coordination and implementation of the interventions used in the CCIP program.

E. Program Monitoring

1. Describe how your organization monitors the progress of its CCIP participants, and how frequently this occurs. Indicate the staff roles involved in CCIP monitoring.

2. List and describe the elements/attributes that are monitored for CCIP participants, and the source of these elements. Do this for each of your targeted chronic conditions/diseases.

F. Outcome Measures

1. What quantitative measures of improvement are used for the CCIP? Provide descriptions of the numerator and denominator of each measure. Do this for each of your targeted chronic conditions/diseases.

2. Indicate the data sources from which each numerator and denominator are obtained. Do this for each of your targeted chronic conditions/diseases.

3. How often are these measures collected and analyzed?

4. Which staff and committees utilize these data?

5. How are improvements made using this information (to either the process, the intervention/service, or the measurements)?

G. Program planning

1. Describe the function, composition and reporting structure of the workgroup or planning committee responsible for your organization’s CCIP.

2. How often does this workgroup/committee meet?

3. Describe how patient and provider input about the CCIP are solicited and used by this committee.

H. Delegation

1. Are any aspects of your organization’s CCIP delegated or outsourced? If so, list the delegated tasks and the contractor/delegated entity performing the tasks:

2. Explain how delegated entities are monitored for compliance with Federal and State requirements, and how often.

3. Explain how delegated entities are monitored for quality assurance purposes, and how often.

I. Incentives

1. Are any aspects of your organization's CCIP part of a national, regional or local collaborative or pay-for-performance initiative? If so, please describe the collaborative/initiative, and the measures upon which your organization is being evaluated.

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- Pending Approval. The time required to complete this information is estimated to average 4 hours 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have comments concerning the accuracy of the time estimate of 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.

Last revised March 2007.

CMS #10209 - CCIP