CMS Pub. 100-16, ch. 5, § 20

MAOs that offer one or more MA plans must have an ongoing Quality Improvement (QI)

program for each of their plans. The purpose of a QI program is to ensure that MAOs have the

necessary infrastructure to coordinate care, promote quality, performance, and efficiency on an

ongoing basis. The requirements for the QI program are based in regulation at 42 CFR§ 422.152.

For each plan, an MAO must:

1. Develop and implement a chronic care improvement program (CCIP) 42 CFR

§422.152(c);

2. Develop and implement a quality improvement project (QIP) 42 CFR §422.152(d);

3. Develop and maintain a health information system (42 CFR §422.152(f)(1));

4. Encourage providers to participate in CMS and HHS QI initiatives (42 CFR

§422.152(a)(3));

5. Implement a program review process for formal evaluation of the impact and

effectiveness of the QI Program at least annually (42 CFR §422.152(f)(2));

6. Correct all problems that come to its attention through internal surveillance, complaints

or other mechanisms (42 CFR §422.152(f)(3));

7. Contract with an approved Medicare Consumer Assessment of Health Providers and

Systems (CAHPS®) vendor to conduct the Medicare CAHPS® satisfaction survey of

Medicare enrollees (42 CFR §422.152(b)(5)); and,

8. Measure performance under the plan using standard measures required by CMS and

report its performance to CMS (42 CFR §422.152(e)(i)).

9. Develop, compile, evaluate, and report certain measures and other information to CMS,

its enrollees, and the general public. Responsible for safeguarding the confidentiality of

the doctor-patient relationship and report to CMS in the manner required cost of

operations, patterns of utilizations of services, and availability, accessibility, and

acceptability of Medicare approved and covered services (42 CFR §422.516(a)).

All MAOs, as part of their application to offer new MA products or expand the service area of an

existing product, must submit a written Quality Improvement Program Plan (QIPP). The QIPP

outlines the elements of an MAO’s QI Program and provides a framework for how a plan will

execute each of the QI program requirements stipulated above. QIPPs are submitted to CMS as

part of the contract and SNP application processes. QIPP templates are included in both the

contract and SNP applications.