Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project

HEALTH PLAN MANAGEMENT SYSTEM
CHRONIC CARE IMPROVEMENT PROGRAM (CCIP)
USER GUIDE
LAST UPDATED 11/07/2013

TABLE OF CONTENTS
Introduction.............................................................................................................................................................2
I.

Getting Started ...............................................................................................................................................5
Accessing HPMS ...................................................................................................................................... 5
CMS User IDs ....................................................................................................................................5
How to Access the HPMS Home Page Using the Internet .................................................................6
How to Access the HPMS Home Page Using the CmsNet ................................................................ 8
How to Access the HPMS CCIP Module ................................................................................................. 9
GATE ...................................................................................................................................................... 10

II.

Plan............................................................................................................................................................... 11
CMS Approval ................................................................................................................................. 30

III. Annual Update ............................................................................................................................................. 31
IV. Copy .............................................................................................................................................................. 44
V.

Upload .......................................................................................................................................................... 48

VI. CCIP Reports ............................................................................................................................................... 50
Communication Report .......................................................................................................................... 50
Status History Report .............................................................................................................................. 54
Appendix I: Contact Information ......................................................................................................................... 58
Appendix II: Glossary of Terms ........................................................................................................................... 59

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INTRODUCTION
All Medicare Advantage Organizations (MAOs) must conduct a Chronic Care Improvement
Program (CCIP) as part of their required Quality Improvement (QI) program described at 42
CFR §422.152. MAOs must submit the CCIP(s) to the Centers for Medicare & Medicaid
Services (CMS) and report progress annually for review. CMS will release submission
deadlines on an annual basis.
MAOs must conduct one CCIP across all non-special needs coordinated care plans offered
under a specified contract, including Medical Savings Account plans (MSAs) and Private Fee
for Service (PFFS) plans that have contracted networks. However, MAOs must also conduct
a separate CCIP for each Special Needs Plan (SNP) offered, including multiple SNPs of the
same sub type. For example, if a MAO offers multiple Dual-eligible SNPs (D-SNPs) under a
single contract, that MAO must identify and implement a separate CCIP for each D-SNP
offered.
The Health Plan Management System (HPMS) CCIP Module serves as the means for MAOs
to submit and report on their CCIPs to CMS. The CCIP module allows MAOs to report on
the CCIP throughout the entire life cycle of the CCIP as defined below:


Plan (Chapter II) – Describes the processes, specifications, and outcome objectives
used to establish the CCIP; The Plan section of the CCIP will only be submitted once
(in the fall of the contract or SNP-PBP’s first operational year).



Annual Update (Chapter III) consists of the Do, Study, and Act sections and will be
completed annually, beginning the first year of CCIP implementation and each year
thereafter for the duration of the project (five years).
o Do - Describes how the CCIP will be conducted, the progress of the
implementation, and the data collection plan;
o Study – Describes and analyzes findings against the benchmark(s) or goal(s),
as determined by the MAO, and identifies trends over several PDSA cycles that
can be considered for the “Act” stage;

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o Act – Summarizes the action plan(s) based on findings and describes the
differences between the established benchmarks and the actual outcomes,
providing information regarding any changes based on actions performed to
improve processes and outcomes, including a short description of actions
performed.

In CY 2012, CMS required that each MA plan conduct a CCIP focused on reducing
cardiovascular disease. MAOs were required to submit only the Plan section of the Plan, Do,
Study, Act (PDSA) cycle. This project is to be implemented over a 5-year period.
Consistent with the CY 2012 requirements, MAOs are required to submit CCIP Plan sections
through the HPMS Plan Reporting Module for their plans that are new in CY 2013. CCIPs
are to focus on the reduction of cardiovascular disease in support of the Million Hearts
campaign. MAOs will submit the same detailed information for CY 2013 CCIP Plan sections
as they did for CY 2012. CCIP submissions for new CY 2013 contracts and new CY 2013
SNP-PBPs will consist of only the Plan section of the Plan, Do, Study and Act model. CMS
staff will review the submissions and, once approved, MAOs will begin collecting data that
will subsequently be used in the CY 2014 Annual Update which will include the “Do, Study
and Act” sections.
MAOs that submitted a CCIP Plan section in CY 2012 must submit their first Annual Update
submission in CY 2013 for each approved CCIP. The purpose of the Annual Update is for
MAOs to provide CMS with information about their ongoing CCIP(s) progress and
experience with CCIP implementation over time. The Annual Update is a summary of those
program assessments and provides a brief analysis of the program’s results so far. MAOs are
expected to retain all applicable CCIP documentation to support their Annual Update and
CMS encourages ongoing program assessments to ensure that the Plan interventions are on
track for achieving improvements in both care delivery and health outcomes for their plan
members.
MAOs submitting Annual Updates are not to stop interventions in order to submit data to
CMS. Rather, MAOs should assess and document activities related to the CCIP on an
ongoing basis, making modifications and revisions as necessary. The details of any such
adjustments should be provided to CMS as part of the Annual Update.
The Health Plan Management System (HPMS) CCIP Module serves as the means for MAOs
to submit their CCIP updates to CMS. The CCIP module does enable MAOs to upload
supporting documentation, however, CMS expects MAOs to enter all necessary substantive
information in the fields provided in the submission module. Any Uploaded documents
should include supplementary information only. CCIP submission reviews will not take
uploaded documents into consideration.
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The CCIP module also gives MAOs the ability to Copy CCIP sections from one plan to
another, as long as certain conditions exist. In addition, the Gates link is provided to the
MAOs to access the latest CCIP submission window (open/close) timeframes.
This document provides an overview and technical instructions for accessing HPMS
and navigating through the CCIP module. Please note that words available in the
Glossary have been italicized. Please also note that Screen Prints (or screens)
contained in this User’s Guide are not intended to display complete functionality and
are for demonstration purposes only. General information about the CCIP and QI
program requirements can be found on the CMS Quality Improvement Program
Website at http://www.cms.gov/Medicare/Health-Plans/Medicare-Advantage-QualityImprovement-Program/Overview.html.

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I. GETTING STARTED
ACCESSING HPMS
The HPMS CCIP Module is hosted on a secure extranet site that users can access via the
Internet using a Secure Sockets Layer (SSL) Virtual Private Network (VPN). Users can also
access the HPMS CCIP Module by dial-up or CMSNet.
HPMS URLs:



For the CMS SSL VPN portal: https://gateway.cms.gov.
For CMSNet: https://hpms.cms.gov/

Contact the system administrator to access the CMSNet if the connection is not available.

CMS USER IDS
Users must have a CMS-issued User ID and password with HPMS access in order to log into
the system. Users will also need to associate their User ID with the specific MA contract
numbers that they will work with in HPMS.
To obtain a new CMS User ID, users must complete a CMS User ID request form, which can
be downloaded and printed from:
http://www.cms.gov/InformationSecurity/Downloads/EUAaccessform.pdf.
This form includes a location for applicants to list the contract numbers to be associated with
the requested User ID. Completed CMS User ID forms must be submitted to CMS at the
following address:
CMS
Attn: Lori Robinson
7500 Security Boulevard
Mailstop C4-18-13
Baltimore, MD 21244-1850
If existing HPMS users need to associate a contract number to their current CMS User ID,
please include the following information in an email to hpms_access@cms.hhs.gov:





User Name,
CMS User ID,
Current Contract Number(s), and
Contract Number(s) to be added.

All questions related to HPMS user access should be directed to hpms_access@cms.hhs.gov.

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HOW TO ACCESS THE HPMS HOME PAGE USING THE INTERNET
STEP 1
Open the web browser (e.g., Internet Explorer) and enter the CMS SSL VPN gateway address
https://gateway.cms.gov in the Address field.

STEP 2
Enter the CMS User ID and password and select “hcfa.gov” as the login service. Click Login
(Table I-1).

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STEP 3
Select the HPMS link from the SSL VPN portal screen to access the HPMS Home screen
(Table I-2).

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HOW TO ACCESS THE HPMS HOME PAGE USING THE CMSNET
STEP 1
Open the web browser (e.g., Internet Explorer) and enter the CMSNet address
https://hpms.cms.gov in the Address field.
Select Yes on the Security Alert pop-up window (Table I-3).

STEP 2
Enter the User Name as hcfa.gov/xxxx – where “xxxx” is the 4-digit CMS User ID. Enter the
password and select OK (Table I-4) to access the HPMS Home screen.

STEP 3
Select the HPMS link from the SSL VPN portal page to access the HPMS Home screen
(Table I-2).
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HOW TO ACCESS THE HPMS CCIP MODULE
All information requested as part of the HPMS CCIP module must be completed unless
otherwise noted.

STEP 1
Select Quality and Performance on the Top Navigation Bar then select CCIP from the flyout menu (Table I-5) to get to the CCIP Start Page screen (Table I-6).

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GATE
The GATES link allows users to view the latest CCIP Submission window (gate open/closed)
information.

STEP 1
On the CCIP Start Page (Table I-6) click on the Gates link on the Left Navigation Bar to get
to the CY 2013 CCIP - Gates screen (Table I-7).

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II. PLAN
The PLAN section allows users to describe the CCIP and outline the expectations, basic
approach, and the applicable intervention(s) that the user will further describe in the Annual
Update - Do, Study, and Act sections. The Plan section demonstrates an improvement
opportunity, identifies what change(s) will be introduced, who will be involved, and the
expected results. The steps should include the development of a comprehensive, wellorganized, consistent, and logical plan that is expected to improve health outcomes and
enrollee satisfaction.
Please note the following information:


ONLY those contracts (H#s) and SNPs that have not submitted the mandatory topic
for CY 2012 are allowed to submit a mandatory topic CCIP for the Plan section for
2013.



Once the Plan section submission window is closed for the CY 2013 CCIP, the user
will be unable to edit the Plan section.



During the data entry process, users may save the data entered on any Enter/Edit page
and exit by clicking the Save & Exit button. Users may come back later to edit the
data entered or continue to enter data.

STEP 1
As shown in Table II-1, on the CCIP Start Page, click on the Plan link on the Left
Navigation Bar to get to the Contract/Plan/Topic Selection screen. (See Chapter I: Getting
Started for help getting to the CCIP Start Page.)

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STEP 2
On the Contract/Plan/Topic Selection screen (Table II-2) first select the applicable contract
(i.e., “H” number). Once the contract is selected, the screen will automatically refresh to show
all available plans within that contract. Users must create an individual CCIP for each SNP
offered under a contract based on the SNP’s target population. The SNPs are identified by
their actual plan number, or plan benefit package (PBP) (e.g., 006, 007). However, users
must create the same CCIP for all of the non-SNP coordinated care plans offered under a
contract. As shown in Table II-2, all non-SNP coordinated care plans under each contract are
bundled together and identified as ‘Non-SNP’.
Once a particular plan is selected, the screen will again automatically refresh to show the
CCIP mandatory topic that has been established for that specific plan. The mandatory topic
will appear with an “M” in front of it. Select the “(M) Decreasing Cardiovascular Disease”
option then click Next, which will take the user to the MAO Information screen (Table II-3).

STEP 3
The MAO Information screen (Table II-3) will default to MAO information that was already
entered in HPMS for that particular plan. Provide all information related to the CCIP title,
and summary.
The MAO information should include contact information, plan type, and program cycle year.
Provide the contract number (H####, R####) and the plan benefit package (PBP) number.
The title of the CCIP must be unique for each CCIP.
Provide the CCIP title (Character Limit: 100) and a summary of the CCIP, which must
include the specific clinical foci and the expected outcomes of the CCIP (Character Limit:
4,000). A CCIP is a clinical program focused on improving the health of a population with

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chronic condition(s). Once diagnosed, chronic conditions require ongoing management to
prevent and control exacerbations and prevent other related conditions from developing.

Note: If the information on the Quality Contact Person or the Compliance Contact Person is
incorrect, the MAO must edit that contact information using the Set-Up Plans function in
HPMS. Instructions on how to update contact information is contained in the Bid Submissions
User’s Manual. This manual can be accessed from the HPMS Home page (Table I-V) under
the following path: Plan Bids > Bid Submission > Select Contract Year > Documentation.
Click Save & Next to get to the PLAN Section (A) screen.

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STEP 4
On the PLAN Section (A) screen (Table II-4) enter information about the basis for selection,
and include all applicable data sources.
A1. Disease State
(Character Limit: 100)
For “A1. Disease State,” provide the targeted disease state(s) or chronic condition(s) for this
CCIP along with the ICD-9-CM code(s). Selection of the ICD-9-CM code(s) must be specific.
Once the MAO enters a disease state in this field, that disease state will auto-populate in other
relevant fields throughout the tool.
A2. Rationale for Selection
(Character Limit: 4,000)
For “A2. Rationale for Selection,” provide a detailed and in-depth description that includes: 1)
the rationale for selecting the specific disease or condition; 2) how the information gathered
from the identified data sources showed a gap in care which supports the need for a CCIP; 3)
the incidence and/or prevalence of the disease or condition within the MA plan’s target
population; and 4) the applicable source data.
A3. Relevance to the Plan Population
(Character Limit: 4,000)
For “A3. Relevance to the Plan Population,” provide a detailed and in-depth description that
is consistent with the overall goal of the CCIP and reflects the needs of the MA plan’s target
population. The description must include: 1) how the CCIP is relevant to the MA plan’s
target population by describing the incidence and/or prevalence of the disease; 2) the current
disease impact on the MA plan members; and 3) how filling the gap in care identified in “A2.
Rationale for Selection” will improve health outcomes.
A4. Anticipated Outcomes
(Character Limit: 4,000)
For “A4. Anticipated Outcomes,” provide a detailed and in-depth description of the
anticipated outcomes. The description must be consistent with the overall goal of the CCIP
and include: 1) how the CCIP relates to the responses in “A2. Rationale for Selection” and
“A3. Relevance to the Plan Population;” 2) what the MA plan expects the CCIP to achieve; 3)
how the MA plan’s target population will be impacted by the outcomes (i.e. health status); 4)
a description of the evidence-based guidelines considered; and 5) how these guidelines will be
effective in producing improved health outcomes.
A5. Data Source(s) for Selected Chronic Condition
For “A5. Data Source(s) for Selected Chronic Condition,” the plan must check all applicable
data sources that were used to identify and support the target disease state or chronic
condition. If selecting “Other Sources,” please describe completely in the text field (Character
Limit: 4,000). A plan may select up to five other sources.
Click Save & Next to get to the PLAN Section (B1) screen.

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STEP 5
On the PLAN Section (B1) screen (Table II-5), use the form displayed on the screen to
describe the program design.
B1. Population Identification Process
The population identification process involves identifying appropriate members with a disease
state who would benefit from disease management. This process is based on a review of
member demographic characteristics, previous healthcare use, and healthcare expenditures.
B1a. Describe the Target Population
(Character Limit: 4,000)
For “B1a. Describe the Target Population,” provide a detailed and in-depth description that is
consistent with the overall goal of the CCIP and includes: 1) the inclusion and exclusion
criteria being used; 2) the rate of incidence among the members related to the inclusion
criteria; 3) the severity of disease level of the members included; and 4) the demographics
and clinical variable(s) used to identify those appropriate for inclusion into the CCIP.
B1b. Method of Identifying Members
For “B1b. Method of Identifying Members,” select all applicable methods that were used to
identify the members for inclusion in the CCIP. If “Other” is selected, enter a detailed
description in the text field (Character Limit: 4,000). Up to four additional methods may be
added.
B1c. Risk Stratification
For “B1c. Risk Stratification,” select a severity level of the members the CCIP will target (i.e.
High, Medium or Low). Risk Stratification relates to the patient acuity level and is measured
in terms of how severe an illness is or how much assistance a patient needs in carrying out
activities of daily living. High-risk patients are identified by a high acuity level and low-risk
patients are identified by a low acuity level.
B1d. Enrollment Method
For “B1d. Enrollment Method,” select the one method that will be used to enroll members
who meet the specified criteria into the CCIP (i.e. Opt in or Opt out).
Click Save & Next to get to the PLAN Section (B2, B3) screen (Table II-6).

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STEP 6
On the PLAN Section (B2, B3) screen (Table II-6) use the form displayed on the screen to
describe any evidence-based information and the care coordination approach.
B2. Evidence-Based Medicine
(Character Limit: 4,000)
Evidence-Based Medicine is the integration of the best research evidence with clinical
expertise and patient values to make clinical decisions. Evidence-Based Medicine ensures
consistency in treatment across the targeted population.
For “B2. Evidence-Based Medicine,” provide a detailed and in-depth description that is
consistent with the overall goal of the CCIP and includes: 1) the evidence-based medical
guideline(s) chosen from a credible and authoritative source; 2) why the guideline(s) was
chosen including how using it will impact health outcomes; 3) how the guideline(s) will be
applied to the CCIP across different demographics and severity of disease levels with an
example provided; and 4) the source and date of the guideline(s).
B3. Care Coordination Approach
(Character Limit: 4,000)
The care coordination approach, or collaborative care model, consists of a multidisciplinary
team that may include physicians, pharmacists, nurses, dieticians, and psychologists. Patientcentered, collaborative care is the foundation of this practice-based model in which the
formation of patient/provider partnerships and community/healthcare system partnerships is
essential for improved outcomes. The collaborative care model is the instrument by which
self-management support is delivered.
For “B3. Care Coordination Approach,” provide a detailed and in-depth description that is
consistent with the overall goal of the CCIP and includes: 1) the components and organization
of the multidisciplinary team which includes both internal and external team members; 2) the
team’s approach for the CCIP; 3) the roles and responsibilities of the team members; 4) how
the team will communicate and work together to support the members and the goal of the
CCIP, with an example provided; and 5) how the individual member’s goals and outcomes
will be assessed and addressed with an example provided (e.g., staff and resources utilized,
and the type of communication being used among team members).
Click Save & Next to get to the PLAN Section (B4) screen (Table II-7).

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STEP 7
On the PLAN Section (B4) screen (Table II-7) select the type of education that applies to the
CCIP. The screen will then refresh to allow the user to enter information based on the type of
education selected. Use the form displayed on the screen to describe the method and the
topics covered.
B4. Education
Patient and/or provider education is an integral part of the CCIP. Patient education focuses on
the provision of education and supportive interventions to increase patients’ skills and
confidence in managing their health problems, including regular assessment of progress and
problems, goal setting, and problem solving support. Empowering patients through education
to more effectively “self-manage” is paramount to improved health outcomes. Provider
education focuses on the provision of the most up to date evidence-based medical guidelines
for the treatment of the disease state or condition that the CCIP is targeting. The education
component may be focused on the targeted patients, the providers, or both.
Type of Education
Indicate if the education is patient focused (Patient Self-Management), provider focused
(Provider Education), or a combination of both by selecting the appropriate option on the
screen. The applicable tables will then be available for completion.
B4a. Patient Self-Management
(Character Limit: 4,000)

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For “B4a. Patient Self-Management” education, provide a detailed and in-depth description
that is consistent with the overall goal of the CCIP and includes the planned methods and the
educational topics that will be used for training, support, monitoring, and follow-up of the
targeted members. The description must include, as applicable: 1) methods that are varied and
take into consideration the different demographics, socioeconomic status, and cultural
backgrounds of the members; 2) educational topics that support improvement in health
outcomes and are designed for various severity of disease levels, demographics,
socioeconomic status, and cultural backgrounds of the members; and 3) training, support,
monitoring, and follow-up.
B4b. Provider Education
(Character Limit: 4,000)In “B4b. Provider Education,” a text box appears above the table to
indicate the type of provider on which the education will focus. A description that specifies
the type of provider for whom education will be provided as part of the CCIP (e.g.,
cardiologists), should be included.
For “B4b. Provider Education,” provide a detailed and in-depth description that is consistent
with the overall goal of the CCIP and provides specific details concerning the planned
methods and educational topics that will be used for training, support, monitoring, and followup of the applicable providers. The description must include: 1) provider training of the
applicable evidence-based guidelines and practice patterns for the identified disease state or
condition; 2) the methods for providing appropriate support for the members in managing
their condition and monitoring of the member; and 3) the methods and frequency for followup of the member.
Note: The user may enter up to six interventions that relate to the overall type of Education of
the CCIP by using “Add” buttons.
Click Save & Next to get to the PLAN Section (B5) screen (Table II-8)

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STEP 8
On the PLAN Section (B5) screen (Table II-8), use the form displayed on the screen to
describe the outcome measures and interventions.
B5: Outcome Measures and Interventions
Outcome measures are used to identify how well the CCIP is working and the final product or
end result. This measurement determines if the CCIP is stable and if the processes that led to
the outcome are functioning effectively and efficiently. Outcome measurement reflects the
impact(s) the CCIP and the intervention(s) had on the health status of the targeted population.
Outcome measures involve setting objectives in measureable terms, identifying the
appropriate data source(s) to measure, and the methodology used to analyze the data.
The Outcome Measures and Interventions table may be repeated a total of three times in order
to identify more than one intervention, if applicable.
B5a. Goal
(Character Limit: 4,000)
The user should select only one goal for the CCIP regardless of the number of interventions it
implements. All interventions should work toward achieving the same goal. Users can enter
up to three interventions in B5d for their stated goal (i.e., the description the user has provided
in “B5a. Goal”). In sections where intervention(s) auto-populate, each intervention will be
carried through. (Note: Users cannot edit text that has been auto-populated from a different
section.)
For “B5a. Goal,” provide a detailed and in-depth description that is consistent with “Section
A. Basis for Selection,” and includes: 1) a goal that is specific and relevant to the disease state
or condition and the CCIP; 2) the evidence or factors considered that show how the goal will
impact health outcomes; and 3) how the goal is measureable and attainable within the
established timeframe.
B5b: Check Boxes for Goal
(Character Limit: 4,000)
For “B5b. Check Boxes for Goal,” select how the goal will impact the MA population by
selecting Clinical, Utilization Access, Satisfaction Survey, or Other. If Other is selected,
provide a description in the text field.
B5c: Benchmark
(Character Limit: 4,000)
Plans will compare the results of their intervention(s) to benchmark data in order to measure
the effectiveness of their interventions at the end of the reporting cycle.
For “B5c. Benchmark,” provide a detailed, in-depth description that is consistent with the goal
of the CCIP and includes: 1) a valid, reliable performance standard that is relevant to the goal
of the CCIP; 2) how the benchmark relates to the demographics of the target population; 3)
how the benchmark reflects the severity of the targeted disease state or condition; 4) reliable
source(s); and 5) the date that the benchmark was measured/established.

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Then, select whether the primary benchmark is baseline, internal or external as defined
below. If the MAO is using more than one type of benchmark, state the other benchmark
sources in the benchmark description above. Plans will compare the results of their
interventions to benchmark data in order to measure their effectiveness. Baseline, internal,
and external benchmarks are defined as follows:





Baseline Benchmark – Select this option if the data was obtained at the end of the
current reporting cycle as the standard of comparison for subsequent reporting cycles.
Baseline benchmark is the first measure used as a point of reference in which a CCIP
can be measured, compared, or judged.
Internal Benchmark – Select this option if the benchmark data is from the MA plan’s
own data sources (e.g., administrative data or claims data).
External Benchmark – Select this option if the benchmark data was obtained from
sources outside of the MAO (e.g., national or regional benchmarks).

B5d. Intervention
(Character Limit: 4,000)
For “B5d. Intervention,” provide a detailed and in-depth description that reflects the strategy
that will be used to improve health outcomes and includes: 1) an explanation of the
intervention(s) being used; 2) how the intervention is measureable and capable of improving
health outcomes; 3) how the intervention relates to the specified goal; and 4) how the
intervention is sustainable over time. The user may enter up to three interventions that relate
to the overall goal of the CCIP by using ‘Add’ button.
B5e. Rationale for Specific Intervention Related to Goal or Benchmark
(Character Limit: 4,000)
For “B5e. Rationale for specific intervention related to goal or benchmark,” provide a detailed
and in-depth description of the process used in developing the intervention and includes: 1)
the reason the intervention was chosen; 2) how the intervention relates to the goal and
benchmark; 3) the factors or evidence considered when developing the intervention that
demonstrates its validity; and 4) the anticipated impact on health outcome(s).
B5f. Measurement Methodology
(Character Limit: 4,000)
Measurement methodology is the means, technique, procedure, or method used to collect data
and measure the effectiveness of the CCIP. Users should describe the methodology they will
use for each unique intervention they plan to implement.
For “B5f. Measurement Methodology,” provide a detailed and in-depth description that
includes: 1) the specific valid and reliable data that will be collected for measurement; 2) a
description of how the measure relates to the intervention, the goal, and the benchmark
included in “B5b. Benchmark;” 3) the systematic method in which the data will be collected;
and 4) the frequency of data collection and analysis.

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B5g. Timeline
(Character Limit: 4,000)
For “B5g. Timeline,” provide a detailed and in-depth description that must be consistent with
the overall goal of the CCIP and include: 1) exact beginning and ending dates from
implementation to the completion of the measurement cycle; 2) an explanation of how the
timeline reflects an appropriate amount of time to complete the planned intervention; and, 3)
the rationale for the expected timeline. MAOs should ensure that the listed timelines are
specific to each intervention and fit within the CCIP program cycle.
Note:
 The CCIP module defaults to one intervention in this section. If necessary, the user
can add more interventions by clicking Add near the bottom of the screen. Also, if
additional interventions already exist for the CCIP, the user can delete an intervention
by clicking Delete.
 If the CCIP already includes more than one intervention, then upon clicking Save &
Next the user will go to the Plan Section (B5) screen for the second intervention (e.g.
Intervention 2). Continue entering all information and clicking Save & Next as
appropriate until information has been entered for each applicable intervention. After
entering all information, the user will proceed to the PLAN Section (B6) screen.
After entering all information for all interventions, click Save & Next to get to the PLAN
Section (B6) screen.

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STEP 9
On the PLAN Section (B6) screen (Table II-9), use the form displayed on the screen to
describe the communication sources.
B6. Communication Sources including the Interdisciplinary Care Team and Patients
Communication sources are the methods used to inform patients, physicians, and ancillary
providers on what is occurring in the CCIP and of any changes that might be made to the
CCIP over time. It may also include communication with the health plan and practice
profiling.
Under “B6a. Sources” and “B6b. Target Audience,” select the appropriate options.
B6a. Sources
For “B6a. Sources,” select how the program will integrate continuous feedback among all
parties involved in the program by marking all that apply. If selecting ‘Other’, please describe
in the text field provided (Character Limit: 4,000).
B6b. Target Audience
For “B6b. Target Audience,” select all parties involved in the program that will be integrated
into the continuous feedback loop by marking all that apply. If selecting ‘Other’, please
describe in the text field provided (Character Limit: 4,000).
After entering all applicable information, click Save & Next to get to the PLAN Section (C)
screen (Table II-10).

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STEP 10
On the PLAN Section (C) screen (Table II-10) use the form displayed on the screen to
provide contact information for the MAO Medical Director, a person designated by the
Medical Director, or other person of authority who is approving the CCIP. This section must
be fully completed. Once the Medical Director or designee approves the CCIP submission
and clicks Save & Next, the user is taken to the Plan Submission Verification screen (Table
II-11).

STEP 11
On the Plan Submission Verification screen (Table II-11) review all information for
accuracy.
Once the user confirms that the information related to the Plan section is accurate, the user
will select Submit to complete the submission process. Click Edit to return to the selection
criteria screens to edit any information. After clicking Submit the user will be taken to the
PLAN Information Submission Confirmation screen (Table II-12) that includes the
following message: “Your data has been submitted.”
Notes: If Edit option is selected on the Plan Submission Verification screen (Table II-11),
user will be able to reopen the Plan section at a later time (before the Plan section submission
window closes) to edit any information until the user is ready to submit the final CCIP to
CMS.
If Submit option is selected, the submission for the topic created will be final and user cannot
edit the submitted topic.
Note: Since this is the MAO’s initial CCIP submission for CY 2013, the submission is
complete at this step, as only the Plan section is to be submitted for review by CMS.

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CMS APPROVAL
Once the user has completed the Plan section, CMS will review the submission and determine
whether it is approved or not. Each user will be notified of its approval status by CMS.
If CMS notifies the user of non-approval, CMS will provide the user with guidance and
assistance on how to improve its submission. Once the user has worked with CMS to
improve its submission, the user must re-submit the Plan section. The user must re-enter
information in the sections where the information has changed when resubmitting specific
sections of the CCIP.
Once the Plan section is approved by CMS, the user can begin to implement the CCIP.

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III. ANNUAL UPDATE
The Annual Update section allows users to the implementation, progress and ongoing
activities of their CCIP initiatives. The CCIP Annual Update is comprised of the Do, Study,
and Act components of the Plan, Do, Study, Act quality improvement model, and serves as a
progress report to document CCIP activity over time. MAOs should assess and document
activities related to these quality initiatives on an ongoing basis, and make modifications to
interventions and/or processes as necessary, and provide the details of any such adjustments to
CMS as part of the Annual Update.
Please note the following information:
 Once the Annual Update section submission window is closed for the CY 2013 CCIP,
the user will be unable to edit the Annual Update section.
 Only approved CY 2012 CCIP Plan sections can submit the CCIP Annual Update
section for CY 2013 Annual Update 1.
 During the data entry process, users may save the data entered on any Enter/Edit page
and exit by clicking the Save & Exit button. Users may come back later to edit the
data entered or continue to enter data.

STEP 1
As shown in Table III-1, on the CCIP Start Page, click on the Annual Update link on the
Left Navigation Bar to get to the Contract/Plan/Program Selection screen. (See Chapter I:
Getting Started for help getting to the CCIP Start Page.)

STEP 2
On the Contract/Plan/Program Selection screen (Table III-2) first select the applicable
contract (i.e., “H” number). Once the contract is selected, the screen will automatically refresh
to show all available plans within that contract. The SNPs are identified by their actual plan

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number, or plan benefit package (PBP) (e.g., 006, 007). As shown in Table III-2, all non-SNP
coordinated care plans under each contract are bundled together and identified as ‘Non-SNP’.
Once a particular plan is selected, the screen will again automatically refresh to show the
CCIP that has been established for that specific plan. Select the topic then click Save &
Next, which will take the user to the DO SECTION (D) screen.

STEP 3
On the DO Section (D) - D. Program Implementation screen (Table III-3), describe the
steps taken to conduct the CCIP; this includes describing any changes to the educational
component, any barrier(s) encountered, its effect(s), and associated mitigation strategies.
Note that the MAO Information will default to MAO information that was already entered in
HPMS for that particular plan.
After completing Do sections D1 – D3 as applicable, click Save & Next, which will take the
user to the STUDY Section (E) screen.
D1. Education
The educational component may be focused on the patients, the providers, or both.
D1a. Patient Self Management – The information is auto-populated from information that
was entered in the approved CY 2012 Plan section for that particular contract.
D1b. Provider Education – The information is auto-populated from information that was
entered in the approved CY 2012 Plan section for that particular contract.

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D1c. Did you conduct proposed education
If you conducted the proposed education in the approved CCIP Plan section, select YES. If
YES, then no further input in this section is necessary.
If you did not conduct the proposed education in the approved CCIP Plan section, select NO.
If NO, use the field provided to explain why the proposed education was not conducted.
Describe what alternate education was used and/or will be used going forward and include the
expected impact the new education will have on reaching the project goal. (Character Limit:
4,000)
D2. Intervention is auto-populated from Plan section “B5d. Intervention.”
D3. Barriers Encountered
For “D3. Barriers Encountered”, identify if there are barriers. If there are barriers, select YES.
If there are no barriers, select NO.
If NO, then no further input in this section is necessary and the user may move forward to the
STUDY Section (E).
If YES, use the field provided to describe, in detail, the actual barrier(s) encountered during
the implementation of the project thus far and describe how the barrier(s) impacted the project
implementation. Then move the Mitigation box and provide the necessary information
(outlined below). If a Non-SNP bundled CCIP has experienced particularly significant
barriers on the PBP level, the MAO should indicate the details of those barriers, including the
affected PBP numbers, here. (Character Limit: 4,000)
Mitigation
If YES, also describe the mitigation plan (i.e. activities implemented in response to the
identified barrier(s)), and include a discussion of how the implementation of these activities
will help achieve the target goal. Mitigation approaches should be reasonable and appropriate
for the documented barriers. Be sure to indicate which barrier a specific mitigation strategy
was used for. (Character Limit: 4,000)
After entering all information, click Save & Next to get to the STUDY Section (E) screen.

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STEP 4
On the STUDY Section (E) - E. Results and Findings screen (Table III-4), describe details
about the results and findings of the project to date, including both quantitative and qualitative
data. Also, provide a detailed analysis of the results, compare the results to the identified
benchmark and indicate whether or not the anticipated goal and/or outcomes were achieved.
The results and findings reported in the STUDY Section (E) should reflect an evaluation of
the intervention(s) implemented during the first year of the CCIP.
After completing Study sections E1 – E9, click Save & Next, which will take the user to the
ACT Section (F) screen.
STUDY Section (E) - E. Results and Findings
The STUDY Section describes the CCIP topic and reports the results of the CCIP, as well as
provides the numerical data where applicable.
E1. Goal – The information is auto-populated from information that was entered in the
approved CY 2012 Plan section for that particular contract.
E2. Benchmark – The information is auto-populated from information that was entered in the
approved CY 2012 Plan section for that particular contract.
E3. Timeframe –The timeframe is reflective of the reporting period and is specified as r
“January 1, 2013 through Annual Update Period.” Because this is the first Annual Update in
the 5-year CCIP cycle for approved CY 2012 Plan sections, the timeframe begins with project
implementation in January 2013 and ends with submission of the first Annual Update..
E4. Total Population
(Number)
At “E4. Total Population,” provide the total number of enrollees in the plan(s) at the time the
Annual Update is due. If there is a significant fluctuation in enrollment during the reporting
period, discuss the reasons why in the “Analysis of Results or Findings” field (E7) below.
Note: With the exception of SNPs, the Annual Updates are submitted at the contract level.
Therefore, the total population and results will reflect the aggregate number of enrolled
beneficiaries and experience across all applicable non-SNP coordinated care plans under that
contract. For SNPs, submit the total population and results for each SNP individually.
E5. Numerator
(Number)
At “E5. Numerator,” provide the number of plan members that met the inclusion criteria as
defined in the Plan section and actually received the project intervention(s). The data in this
field must be reported as either a whole number or percentage only.

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E6. Denominator
(Number)
At “E6. Denominator,” provide the total number of plan members that met inclusion criteria
and were eligible to receive the program interventions as defined in the Plan section. The data
in this field must be reported as either a whole number or percentage only.
For example: If an MAO has 100 enrollees that met the inclusion criteria for participation,
and 35 of those 100 enrollees participate in the CCIP, the numerator is 35, and the
denominator is 100. The 35 members who satisfied the inclusion criteria (the numerator) are
also known as the targeted population described in the Plan Section. In summary, the
numerator is the number of enrollees who participated in the intervention and the
denominator is the number of enrollees who were eligible to participate.
E7. Results and/or Percentage Character Limit: 4,000)
At “E7. Results and/or Percentage,” provide any outcomes data available at the time the
update is due and indicate the data source and data collection period. Note that for reliable
and consistent measurement, CMS recommends that MAOs use the same primary data source
over time for the CCIP Annual Updates so that the findings are comparable. MAOs should
avoid using different data sources for each reporting year. Please note that this field allows for
both numerical data and text, so that quantitative and qualitative data can be provided here.
For example: 11.8 percent all-cause 30 day readmission rate for 2012.
E8. Other Data or Results
(Character Limit: 4,000)
At “E8. Other Data or Results,” provide any additional outcomes data or results pertinent to
the project, and indicate the data source and data collection period.
For Example: MAOs may use HEDIS data as their primary data source for measurement,
however, some may also use claims data or other sources of internal data, to measure the
impact of their intervention(s).
If no other data or results are present, enter “not applicable” in the available field. Please note
that this field allows for both text and numerical data, so that quantitative and qualitative data
can be provided here.
E9. Analysis of Results or Findings
(Character Limit: 4,000)
At “E9. Analysis of Results or Findings,” provide a detailed analysis and description of the
CCIP results and findings, including what was achieved in relation to the project goal and the
significance of the demonstrated results. The analysis should reflect key aspects of the
intervention(s) employed (or other applicable elements of the plan section) that contribute to
the overall improvement and/or achievement of the target goal. Users with a Non-SNP
bundled CCIP may also use this field to describe any significant PBP-specific results where
appropriate.

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STEP 5
On the ACT Section (F) - F. Next Steps screen (Table III-5), describe the next steps for the
CCIP by providing details about the Action Plan and any revisions to the interventions,
changes in methodology, adjusted goal, and any other items of interest that occurred during
the first year reporting period. This includes information regarding the next steps for the
CCIP in the upcoming year. The MAO should also describe best practices and lessons
learned as applicable.
After completing Act sections F1 – F4, click Save & Next, which will take the user to the
CCIP Annual Updates Review screen...

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ACT Section (F) - F. Next Steps
G1. Action Plan
At “G1. Action Plan,” select any Action Plans that your CCIP will take in the implementation
year as a result of STUDY findings. Users may select Revise Intervention, Revise
Methodology, Change Goal, or Other. Please select all that apply.
Select Revise Intervention if any changes have been made to the intervention(s) identified in
the Plan submission, including deleting, modifying, or adding a new intervention. Provide an
explanation of those changes in the Action Plan Description and include a brief description of
how this revision is expected to help achieve your stated goal.
Select Revise Methodology if any changes have been made to the method/s used to collect
data or measure the effectiveness of a project intervention. Provide an explanation of those
changes in the Action Plan Description and include a brief description of how this revision is
expected to help achieve your stated goal.
Select Change Goal if the CCIP’s goal has changed. Provide the new goal in the Action Plan
Description and include an explanation of why you have decided to change the goal, including
a description of how the current interventions will help achieve the new goal.
Select Other if you have made any other changes to your CCIP. Provide a detailed
description of changes in the Action Plan Description. (Character Limit: 4,000)
If your CCIP has been successful thus far and you are on track to achieve planned outcomes
and therefore your MAO has no plans to change any activity, please select Other and state
your plans to keep the CCIP unchanged in the Action Plan Description.

G2. Action Plan Description
(Character Limit: 4,000)
At “G2. Action Plan Description,” describe the selected Action Plan(s) based on the results
and lessons learned to date. Include how the next steps will be implemented as well as how
this plan will work toward achieving the project goal. Include in the discussion details about
the proposed changes, whether or not these changes have already been implemented, and the
rationale behind the changes. The Annual Update reflects progress to date; however, it also
represents a snap shot in time. As such, the Action Plan may reflect revisions, e.g., increased
outreach efforts, that have already occurred during the first year of implementation, as well as
proposed revisions that will be implemented in the future as part of the next steps.

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G3. Describe "Best Practices”
(Character Limit: 4,000)
At “G3. Describe “Best Practices,” describe any identified Best Practices that have resulted
from the findings and that have worked well in producing positive outcomes. Include a
detailed description of any identified best practices including: how you determined best
practices(s), how those practices affected the CCIP, and how you will share the details of
those practices with others. If no Best Practice was found during the CY 2013
implementation year, please indicate “Not Applicable” in the field.
G4. Describe "Lessons Learned"
(Character Limit: 4,000)
At “G4. Describe “Lessons Learned,” describe any identified Lessons Learned, including a
summary of how the interventions implemented during the CY 2013 implementation year
impacted the results of the project, members, providers, and/or other stakeholders, whether
positive or negative.

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STEP 6
On the CCIP Annual Update Review screen (Table III-6) review all information for
accuracy.
Once the user confirms that the information related to the Annual Update section is accurate,
the user will select Submit to complete the submission process. Click Edit to return to the
Contract/Plan/Program Selection screens to edit any information. After clicking Submit,
the user will be taken to the Annual Update Submission Confirmation screen (Table III-7)
that includes the following message: “Your data has been submitted.”
Notes: If Edit option is selected on the CCIP Annual Update Review screen (Table III-6),
user will be able to reopen the Annual Update section at a later time (before the Annual
Update section submission window closes) to edit any information until the user is ready to
submit the final CCIP to CMS.
If Submit option is selected, the submission for the program created will be final and user
cannot edit the submitted topic.

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IV.

COPY

The Copy functionality allows users to Copy CCIP sections from one plan to another, as long
as certain conditions exist. In particular:



The Plan section from one CCIP may be copied to a second CCIP if the second CCIP
has no Plan section or only has a Plan section and no other sections.
When copying a section, the source and target sections cannot be for the same plan.

CCIP Copy Functions General Rules
#
1.

Source Criteria
Mandatory Topic

Target Criteria
Target topic not yet created
-

The title of the mandatory topic will be copied as a “Copy
of…” (Note that the mandatory topic will not be copied).
All data entered in the Enter/Edit pages of the source topic
will be copied.

Target mandatory topic not yet created
-

The title of the mandatory topic will be copied as a “Copy
of…” (Note that the mandatory topic will not be copied).
All data entered in the Enter/Edit pages of the source topic
will be copied.

Target topic created
-

The title will be retained for a topic created.
All data entered in the Enter/Edit pages of the source topic
will be copied.

Target mandatory topic created
-

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The title will be retained for a topic created.
All data entered in the Enter/Edit pages of the source topic
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STEP 1
As shown in Table IV-1, on the CCIP Start Page click on the Copy link on the Left
Navigation Bar to get to the Criteria Selection screen. (See Chapter I: Getting Started for
help getting to the CCIP Start Page.)

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STEP 2
On the Criteria Selection screen (Table IV-2) first select a section to copy.
Once the appropriate section is selected, the screen will automatically refresh to show
available SOURCE contracts.
 Select the SOURCE contract and the screen will again automatically refresh to show
available plans.
 Select the SOURCE plan and available CCIP topics will appear.
 Select the SOURCE CCIP topic to copy.
After selecting all sources, follow the same procedures to select the TARGET criteria. After
selecting all TARGET criteria, click Next to get to the Copy Verification screen.

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STEP 3
On the Copy Verification screen (Table IV-3) review all information for accuracy, and then
click Copy to get to the Copy Confirmation screen.
The Copy Verification screen included the following notes:
 Please remember to review the SOURCE data for accuracy before you copy the
information.
 The PLAN section is the only section that you can create a new topic for the TARGET
data.
 The TARGET information can still be edited for the Enter/Edit sections.
On the Copy Confirmation screen (Table IV-4) click OK to return to the Criteria Selection
screen.
Note: In order to submit a copied CCIP to CMS, the user must go through each section of the
Plan section and select Submit on the Plan Submission Verification screen (Table II-11).

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V. UPLOAD
Take the following steps to upload supporting documentation for the CCIP. All files must be
uploaded in .zip format that is NOT password protected.
Note:
File names must include the corresponding contract number, and plan id for SNP plans
(example: Z1234001). If your organization is uploading one document for multiple nonSNPs, please include "nonsnp" after the contract number and exclude the plan ids in the file
name (example: Z1234nonsnp).

STEP 1
As shown in Table V-1, on the CCIP Start Page click on the Upload link on the Left
Navigation Bar to get to the Criteria Selection screen. (See Chapter I: Getting Started for
help getting to the CCIP Start Page.)

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STEP 2
On the Contract/Plan/Topic Selection screen (Table V-2) first select a contract. Once the
contract is selected, the screen will automatically refresh to show available plans. Then select
a plan and the screen will again automatically refresh to show CCIP topics. Select an existing
topic.
After selecting the contract, plan and topic, select Browse to locate the .zip file being
uploaded. Then click Next to get to the Upload Confirmation screen (Table V-3).
Notes: Users may upload supporting documentation for a CCIP on the mandatory topic any
time before the CCIP submission window closes. Users may upload supporting
documentation for a CCIP on a secondary (or self-identified) topic, only after the Plan section
is completed and saved, but before the CCIP submission window closes.

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VI.

CCIP REPORTS

The CCIP Reports functionality allows users to access and view the Communications
Report, Score Report, and the Status History Report. The reports provide easy and quick
reference to CCIP communication emails, approval results, and the status of CCIP
submissions.
Take the following steps to generate reports for the CCIP.

STEP 1
As shown in Table VI-1, on the CCIP Start Page click on the CCIP Reports link on the Left
Navigation Bar to get to the CCIP Reports - Select a Report screen, Table VI-1. (See
Chapter I: Getting Started for help getting to the CCIP Start Page.)

STEP 2
On the CCIP Reports - Select a Report screen (Table VI-2) first select a report.

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COMMUNICATION REPORT
The Communications Report displays CCIP generated communication emails. Users can
only access the reports for those contracts that are associated with their User ID.

STEP 3
As shown in Table VI-3, select Communications Report then select Next to get to the
Communications Report contract selection screen.

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STEP 4
On the Communications Report contract selection screen (Table VI-4), select one or more
contracts then select Next to generate the report.
Note:
 To select more than one contract, hold down the while selecting the
contracts.
 By default, the most recent contract year is selected in the Filter by Year. User may
select a desired contract year to generate the report.

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STEP 5A
After reviewing information on the Communications Report Results screen (Table VI-5a),
users can view E-mail details.

STEP 5B
To view the “Subject” and “Message” details of an email, select View in the last column of
the Communications Report Results (Table VI-5a). A pop-up screen will appear (Table VI5b). After reviewing the data, select the Print link to print or Close to close the pop-up
screen.

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STATUS HISTORY REPORT
The Status History Report provides a history of the statuses of a CCIP submission and the
ability to view each submitted version of the CCIP.

STEP 6
As shown in Table VI-6, select the Status History Report option then select Next to get to
the Status History Report contract selection screen.

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STEP 7
On the Status History Report contract selection screen (Table VI-7), select one or more
contracts then select the Next button to get to the Status History Report Results screen.
Note:
 To select more than one contract, hold down the while selecting the
contracts.
 By default, the most recent contract year is selected in the Filter by Year. User may
select a desired contract year to generate the report.

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STEP 8A
After reviewing information on the Status History Report Results Screen (Table VI-8a),
users can view the details of the submitted CCIP.

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STEP 8B
To view the details of the submitted CCIP, select View in the last column of the Status
History Report Results (Table VI-8a). The Status History Report Detail screen (Table VI8b) will populate. After reviewing the data, select the Print link to print or Close to close the
pop-up screen.

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APPENDIX I: CONTACT
INFORMATION
Subject Matter

Name

Phone

Email Address / Web Address



HPMS
Technical
Help

HPMS Help Desk

800-220-2028

HPMS@cms.hhs.gov



Password
Reset
Requests

CMS Action
Desk

410-786-2580

N/A



HPMS User
Access
Questions

HPMS User
Access Mailbox

N/A

hpms_access@cms.hhs.gov



CCIP
Questions

CMS MA Quality
Improvement
Team Mailbox

N/A

MAQuality@cms.hhs.gov

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APPENDIX II: GLOSSARY OF TERMS
Action Plan

A defined or organized process or steps taken to achieve a particular goal
or to reduce the risk of future events.

Analysis

A systematic evaluation of the data and/or results of the project/program.

Benchmark

A point of reference by which something can be measured, compared, or
judged. It can be an industry standard or internal baseline against which a
program indicator is monitored and found to be above, below or
comparable to the benchmark.






Baseline Benchmark – Data obtained at the end of the current
reporting cycle as the standard of comparison for subsequent
reporting cycles. The first measure used as a point of reference in
which a project or program can be measured, compared, or
judged.
External benchmark – Data obtained from sources outside of the
MAO (e.g., national or regional benchmarks). At the end of the
measurement cycle, this data is used to measure internal results
against to determine the level of success or failure of the
program/project.
Internal benchmark - Data used from the plan’s own data
sources (e.g., administrative data or claims data) for comparison.

A set of interventions designed to improve the health of individuals who
Chronic Care
live with multiple or sufficiently severe chronic conditions, and includes
Improvement
Program (CCIP) patient identification and monitoring. Other programmatic elements may
include the use of evidence-based practice guidelines, collaborative
practice models involving physicians as well as support-service
providers, and patient self-management techniques. (Publication 100-16
Medicare Managed Care Manual, Chapter 5)
Evidence-based
Medicine

The practice of making clinical decisions using the best available
research evidence, clinical expertise, and patient values.

Intervention

The Agency for Healthcare Research and Quality (AHRQ) defines
intervention as “A change in process to a health care system, service, or
supplier, for the purpose of increasing the likelihood of optimal clinical
quality of care measured by positive health outcomes for individuals.”

Methodology

The means, technique, procedure, or method used to collect data or
measure the effectiveness of a program/project or intervention.

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Plan, Do, Study,
Act (PDSA)

A quality improvement model that is cyclical in nature and includes
planning, implementing, studying a change, and acting on the results of
that change.

Program/Project Cycle year refers to a logical sequence of activities to accomplish the
program or project’s goals or objectives. The CCIP cycle year and the
Cycle Year
QIP cycle year each begin on an established date. Together, each cycle of
PDSA is a full cycle year. Subsequent cycle years begin on the
anniversary of the beginning of the first program or project year. The
cycle year may be independent of the CMS review cycle.
Special Needs
Plan (SNP)

An MA coordinated care plan that limits enrollment to special needs
individuals who are 1) institutionalized, 2) dually eligible for Medicare
and Medicaid, or 3) diagnosed with a severe or disabling chronic
condition. (Publication 100-16 Medicare Managed Care Manual, Chapter
16b)

Target
Population/
Audience

A selected group of MA plan members that meet eligibility criteria for
participation in a CCIP.

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