Crosswalk - Qualifying Payment Arrangement Form

Revisions to MAQI Qualifying Arrangement Form - CMS-10673
Issue
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Page
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1

Purpose.

Maintain “may” as opposed to
changing to “will”.

2

1

Purpose.

Add a language as a third
paragraph in the purpose section
to support an independent
evaluation activities.

3

1

Deadlines.

4

2

5

2

6

5

MAQI
Participation
Identifying
Information.
MAQI
Participation
Identifying
Information.
Quality Measure
Use.

Change the submission period
from Oct. 8 – Nov. 8, 2018 to
Oct. 24 – Nov. 21, 2018.
Delete the first statement in
Section 1: A1 and maintained the
second sentence.

1

Section

Action to be Performed

Change “MAQI Participant” to
“Applicant” in Section 1: A2.
Add an Evaluation question to
the end of “Quality Measure use”
to support evaluation activities.

Changes to the Form

Reason for the Change

Maintained the word “may” instead of changing to
“will” in the first paragraph on two areas in the
purpose section for clarification.
Added this language as a third paragraph: “A
federally mandated independent evaluation will
be conducted of the MAQI demonstration.
Evaluation activities are aimed at understanding
the effects of the MAQI Demonstration. You may
be contacted to provide additional information.”

Revised for clarification purposes.

Changed the 30 day submission period to:
October 24 – November 21, 2018.

Revised to align the submission
period with MAQI Timeline.

Deleted “Are you reporting on behalf of more than
one MAQI participant? [Y/N] If yes,” and
maintained “Complete this section for each MAQI
participant for whom you are reporting.”
Changed MAQI Participant to “Applicant”.

Revised for clarification purposes.

Added this language as a new paragraph to
support evaluation activities:
Past Payment Arrangements (for informational
purposes only).

Revised to clarify data/information
needed to support evaluation
activities.

In 2017, did you participate in any Medicare
Advantage plan with requirements similar to those
described above? [Y/N] (This information will not
1

Revised to clarify data/information
needed to support evaluation
activities.

Revised for clarification purposes.

Issue
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Page
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7

7

8

7

9

9

10

1

Section

Action to be Performed

Changes to the Form

Reason for the Change

be used to determine eligibility for the MAQI
demonstration.)
Certification
Statement –
Third Party …
Certification
Statement – For
a third Party
submitting …
PRA Disclosure
Statement

Modify the second sentence so it
does not reference “section 1. A
or B” of the form.
Modify the second sentence for
clarity.

Top right corner
of the Form

Fill in the OMB approved number
and the expiration date.

Add the OMB four digit approval
number and the expiration date.

Changed the reference “section 1. A or B” of the
form to a statement ...”the MAQI participant
identifying information section of this form”.
Changed the “authorize [insert Third Party Name]
to submit this Form on my behalf.” to “am
authorized to submit this Form on behalf of the
MAQI Participant.”
Will need to add OMB approved number and the
expiration date in the PRA Disclosure Statement.
Fill in the OMB approved four digit number and
the expiration number on the top right corner of
the form.

2

Revised for clarification purposes.
Revised for clarification purposes.

Edit to include the OMB approved
number and the expiration date as
required by OMB.
To display the OMB approved
number and the expiration date as
required by OMB.