Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project

HEALTH PLAN MANAGEMENT SYSTEM
QUALITY IMPROVEMENT PROJECT (QIP)
USER GUIDE
LAST UPDATED 11/07/2013

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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 HPMS Using the CmsNet ........................................................................................................ 8
How to Access the HPMS QIP Module ................................................................................................................. 9
Gate .........................................................................................................................................................................10

II. Plan ........................................................................................................................................................................11
CMS Approval .....................................................................................................................................................27
III. Annual Update .................................................................................................................................................... 27
IV. Copy.......................................................................................................................................................................40
V. Upload.....................................................................................................................................................................44
VI. QIP Reports...........................................................................................................................................................41
Communication Report .........................................................................................................................................42
Status History Report ............................................................................................ Error! Bookmark not defined.50
Appendix I: Contact Information ...............................................................................................................................53
Appendix II: Glossary of Terms .................................................................................................................................55

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INTRODUCTION
All Medicare Advantage Organizations (MAOs) must conduct a Quality Improvement Project (QIP) as
part of their required Quality Improvement (QI) program described at 42 CFR §422.152. MAOs must
submit the QIP(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 QIP 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 QIP 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 QIP for each D-SNP offered.
The Health Plan Management System (HPMS) QIP Module serves as the means for MAOs to submit
and report on their QIPs to CMS. The QIP module allows MAOs to report on the QIP throughout the
entire life cycle of the QIP as defined below:


Plan (Chapter II) – Describes the processes, specifications, and outcome objectives used to
establish the QIP; The Plan section of the QIP 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 QIP implementation and each year thereafter for the
duration of the project (three years).
o Do - Describes how the QIP 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;
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.

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In CY 2012, CMS required that each MA plan conduct a QIP focused on reducing 30-day all-cause
hospital readmission rates. 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 3-year period.
Consistent with the CY 2012 requirements, MAOs are required to submit QIP Plan sections through the
HPMS Plan Reporting Module for their plans that are new in CY 2013. QIPs are to focus on the
reduction of 30-day all-cause hospital readmissions. MAOs will submit the same detailed information
for CY 2013 QIP Plan sections as they did for CY 2012. QIP 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 QIP Plan section in CY 2012 must submit their first Annual Update submission
in CY 2013 for each approved QIP. The purpose of the Annual Update is for MAOs to provide CMS
with information about their ongoing QIP(s) progress and experience with QIP implementation over
time. The Annual Update is a summary of those project assessments and provides a brief analysis of the
project’s results so far. MAOs are expected to retain all applicable QIP documentation to support their
Annual Update and CMS encourages ongoing project 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 QIP 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) QIP Module serves as the means for MAOs to submit
their QIP updates to CMS. The QIP 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. QIP
submission reviews will not take uploaded documents into consideration.
The QIP module also gives MAOs the ability to Copy QIP 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 QIP
submission window (open/close) timeframes.
This document provides an overview and technical instructions for accessing HPMS and navigating
through the QIP 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 QIP and
QI program requirements can be found on the CMS Quality Improvement Program Website at
http://www.cms.gov/Medicare/Health-Plans/Medicare-Advantage-Quality-ImprovementProgram/Overview.html.
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I. GETTING STARTED
ACCESSING HPMS
The HPMS QIP 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 QIP
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 contract numbers that they will work with in
HPMS.
To obtain a new CMS User ID complete a CMS User ID request form, download and print 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 I1).

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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 HPMS 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 QIP MODULE
All information requested as part of the HPMS QIP Module must be completed unless otherwise noted.

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

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

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

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II. PLAN
The PLAN section allows users to describe the QIP and outline the expectations, basic approach, and
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, well-organized, 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 QIP for the Plan section for 2013.
Once the Plan section submission window is closed for the CY 2013 QIP, 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 QIP Start Page click on the Plan link on the Left Navigation Bar to get
to the Contract/Plan/Topic Selection screen. (See above Chapter I: Getting Started for help getting to
the QIP 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 QIP 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 QIP 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 QIP topic that
has been established for that specific plan. The mandatory topic will appear with an “M” in front of it.
Select the “(M) Reducing All-Cause Hospital Readmissions” option. Then click Next, which will take
the user to the MAO Information & Background screen.

STEP 3
The MAO Information & Background screen (Table II-3) will default to MAO information that was
already entered in HPMS for that particular plan.

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.

On the MAO Information & Background screen, enter the name of the QIP Title, indicate whether the
project Focus is ‘Clinical’ or ‘Non-Clinical’, and if applicable, enter the ‘Domain.’
The name of the QIP Title must be unique for each QIP. A ‘Domain’ will represent an area of focus
for the QIP, and serves as a basis for development of the QIP topic that aligns with the National Quality
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Strategy to help the MAO develop QIPs that will result in improved enrollee satisfaction and health
outcomes. Then click Save & Next, which will take the user to the PLAN Section (C) screen.

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STEP 4
On the PLAN Section (C) screen (Table II-4), use the form displayed on the screen to describe the
applicable data sources used for problem identification. Note the additional fields in which the user may
include “other sources” of data that may apply (“Other source” has a character limit of 4,000). Then
click Save & Next, which will take the user to the PLAN Section (D) screen.

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STEP 5
On the PLAN Section (D) screen (Table II-5), use the form displayed on the screen to describe, if
applicable, any Model(s) of Care (MOC) elements the QIP is based on. Then click Save & Next, which
will take the user to the PLAN Section (E) screen.
Note: PLAN Section (D) is optional for SNPs, as the QIP may directly relate to the established MOC
for that SNP. However, this component of the module is not applicable to non-SNP plan types because
the MOC is unique to MA SNP products. If a SNP elects to implement a QIP based on an element of its
MOC, the user must complete this section and must identify the specific element of the MOC that the
project is focusing on by checking all that apply. If the SNP’s QIP is not based on the MOC or if this is
a non-SNP plan type, the user must select “Not Applicable.”

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STEP 6
On the PLAN Section (E) screen (Table II-6), use the form displayed on the screen to describe the QIP,
the member impact, the anticipated outcomes, and the rationale for the selection. Then click Save &
Next, which will take the user to the PLAN Section (F) screen.
After completing Plan sections E1 – I4, click Save & Next, which will take the user to the PLAN
Section (F) screen
E1. Description of the QIP
(Character Limit: 4,000)
For “E1. Description of the QIP,” provide a detailed and in-depth description of the QIP that includes:
1) the identified opportunity for improvement; 2) the methodology utilized by the plan to determine the
opportunity for improvement; 3) the data source(s) utilized in determining the QIP; 4) an estimate of the
number of MA plan individuals affected by the project; and, 5) the specific timeframes and percentages
where applicable.
E2. Impact on MemberFor “E2. Impact on Member,” provide the intent of the QIP by selecting
whether it impacts the MA plan population by improving health outcomes, improving member
satisfaction, or both. (Check all that apply)
If “Other” is selected, describe the impact in the text field (Character Limit: 4,000).
E3. Anticipated Outcomes
(Character Limit: 4,000)
For “E3. Anticipated Outcomes,” provide a detailed and in-depth description that is consistent with the
overall goal of the project and includes: 1) the clinical and/or non-clinical outcomes the MA plan
expects the project to achieve; 2) how the members will be positively impacted by the outcomes; 3) why
the outcomes are expected; and 4) the evidence or benchmark that was used to determine the anticipated
outcomes. This description should be consistent with the QIP topic and domain identified in Step 4
above.
E4. Rationale for Selection
(Character Limit: 4,000)
For “E4. Rationale for Selection,” provide a detailed and in-depth description that includes: 1) why the
project chosen is appropriate for the MA plan’s target population; 2) the clinical significance and/or
non-clinical significance of the project; 3) the incidence and/or prevalence of the opportunity for
improvement within the MA plan’s target population; 4) the impact the issue is currently having on the
MA plan population; and, 5) data, case studies, or specific examples that provide evidence of the
project’s relevancy to the target population.

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STEP 7
On the PLAN Section (F) screen (Table II-7) use the form displayed on the screen to describe any
previous attempts to address the problem that the QIP will be addressing. Then for each intervention,
provide information about the previous attempts; namely, the cycle/year, intervention, outcome
achieved, and priority assessed.
Plan Section (F) may or may not be applicable. If the MA plan has made no previous attempts to
address the identified topic (i.e. opportunity for improvement), the user must select “Not Applicable,” at
which point all other fields will be inaccessible.
After completing Plan sections F1 – F4 as applicable, click Save & Next, which will take the user to the
STUDY Section (G1) screen. F1. Cycle/Year
For “F1. Cycle/Year,” provide the project cycle year in which the issue was previously addressed.
F2. Intervention
(Character Limit: 4,000)
For “F2. Intervention,” provide a brief explanation of all interventions that were previously used to
address the issue or achieve the goal. The MA plan may enter up to three interventions that related to
the overall goal of the QIP.
F3. Outcome Achieved
(Character Limit: 4,000)
For “F3. Outcome Achieved,” provide a brief explanation of any clinical and/or non-clinical outcomes
achieved from previous intervention(s).
F4. Priority Assessed
(Character Limit: 4,000)
For “F4. Priority Assessed,” identify the level of priority assessed that was given to each intervention
used to address the issue. Identify the level of priority in terms of Low, Medium, or High where each is
defined as follows:
 Low priority does not require immediate attention.
 Medium priority requires watching the issue for progression.
 High priority requires immediate attention to resolve the issue.
After indicating the priority level, describe why the particular priority level was selected.
Note:
 The QIP 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 QIP, the user can delete an intervention by clicking Delete.
 If the QIP already includes more than one intervention, then upon clicking Save & Next the user
will go to the PLAN Section (F) 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 all interventions. After entering all information, the user will proceed to the
PLAN Section (G1) screen.

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STEP 8
On the PLAN Section (G1) screen (Table II-8), use the form displayed on the screen to describe the
target goal and benchmark. Then for each intervention, provide information about the planned
intervention, inclusion criteria, methodology, and timeframe.
One goal for each QIP is identified regardless of the number of intervention(s). All interventions should
be working toward achieving the same goal. Plans may submit up to three intervention(s) for their
‘Target Goal.’ In sections where interventions auto-populate, each intervention will be carried through.
‘Intervention’ will auto-populate from ‘Planned Intervention.’ (Note: Users cannot edit text that has
been auto-populated from a different section.)
G1a. Target Goal
(Character Limit: 4,000)
For “G1a. Target Goal,” provide a detailed and in-depth description consistent with the ‘Basis for
Selection’ section, including: 1) how the target goal will benefit the MA plan’s target population; 2)
how the target goal is measurable; 3) how the target goal is attainable within the set timeframe; and, 4)
numbers and/or percentages where applicable.
G1b. Benchmark
For “G1b. Benchmark,” identify whether the benchmark being used is baseline, internal, or external.
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 MAO will use the data obtained at the end of the
current reporting cycle as the standard comparison for subsequent reporting cycles in the QIP.
 Internal Benchmark – Select this option if the benchmark data is from the MA plan’s own data
sources (e.g., administrative data, claims data).
 External Benchmark – Select this option if the benchmark data is obtained from sources outside
of the MAO (e.g., national or regional benchmarks).
Note that only one type of benchmark may be selected for G1b. If the MA plan is using more than one
type of benchmark, select the primary benchmark type here and state the other benchmark sources in the
“G1c. Rationale” description below.
G1c. Rationale
(Character Limit: 4,000)
For “G1c. Rationale,” provide a detailed and in-depth description that includes: 1) why the goal was
chosen; 2) the evidence or method used to determine that the goal is appropriate to the QIP; 3) the
benchmark that was chosen to measure the goal; and, 4) how the benchmark relates to the goal.
G1d. Planned Intervention
(Character Limit: 4,000)
For “G1d. Planned Intervention,” provide a detailed and in-depth description consistent with the goal of
the project and includes: 1) an explanation of the planned intervention; 2) how the intervention is
capable of achieving the goal; 3) how the intervention relates to the 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
QIP by using ‘Add’ button.
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G1e. Inclusion Criteria
(Character Limit: 4,000)
For “G1e. Inclusion Criteria,” provide a detailed and in-depth description consistent with the overall
objective of the QIP and includes: 1) the demographic and/or clinical characteristics of the target
population; 2) the rationale for inclusion and exclusion of specific demographics; 3) the methodology
the plan will use to identify members for inclusion and exclusion; 4) the evidence and/or observations
that support the inclusion and exclusion rationale; and, 5) numbers and/or percentages where applicable.
“Inclusion Criteria” must be provided for each intervention. If the “Inclusion Criteria” are the same for
each intervention, the user is not required to repeat the information but must write “same as above” in
the text box provided.
G1f. Methodology
(Character Limit: 4,000)
For “G1f. Methodology,” provide a detailed, in depth description consistent with the goal and
intervention of the QIP and includes: 1) the description of the data that will be collected for the
measurement; 2) how the data will be collected; 3) how the data is capable of measuring outcomes; and,
4) the systematic method and frequency of data collection.
Measurement methodology is the means, technique, procedure, or method used to collect data and
measure the effect of an intervention. MAOs should describe the methodology used for each unique
intervention they plan to implement.
G1g. Timeframe
(Character Limit: 4,000)
For “G1g. Timeframe,” provide a detailed and in-depth description consistent with the overall QIP and
includes: 1) exact beginning and ending dates for the measurement cycle; 2) an explanation of how the
timeframe reflects an appropriate amount of time to complete the planned intervention; and, 3) the
rationale for the expected timeframe. MAOs should ensure that they list timeframes specific to each
intervention and that fit within their QIP project cycles.
Note:
 The QIP 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 QIP, the user can delete an intervention by clicking Delete.
 If the QIP already includes more than one intervention, then upon clicking Save & Next the user
will go to the PLAN Section (G1) screen for the second intervention (e.g. Intervention 2).
Continue entering all information and clicking Save & Next as appropriate until all applicable
information has been entered for each intervention. After entering all information, the user will
proceed to the PLAN Section (G2) screen.
After entering all information for all interventions, click Save & Next to get to the PLAN Section (G2)
screen.

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STEP 9
On the PLAN Section (G2) screen (Table II-9), use the form displayed on the screen to describe the risk
assessment.
After completing Plan sections G2b-G2d, click Save & Next, which will take the user to the PLAN
Section (H) screen.
G2b. Target Audience
(Character Limit: 4,000)
For “G2b. Target Audience,” provide a detailed and in-depth description that is consistent with
“Inclusion Criteria” and includes: 1) a description of the members potentially affected by the anticipated
barrier to the intervention(s); 2) how the barrier could affect the different demographic groups within
the target audience; 3) how members are expected to be affected; and, 4) numbers and percentages
where applicable.
G2c. Anticipated Barrier
(Character Limit: 4,000)
For “G2c. Anticipated Barrier,” provide a detailed and in-depth description that includes: 1) the
potential barrier to the success of the intervention; 2) why the barrier is anticipated; and 3) how the
barrier could prevent or hinder the goal from being reached.
G2d. Mitigation Plan
(Character Limit: 4,000)
A mitigation plan is an action plan designed to correct significant problems that could prevent the goal
from being reached in a QIP. For “G2d. Mitigation Plan,” provide a detailed and in-depth description
that includes: 1) the mitigation plan that will be implemented should the barrier occur; and, 2) how the
plan is expected to mitigate the barrier.
Note:
 If the QIP already includes more than one intervention, then upon clicking Save & Next the user
will go to the PLAN Section (G2) 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 all interventions. After entering all information, the user will proceed to the
PLAN Section (H) screen.
 Each ‘Intervention’ will auto-populate from ‘Planned Intervention.’ Users cannot edit text that
has been auto-populated from a different section.

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STEP 10
On the PLAN Section (H) 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 that is approving the project. This section must be completed in full. Once the
Medical Director or designee approves the QIP submission and clicks Save & Next, the user is taken to
the PLAN Submission Verification screen.

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. Click Edit to return to the screens to Contract/Plan/Topic Selection screen, and user may
select the topic created to edit. After clicking Submit the user will be taken to the PLAN Submission
Confirmation screen (Table II-12) that includes the following message: “Your data has been
submitted.”
Notes: If Edit option is selected, user may edit the topic created, and if Submit option is selected, the
submission for the topic created will be final and user cannot edit the submitted topic.
Reminder: The CY 2013 submission is complete at this step, as only the Plan section is to be submitted
for review.

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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 the 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 QIP.
Once the Plan section is approved, the user can begin to implement the QIP.

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III. ANNUAL UPDATE
The Annual Update section allows users to describe the implementation, progress and ongoing
activities of their QIP initiatives. The QIP 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 QIP 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 QIP, the user
will be unable to edit the Annual Update section.
 Only approved CY 2012 QIP Plan sections can submit the QIP 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 QIP Start Page click on the Annual Update link on the Left
Navigation Bar to get to the Contract/Plan/Topic Selection screen. (See above Chapter I: Getting
Started for help getting to the QIP Start Page.)

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STEP 2
On the Contract/Plan/Topic 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. Users must create an individual QIP 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 (e.g., 006, 007). However, users must create the same QIP for all of the non-SNP coordinated
care plans offered under a contract. 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 QIP topic that
has been established for that specific plan. The mandatory topic will appear with an “M” in front of it.
Select the “(M) Reducing All-Cause Hospital Readmissions” option. Then click Next, which will take
the user to the DO SECTION (I) screen.

STEP 3
On the DO Section (I) screen (Table III-3), describe any barrier(s) encountered, its effect(s), and
associated mitigation strategies. The information reported in the DO Section should reflect the
implementation of the QIP. Note that the MAO Information will default to MAO information that was
already entered in HPMS for that particular plan.
After completing Do sections I1 – I6 as applicable, click Save & Next, which will take the user to the
STUDY Section (J) screen.
I1. Goal
Will default to information that was entered in the approved CY 2012 PLAN section for that particular
contract.

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I2. Benchmark
Will default to information that was entered in the approved CY 2012 PLAN section for that particular
contract.
I3. Intervention
Will default to information that was entered in the approved CY 2012 PLAN section for that particular
contract.
I4. Target Audience
Will default to information that was entered in the approved CY 2012 PLAN section for that particular
contract.
I5. Timeframe
The timeframe is reflective of the reporting period and is specified as “January 1, 2013 through Annual
Update Period.” Because this is the first Annual Update in the 3-year QIP 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.
I6. Barriers Encountered
At “I6. 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 (J).
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 QIP has experienced particularly significant barriers on the PBP level, the MAO
should indicate the details of those barriers, including the affected PBP numbers. (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)

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STEP 4
On the STUDY Section (J) 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 (J) should
reflect an evaluation of the intervention(s) implemented during the first year of the QIP.
After completing Study sections J1 – J6, click Save & Next, which will take the user to the ACT
Section (K) screen.

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J1. Total Population
(Number)
At “J1. 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 (J6) below, as the total population included in
the study section may be different from what was estimated in the Plan section.
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.
J2. Numerator
(Number)
At “J2. 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.
J3. Denominator
(Number)
At “J3. Denominator,” provide the total number of plan members that met inclusion criteria and were
eligible to receive the project 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 QIP, 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.
J4. Results and/or Percentage
(Character Limit: 4,000)
At “J4. 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 QIP
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.

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J5. Other Data or Results
(Character Limit: 4,000)
At “J5. 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.
J6. Analysis of Results or Findings
(Character Limit: 4,000)
At “J6. Analysis of Results or Findings,” provide a detailed analysis and description of the QIP 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 QIP may also use this field to describe any
significant PBP-specific results where appropriate.

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STEP 5
On the ACT Section (K) screen (Table III-5), describe the next steps for the QIP 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 QIP in the upcoming year. The MAO should also describe best practices
and lessons learned as applicable.
After completing Act sections K1 – K4, click Save & Next, which will take the user to the QIP Annual
Updates Review screen.
K1. Action Plan
At “K1. Action Plan,” select any Action Plans that your QIP will take in the upcoming 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 QIP’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 QIP. Provide a detailed description of
changes in the Action Plan Description. (Character Limit: 4,000)
If your QIP 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 QIP
unchanged in the Action Plan Description.

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K2. Action Plan Description
(Character Limit: 4,000)
At “K2. 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.
K3. Describe “Best Practices”
(Character Limit: 4,000)
At “K3. Describe “Best Practices,” discuss 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 QIP, 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.
K4. Describe “Lessons Learned”
(Character Limit: 4,000)
At “K4. 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 QIP 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 QIP Annual Update data has been submitted.”

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Notes: If Edit option is selected on the QIP 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 QIP 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 QIP sections from one plan to another, as long as certain
conditions exist. In particular:



The Plan section from one QIP may be copied to a second QIP if the second QIP 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.

QIP 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
-

HPMS

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

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STEP 1
As shown in Table IV-1, on the QIP 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 QIP 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 QIP topics will appear.
 Select the SOURCE QIP topic to copy.
After selecting all SOURCE criteria, 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 (Table IV-4) screen.
The Copy Confirmation screen included the following notes:
 Please remember to review the SOURCE data for accuracy before you copy the information.
 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.

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V. UPLOAD
Take the following steps to upload supporting documentation for the QIP. All files must be uploaded in
.zip format.
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 non-SNPs,
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 QIP 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 QIP 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. Users must create a unique QIP
for each of the SNPs offered under a contract based on the SNP’s target population. The SNPs are
identified by their plan number. However, users may create the same QIP for all of the non-SNP
coordinated care plans offered under a contract. The non-SNP coordinated care plans under each
contract are identified as ‘Non-SNP.’ Select an existing topic.
After selecting the contract, plan and topic, select Browse to locate the .zip file being uploaded. Then
click Next, which will take the user to the Upload Confirmation screen (Table V-3).

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

STEP 1
As shown in Table VI-1, on the QIP Start Page click on the QIP Reports link on the Left Navigation
Bar to get to the QIP Reports - Select a Report screen, Table VI-2. (See Chapter I: Getting Started for
help getting to the QIP Start Page.)

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

COMMUNICATION REPORT
The Communications Report displays QIP 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 VI-5b). 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 QIP submission and the ability to
view each submitted version of the QIP.

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 QIP.

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STEP 8B
To view the details of the submitted QIP, select View in the last column of the Status History Report
Results (Table VI-8a). The Status History Report Detail screen (Table VI-8b) 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



QIP
Questions

CMS MA Quality
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.

Barrier

An obstruction or something that impedes; anything that prevents
progress or makes it difficult to achieve the desired goal or expected
outcome.

Baseline Year

The year the program/project is first implemented.

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.





Domain

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.

Topics that align with the National Quality Strategy to help the Medicare
Advantage Organization’s (MAO’s) develop QIPs that will result in
improved enrollee satisfaction and health outcomes.








Safer Patient Care
Patient Centered Care
Effective Care Coordination
Effective Prevention and Treatment
Promotion of Healthy Living
Effective Communication
Improving Affordability

Inclusion and
Exclusion
Criteria

Defined parameters used to determine whether an enrollee may or may
not be eligible to participate in the program/project or particular
intervention.

Intervention

The Agency for Healthcare Research and Quality (AHRQ) defines

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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.

Models of Care
(MOC)

A structured care management process and system that enables MA plans
to provide coordinated care for special needs patients. (Publication 10016 Medicare Managed Care Manual, Chapter 16b)

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.

Priority

Precedence, especially established by order of importance or urgency.




Low priority does not require immediate attention.
Medium priority requires watching the issue for progression of the
problem.
High priority requires immediate attention to resolve the problem.

Quality
Improvement
Project (QIP)

An organization’s initiative that focuses on specified clinical and nonclinical areas to improve enrollee satisfaction and health outcomes.
(Publication 100-16 Medicare Managed Care Manual, Chapter 5)

Mitigation Plan

A timely action to correct and prevent significant suspected or identified
systemic problems or barriers that could prevent the goal from being
reached.

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 QIP.

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