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pdfPRA - All Comments/Responses
#
Source
Tool
(CCIP,
QIP,
Both)
Section:
(General,
Plan, Do,
Study,
Act)
SubSection
Comments, Requests and/or Recommendation
1 AHIP
Both
General
All
Commenter requests tool instructions issued with
tools to judge burden.
2 AHIP
Both
General
All
3 AHIP
Both
General
All
4 AHIP
Both
General
All
5 AHIP
QIP
General
All
6 AHIP
Both
General
All
7 AHIP
CCIP
General
All
8 AHIP
QIP
General
9 AHIP
Both
General
10 AHIP
QIP
General
CMS Decision (Accept, Accept with Modification, Reject,
Clarify)
Clarification - CMS is planning training, tentatively scheduled for
November 2011, where we will provide thorough guidance
regarding what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter requests detailed scoring criteria.
Clarification - CMS is planning training, tentatively scheduled for
November 2011, where we will provide thorough guidance
regarding what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter requests more time to incorporate new Clarification - CMS is planning training, tentatively scheduled for
CMS requirements into their ongoing projects for feb November 2011, where we will provide thorough guidance
2012 submission.
regarding what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter recommends changing February deadline Accept - CMS understands the burden impact related to
for initial submission because SNP plans are also
submitting multiple requirements within the same month.
submitting S&P measures in February
Based on comments, we have decided to move the deadline of
initial submission to March 2012.
Commenter recommends that SNPs not be required Reject - In line with CMS priorities, we feel it is necessary for
to pursue a 4th QIP requirement because S&P
SNPs to submit a QIP specific to all cause readmissions.
measures already require 3 QIPs
Commenter requests guidance that explains
relationship between both tools and SNP-specific
requirements
Clarification - CMS is planning training, tentatively scheduled for
November 2011, where we will provide thorough guidance
regarding what is expected in the 2012 submissions of QIPs and
CCIPs.
Reject - In line with national priorities, CMS is requiring CCIPs
related to decreasing cardiovascular disease from all plan types.
Commenter recommends excepting C-SNPs from the
requirement to submit a CCIP related to
cardiovascular disease because they might have other
important targets related to their beneficiary
population(e.g. ESRD)
All
Commenter recommends that plans have electronic Accept with Clarification - CMS is taking this comment under
ability to upload one QIP for multiple contracts.
consideration and is working to accommodate within the
capabilities of our systems.
All
Commenter recommends a revised burden of hours
Accept with Clarification - Based on comments, CMS is revising
for the whole package because we did not take into
the burden of hours to 15 hours for the QIP tool and 15 hours
account preparation for submission
for the CCIP tool
Medicare
Commenter requests instructions on how to complete Clarification - CMS is planning training, tentatively scheduled for
Advantage "Identification #"
November 2011, where we will provide thorough guidance
Organization
regarding what is expected in the 2012 submissions of QIPs and
(MAO)
CCIPs.
Information
Page 1
PRA - All Comments/Responses
#
Source
Tool
(CCIP,
QIP,
Both)
Section:
(General,
Plan, Do,
Study,
Act)
SubSection
Comments, Requests and/or Recommendation
11 AHIP
QIP
General
Medicare
Commenter requests instructions on how the "Project
Advantage Cycle" field relates to PDSA
Organization
(MAO)
Information
12 AHIP
QIP
General
13 AHIP
QIP
Plan
14 AHIP
QIP
Plan
15 AHIP
QIP
Plan
16 AHIP
QIP
Plan
17 AHIP
QIP
Plan
18 AHIP
QIP
Plan
19 AHIP
QIP
Plan
20 AHIP
QIP
Plan
Background Commenter requests instructions on how to complete Clarification - CMS is planning training, tentatively scheduled for
the "Domain" field.
November 2011, where we will provide thorough guidance
regarding what is expected in the 2012 submissions of QIPs and
CCIPs.
Basis for
Commenter recommends adding field "Other" under Accept - CMS accepts this comment and is working to
Selection
the heading "Impact on Member"
accommodate this request within the system.
Budget and Commenter requests the revision of definitions under Clarification - Thank you for your comment. Based on
Resources
"Priority Assessed" to identify how they relate to
comments, CMS has chosen to delete this section.
either QIP or Intervention
Prior Focus Commenter requests instructions on how to complete Clarification - CMS is planning training, tentatively scheduled for
the "Prior Focus" Section, specifically how much detail November 2011, where we will provide thorough guidance
to provide
regarding what is expected in the 2012 submissions of QIPs and
CCIPs.
Project Goal Commenter requests guidance explaining the terms
Clarification - CMS is planning training, tentatively scheduled for
and
"Baseline/Internal/External and their benchmarks
November 2011, where we will provide thorough guidance
Benchmark
regarding what is expected in the 2012 submissions of QIPs and
CCIPs.
Project Goal Commenter requests instructions describing the
Clarification - CMS is planning training, tentatively scheduled for
and
difference between use of "Planned Intervention" in November 2011, where we will provide thorough guidance
Benchmark H.1 and "Intervention" in H.2
regarding what is expected in the 2012 submissions of QIPs and
CCIPs.
Plan Project Commenter requests instructions on who in the
Clarification - CMS is planning training, tentatively scheduled for
Approval
organization should complete this section
November 2011, where we will provide thorough guidance
regarding what is expected in the 2012 submissions of QIPs and
CCIPs.
CMS
Commenter requests guidance on the CMS Regional Clarification - CMS is planning training, tentatively scheduled for
Regional
Office Approval Process
November 2011, where we will provide thorough guidance
Office
regarding what is expected in the 2012 submissions of QIPs and
Approval
CCIPs.
CMS
Commenter recommends adding language "The above Accept - CMS accepts this comment and will update the tool to
Regional
information will remain in the system for reporting in include the language requested.
Office
subsequent years" to match the CCIP tool language
Approval
Page 2
CMS Decision (Accept, Accept with Modification, Reject,
Clarify)
Clarification - CMS is planning training, tentatively scheduled for
November 2011, where we will provide thorough guidance
regarding what is expected in the 2012 submissions of QIPs and
CCIPs.
PRA - All Comments/Responses
#
Source
Tool
(CCIP,
QIP,
Both)
Section:
(General,
Plan, Do,
Study,
Act)
SubSection
Comments, Requests and/or Recommendation
21 AHIP
QIP
Do
Goal and
Benchmark
22 AHIP
QIP
Study
Results
Commenter requests clarification on the definition of Clarification - CMS is planning training, tentatively scheduled for
risk mitigation and measurement methodology (as
November 2011, where we will provide thorough guidance
compared to methodology in section h.1)
regarding what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter requests instructions on whether this
Clarification - CMS expects to provide guidance in the late Fall of
section is to provide summary level data and how
2011 on what is expected in the 2012 submissions of QIPs and
multiple interventions would get to this page
CCIPs.
23 AHIP
QIP
Act
Summary of
Findings or
Study
Conclusions
Commenter recommends increasing burden of hours Reject - The calculation for burden of hours already includes the
because the narrative fields in this section will
burden associated with submission utilizing HPMS.
substantially increase the time necessary to complete
the tool depending on the amount of detail required.
24 AHIP
QIP
Act
Commenter recommends sections M, N, and O be
required at the end of the QIP and not annually
Reject - CMS is requiring annual submission to allow plans the
ability to track progress.
25 AHIP
QIP
Act
Root Cause
Analysis
Description
Root Cause
Analysis
Description
Accept - CMS accepts this comment and will update the tool to
include the language requested.
26 AHIP
CCIP
General
Commenter recommends moving the "Root Cause
Analysis Description" subsection before the "Next
Steps" subsection to more accurately reflect the flow
of the process
Commenter requests instructions on whether CCIPs
can be longer or shorter than 5 years
27 AHIP
CCIP
Plan
28 AHIP
CCIP
Plan
29 AHIP
CCIP
Plan
30 AHIP
CCIP
Plan
31 AHIP
CCIP
Plan
All
CMS Decision (Accept, Accept with Modification, Reject,
Clarify)
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Basis for
Commenter recommends for the "Disease State" field Clarification - Section A currently allows for more than one
Selection
to allow for more than one condition
condition within the "Disease State" field.
Program
Commenter recommends giving plans the ability to
Accept - CMS accepts this comment and and is working to
Design
select more than one "Method of Identifying
accommodate this request within the system.
Members" from the drop down list
Evidence
Commenter requests instructions on what to include Clarification - CMS expects to provide guidance in the late Fall of
Based
in "Evidence Based Medicine" section
2011 on what is expected in the 2012 submissions of QIPs and
Medicine
CCIPs.
Practice
Commenter requests instructions on level of detail
Clarification - CMS has renamed this section as "Care
Model
that should be provided in "Practice Model" section
Coordination Approach" to clarify the intent of what is required
in this field. CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Patient Self Commenter recommends a more flexible set of
Clarification - CMS acknowledges the need for plans to be
Management categories in this section because the current buckets flexible in their plan activities and requests plans utilize the
Education
may not reflect all plan activities
"Other" category for this purpose.
Page 3
PRA - All Comments/Responses
#
Source
Tool
(CCIP,
QIP,
Both)
Section:
(General,
Plan, Do,
Study,
Act)
SubSection
Comments, Requests and/or Recommendation
32 AHIP
CCIP
Plan
Patient Self Commenter requests instructions and examples of
Management activities that fit within each category currently
Education
included.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
33 AHIP
CCIP
Plan
Outcome
Commenter requests guidance explaining the terms
Measures
"Baseline/Internal/External and their benchmarks
and
Interventions
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
34 AHIP
CCIP
Plan
Budget and
Resources
35 AHIP
CCIP
Plan
36 AHIP
CCIP
Plan
Clarification - CMS understands the impact of burden related to
breaking out financial data specific to quality activities and will
be deleting this section.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
37 AHIP
CCIP
Do
38 AHIP
CCIP
Do
Risk
Mitigation
39 AHIP
CCIP
Study
Results
40 BCBSA
Both
General
All
41 BCBSA
Both
General
All
42 BCBSA
Both
General
All
Commenter recommends changing the April 2012
submission date to September 2012 in order to better
align with the availability of current HEDIS data. MAOs
select topics based on this data.
43 BCBSA
Both
General
All
Commenter requests pass/fail feedback from CMS as Clarification - CMS expects to provide guidance in the late Fall of
part of the bi-annual submission cycle.
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter requests guidance clarifying how this
section will be scored by CMS; if no relevance, AHIP
recommends deletion
MAO CCIP
Commenter requests instructions on who in the org
Responsibilit should complete this section
y
CMS
Commenter requests guidance on CMS Regional Office
Regional
Approval Process
Office
Approval
All
Commenter recommends adding the ability to embed
documents in response throughout this section.
CMS Decision (Accept, Accept with Modification, Reject,
Clarify)
Accept - CMS will ensure upload capability throughout QIP and
CCIP submissions.
Commenter requests clarification on the definition of Clarification - CMS expects to provide guidance in the late Fall of
risk mitigation
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter requests instructions on what to include Clarification - CMS expects to provide guidance in the late Fall of
in the "Results" Section
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter recommends CMS provide instructional Clarification - CMS expects to provide guidance in the late Fall of
guides similar to ones previously supplied
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter supports February 2012 submission date Clarification- Thank you for your support.
as it allows for use of data collected in 2011
Page 4
Clarification - CMS will take this comment under consideration
and will ensure submission deadline information is shared in
guidance released in the late Fall of 2011 on what is expected in
the 2012 submissions of QIPs and CCIPs.
PRA - All Comments/Responses
#
Source
Tool
(CCIP,
QIP,
Both)
Section:
(General,
Plan, Do,
Study,
Act)
SubSection
Comments, Requests and/or Recommendation
CMS Decision (Accept, Accept with Modification, Reject,
Clarify)
44 BCBSA
Both
General
All
45 BCBSA
Both
General
All
Commenter requests instructions on whether new
plans will not be expected to provide QIP/CCIP topic
selections until their 2nd year.
Commenter recommends plans have electronic ability
to upload one QIP and one CCIP for multiple contracts.
46 BCBSA
Both
General
All
Commenter recommends that plans have electronic
ability to upload attachments at a minimum during
review and approval process with the Regional Office
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Clarification - CMS will consider this comment in the future but
will not be able to accommodate this comment in the systems
at this time.
Clarification- CMS will ensure upload capability throughout QIP
and CCIP submissions.
47 BCBSA
Both
General
All
Commenter recommends that plans have the
electronic ability to allow multiple plan users to edit
their documents prior to submission to CMS
48 BCBSA
Both
General
All
Commenter requests guidance on RO Approval
Process
49 BCBSA
QIPs
General
All
50 BCBSA
QIP
Plan
Budget and
Resources
Commenter requests guidance clarifying how the
Accept - CMS understands the impact of burden related to
Budget and Resources Section will be scored by CMS; breaking out financial data specific to quality activities and will
if no relevance, commenter recommends deletion
be deleting this section.
51 BCBSA
QIP
Act
Action Plan
Description
52 BCBSA
QIP
Act
Root Cause
Analysis
Description
53 BCBSA
CCIP
Plan
54 BCBSA
CCIP
Plan
Basis for
Selection
Evidence
Based
Medicine
Commenter requests instructions on how to complete
Section O because this narrative field could take a
substantial amount of time
Commenter requests instructions on how to complete
the "Root Cause Analysis Description" section because
this narrative field could take a substantial amount of
time
Commenter recommends the "Disease State" field to
allow for more than one condition
Commenter requests clarification on CMS'
expectations of responses to the "Evidence Based
Medicine" field.
Clarification - CMS will allow plans to assign users responsible
for submission who will then be able to upload information
through HPMS. CMS will assign a window of opportunity for
submission and will accept the last version created during the
window of opportunity.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter states that plans are currently required to Clarification - CMS expects to provide guidance in the late Fall of
maintain a QIP for a minimum of 3 years and longer if 2011 on what is expected in the 2012 submissions of QIPs and
there is no evidence of improvement; they
CCIPs.
recommend termination of existing QIPs to avoid
confusion and administrative burden as they move
into the new CMS requirements.
Page 5
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Clarification - Section A currently allows for more than one
condition within the "Disease State" field.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
PRA - All Comments/Responses
#
Source
Tool
(CCIP,
QIP,
Both)
Section:
(General,
Plan, Do,
Study,
Act)
SubSection
Comments, Requests and/or Recommendation
CMS Decision (Accept, Accept with Modification, Reject,
Clarify)
55 BCBSA
CCIP
Plan
Patient Self Commenter recommends removal of the categories in Clarification - CMS acknowledges the need for plans to be
Management the Patient Self Management Education section
flexible in their plan activities and requests plans utilize the
Education
because the current buckets do not match the way
"Other" category for this purpose.
patient education is currently done
56 BCBSA
CCIP
Plan
Budget and
Resources
Commenter requests guidance on how this section
will be scored by CMS; if no relevance, commenter
recommends deletion (specifically because plans
already provide overhead estimates in bid process
which includes quality dollars - breaking this number
down would be burdensome)
Accept - CMS understands the impact of burden related to
breaking out financial data specific to quality activities and will
be deleting this section.
57 BCBST
Both
General
All
58 BCBST
Both
General
All
Commenter recommends that CMS does not use the
2010 data as a baseline because the current tool was
not available at that time.
Commenter requests instructions because the tools
are not consistent with the scoring described in the
Medicare Managed Care Manual Chapter 5
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
59 Gateway
CCIP
General
All
60 Gateway
CCIP
General
All
61 Gateway
CCIP
Plan
Budget and
Resources
62 Gateway
QIP
General
All
63 Gateway
QIP
General
Background Commenter requests clarification of what is required
in the field "Domain"
64 Gateway
QIP
Plan
65 Gateway
QIP
Plan
Based on
Model of
Care
Basis for
Selection
Commenter requests guidance as to whether plans
need to submit a separate template for each condition
being managed or just one CCIP
Commenter requests guidance on how to use this
template if their 2010 CCIP was approved
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter recommends removal of the Budget and Accept - CMS understands the impact of burden related to
Resource Section or requests guidance on how budget breaking out financial data specific to quality activities and will
section will be scored
be deleting this section.
Commenter requests instructions because the tools
Clarification - CMS expects to provide guidance in the late Fall of
are not consistent with the scoring described in the
2011 on what is expected in the 2012 submissions of QIPs and
Medicare Managed Care Manual Chapter 5
CCIPs.
Commenter requests guidance as to what CMS is
requiring for SNPs in this section
Commenter requests information regarding what is
required in the Basis for Selection Subsection.
Page 6
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
PRA - All Comments/Responses
#
Source
Tool
(CCIP,
QIP,
Both)
Section:
(General,
Plan, Do,
Study,
Act)
SubSection
66 Gateway
QIP
Plan
Budget and
Resources
67 Gateway
QIP
Plan
68 Gateway
QIP
Plan
69 Gateway
QIP
Plan
70 Gateway
QIP
Do
71 Gateway
QIP
Study
72 Kaiser
QIP
General
73 Kaiser
QIP
Plan
74 Kaiser
QIP
Plan
75 Kaiser
QIP
Plan
76 Kaiser
QIP
Do
Comments, Requests and/or Recommendation
CMS Decision (Accept, Accept with Modification, Reject,
Clarify)
Commenter requests guidance on how this section
will be scored by CMS; if no relevance, commenter
recommends deletion
Prior Focus Commenter requests guidance on how to complete
the "Prior Focus" Subsection, specific guidance related
to measurement cycle
Project Goal Commenter requests definitions for how
and
baseline/internal/external is used in the Project Goal
Benchmark and Benchmark subsection
Plan Project Commenter requests clarification as to whom to
Approval
include as the "responsible person" in the Plan Project
Approval subsection
Goal and
Commenter requests definition of risk mitigation and
Benchmark how it correlates to the Risk Assessment subsection in
the Plan Section and the Risk Mitigation subsection of
the Do Section.
Results
Commenter recommends giving plans the ability to
measure more than one intervention in the Results
subsection.
Medicare
Commenter requests information as to whether CMS
Advantage will dictate Project Cycle and if so recommends
Organization deleting from tool for required QIPs
(MAO)
Information
Accept - CMS understands the impact of burden related to
breaking out financial data specific to quality activities and will
be deleting this section.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Based on
Model of
Care
Basis for
Selection
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Reject - The "Basis of Selection" subsection will be utilized to
capture Basis of Selection information for all QIPs including that
which is required in 2012.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter requests clarification on CMS
expectations for Plan Section, "Based on Model of
Care" subsection
Commenter recommends deletion of "Basis of
Selection" subsection for the QIP that CMS is requiring
for 2012
Project Goal Commenter requests information related to the Risk
and
Assessment subsection; Commenter states Risk
Benchmark Assessment section is misnamed because information
sought seems to be the particular interventions that
the MAO intends to implement and not the risks it
expects to encounter
Goal and
Benchmark
Accept - CMS accepts this comment and and is working to
accommodate this request within the system.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter requests clarification as to whether the
Clarification - CMS expects to provide guidance in the late Fall of
tool is being used for hospital readmission QIPs and if 2011 on what is expected in the 2012 submissions of QIPs and
CMS is dictating the timeframe
CCIPs.
Page 7
PRA - All Comments/Responses
#
Source
Tool
(CCIP,
QIP,
Both)
Section:
(General,
Plan, Do,
Study,
Act)
SubSection
Comments, Requests and/or Recommendation
CMS Decision (Accept, Accept with Modification, Reject,
Clarify)
77 Kaiser
CCIP
Plan
Basis for
Selection
78 Kaiser
CCIP
Plan
Practice
Model
Commenter recommends deletion of Basis for
Selection section when tool is used for required
cardiovascular disease topic
Commenter requests information on what is required
in Practice Model Section
Reject - "Basis for Selection" will be utilized to capture Basis of
Selection information for all CCIPs including that which is
required in 2012.
Clarification - CMS has renamed this section as "Care
Coordination Approach" to clarify the intent of this field. CMS
expects to provide guidance in the late Fall of 2011 on what is
expected in the 2012 submissions of QIPs and CCIPs.
79 Kaiser
CCIP
Plan
Budget and
Resources
80 Kaiser
CCIP
Plan
81 Kaiser
CCIP
Plan
82 Kaiser
CCIP
Study
Results
83 OneCare
Both
General
All
84 OneCare
QIP
General
85 OneCare
QIP
Plan
86 OneCare
QIP
Plan
Commenter recommends deletion of the Budgt and
Resource Section stating that "[w]hen CCIP is on the
CMS mandated topic of decreasing cardiovascular
disease, CMS should either delete this section or
provide the inputs for it so the baseline is the same for
all MAOs"
Budget and Commenter states that it is unclear how CMS will use
Resources
the budget section and that it does not match the
wording in budget section of QIP tool
MAO CCIP
Commenter requests guidance as to who should be
Responsibilit identified as the "responsible person" in the MAO
y
CCIP Responsibility Section
Accept - Based on comments, CMS will be deleting the Budget
and Resource Section
Accept - Based on comments, CMS will be deleting the Budget
and Resource Section
Clarification - CMS expects the Medical Director to complete
this section. CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter recommends revising the "Results"
Reject - CMS has created the tools to address the specifics
section of the CCIP tool to match its counterpart in the involved in the creation of a QIP and a CCIP. The tools look
QIP tool
different because the QIP is meant to accommodate a project
and a CCIP is meant to accommodate a program.
Commenter recommends revising the burden hour
estimate as follows: QIP - 8-10 hours and CCIP - 10-12
hours
Background Commenter requests clarification as to what is
required in the "Domain" field of the Background
subsection.
Budget and Commenter recommends deletion of the Budget and
Resources
Resource Section or guidance as to how the budget
section will be used
Budget and Commenter requests information on how the Priority
Resources
Assessed field relates to financial resources
Page 8
Accept with Clarification - Based on comments, CMS is revising
the burden of hours to 15 hours for the QIP tool and 15 hours
for the CCIP tool
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Accept - Based on comments, CMS will be deleting the Budget
and Resource Section
Accept - Based on comments, CMS will be deleting the Budget
and Resource Section
PRA - All Comments/Responses
#
Source
Tool
(CCIP,
QIP,
Both)
Section:
(General,
Plan, Do,
Study,
Act)
SubSection
Comments, Requests and/or Recommendation
CMS Decision (Accept, Accept with Modification, Reject,
Clarify)
87 OneCare
QIP
Plan
Prior Focus
88 OneCare
QIP
Plan
89 OneCare
QIP
Plan
90 OneCare
QIP
Do
91 OneCare
QIP
Act
92 OneCare
CCIP
Plan
93 OneCare
CCIP
Plan
Outcome
Measures
and
Interventions
Commenter requests guidance as to whether a
Clarification - CMS expects to provide guidance in the late Fall of
specific rate for a goal should be provided or whether 2011 on what is expected in the 2012 submissions of QIPs and
the organization is simply to identify improvement in CCIPs.
a particular area
94 OneCare
CCIP
Plan
95 OneCare
CCIP
Plan
Outcome
Measures
and
Budget and
Resources
96 OneCare
CCIP
Do
97 OneCare
CCIP
Study
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Accept - CMS understands the impact of burden related to
breaking out financial data specific to quality activities and will
be deleting this section.
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter recommends that within the results table, Reject - There are situations when the denominator will not
sampling/percent of total population and exclusions necessarily equal the final sample size.
should be discussed in the Measurement
Methodology; this column should be eliminated as the
final sample size will equal the denominator
Commenter recommends deletion of the "Prior Focus" Reject - The information required in the "Pior Focus", "Basis of
subsection because some of the information may be Selection" and "Risk Assessment" subsections are not the same.
included in Basis of Selection and/or Risk Assessment
(H2) sections
Project Goal Commenter requests definition of baseline benchmark Clarification - CMS expects to provide guidance in the late Fall of
and
2011 on what is expected in the 2012 submissions of QIPs and
Benchmark
CCIPs.
Project Goal Commenter requests information as to what is meant Clarification - CMS expects to provide guidance in the late Fall of
and
by inclusion criteria in relation to interventions
2011 on what is expected in the 2012 submissions of QIPs and
Benchmark
CCIPs.
Goal and
Commenter recommends revising the "Goal and
Reject - The information required in the "Risk Assessment"
Benchmark Benchmark" subsection and identifying it as
subsection, in the "Plan" Section is related to activities planned
"Measurement Methodology". Since it will be
and the information required in the "Risk Mitigation" of the Do
important to understand how baseline and successive Section relates to activites that have already been implemented.
measurements are calculated, this section should
We expect plans to distinguish between the Plan and Do
Action Plan Commenter requests information on how CMS will
Clarification - CMS expects to provide guidance in the late Fall of
Description use information in this "Action Plan Description"
2011 on what is expected in the 2012 submissions of QIPs and
section
CCIPs.
Patient Self Commenter recommends moving the specific
Accept - CMS accepts this comment and and is working to
Management methods and topics related to Patient Self
accommodate this request within the system.
Education
Management Education (B4) to the "Do" Section
Commenter requests guidance including specific
criteria for population, indicator, sampling
methods/selection id used, numerator, denominator,
Commenter recommends eliminating the budget
section because it will be difficult to break down
budget this way
Intervention Commenter requests information as to how plans
report more than one intervention within the tool
Results
Page 9
PRA - All Comments/Responses
#
Source
Tool
(CCIP,
QIP,
Both)
Section:
(General,
Plan, Do,
Study,
Act)
SubSection
Comments, Requests and/or Recommendation
CMS Decision (Accept, Accept with Modification, Reject,
Clarify)
98 OneCare
CCIP
Act
All
Commenter recommends that the Act section in the
CCIP tool should mirror the Act Section in the QIP
reporting tool
Reject - CMS has created the tools to address the specifics
involved in the creation of a QIP and a CCIP. The tools look
different because the QIP is meant to accommodate a project
and a CCIP is meant to accommodate a program.
99 SNP
Alliance
Both
General
All
Commenter states that there is duplication between Reject -These tools are specific to requirements set forth in 42
CCIP/QIP/and other Measures and wants CMS to
CFR § 422.152
streamline reporting requirements for SNPs since they
report all standard MA data in addition to model of
care and S&P data as well as Medicaid data for duals
(e.g. why not allow SNPs to submit a single set of QIPs
to Medicare and Medicaid that focus on the clinical
problems of the target population instead of requiring
them to submit QIPs/CCIPs/S&P Measure 3 and
Medicaid QIPs/PIPs?)
100 SNP
Alliance
Both
General
All
Commenter recommends revision to burden of hours Accept with Clarification - Based on comments, CMS is revising
citing that their experience is that the burden of hours the burden of hours to 15 hours for the QIP tool and 15 hours
will be much greater than 5 hours
for the CCIP tool
101 SNP
Alliance
Both
General
All
Commenter recommends that plans be permitted to Reject - CMS expects plans to complete submissions based on
complete and report on existing QIPs/CCIPs under the active tools; the previous collection tool has expired (OMB Form
template the plan originally used for the project.
# 10209 )
102 SNP
Alliance
Both
General
All
Commenter recommends that SNPs be allowed to
exclusively focus projects on the target population
served and not be required to study populations or
projects that may not be relevant to targeted focus
103 SNP
Alliance
CCIPs
General
All
Commenter requests clarification on what a quality
"improvement" project for I-SNPs would look like
104 SNP
Alliance
QIP
Plan
Budget and
Resources
105 SNP
Alliance
106 UPCA
QIP
Plan
Both
General
Budget and
Resources
All
Reject - In line with national priorities, CMS is requiring CCIPs
related to decreasing cardiovascular disease from all plan types.
Clarification - There are numerous examples of CCIPs that could
improved outcomes in an insitutional population including
projects that focus on reducing falls, incontinence, decubitus
ulcers, etc.
Commenter requests clarification on CMS expectation Clarification- Based on comments, CMS will be deleting the
in the "financial resource" field of the Budget and
Budget and Resource Section
Resource subsection.
Commenter requests guidance as to what is required Clarification- Based on comments, CMS will be deleting the
in the "Priority Assessed" subsection
Budget and Resource Section
Commenter requests guidance clarifying distinction
Clarification - CMS expects to provide guidance in the late Fall of
between the terms "benchmark" and "goal" in both 2011 on what is expected in the 2012 submissions of QIPs and
the QIP and the CCIP tools
CCIPs.
Page 10
PRA - All Comments/Responses
#
Source
Tool
(CCIP,
QIP,
Both)
Section:
(General,
Plan, Do,
Study,
Act)
SubSection
Comments, Requests and/or Recommendation
107 UPCA
QIP
Plan
Commenter requests guidance as to what is required
in the "Based on Model of Care Section"
108 UPCA
QIP
Plan
Based on
Model of
Care
All
109 UPCA
QIP
Do
Goal and
Benchmark
110 UPCA
QIP
Act
Action Plan
Description
111 UPCA
CCIP
All
All
112 UPCA
CCIP
Plan
Outcome
Measures
and
Interventions
113 UPCA
CCIP
Do
All
114 UPCA
CCIP
Do
Results or
Findings
115 UPCA
CCIP
Study
Results
CMS Decision (Accept, Accept with Modification, Reject,
Clarify)
Clarification - CMS expects to provide guidance in the late Fall of
2011 on what is expected in the 2012 submissions of QIPs and
CCIPs.
Commenter recommends renumbering the
Accept - CMS accepts this comment and will update the tool to
subsections within the Plan Section similar to the way reflect the change in sections.
the subsections are numbered under the subsection
"Basis of Selection"
Commenter recommends revising the Goal and
Reject - The commenter's suggestion is too narrow, and does
Benchmark subsection to "Barriers Encountered
not capture all that we intend to convey with the "Goal and
During Implementation"
Benchmark" title in section K1.
Commenter recommends that the Action Plan
Accept with Clarification - CMS is taking this comment under
Description Next Steps should auto populate from the consideration and is working to accommodate within the
Next Steps subsection in the Act Section
capabilities of our systems.
Commenter recommends renumbering all items in the Accept - CMS accepts this comment and will update the tool to
reporting tool should be numbered in all sections
reflect the change in sections.
similar to Program Design subsection for easy
identification
Commenter recommends Outcome Measure and
Reject - We are including clarification in the Goal and
Interventions (Goal and Benchmark) be separated
Benchmark section to describe how outcome measures fit into
because both are required
this section.
Commenter recommends removing the cycle period
because it is already captured on the first page
Accept with Clarification -CMS will consider adding an autopopulation features for the cycle period within system
limitations.
Commenter recommends removing results or findings Reject - The "DO" section helps plans monitor interim findings,
because this section is captured in the study section. while the "STUDY" section is used to report final findings.
Commenter recommends moving analysis of results or Reject - To minimize burden, CMS prefers the results in table
findings below the table and allow more space for the format.
narrative
Page 11
| File Type | application/pdf |
| Author | Vanessa Sammy |
| File Modified | 2011-11-01 |
| File Created | 2011-11-01 |