QIO Program 13th SoW

QIO Program 13^th SoW 

The Centers for Medicare & Medicaid Services (CMS) has launched the 13th Scope of Work to support healthcare quality improvement and the Secretary's Make America Healthy Again (MAHA) initiative. As one of the largest federally funded quality improvement programs in the country, CMS directs Quality Improvement Organizations (QIOs) to collaborate with healthcare providers nationwide to improve outcomes for Medicare beneficiaries. The QIO Program has two core contract functions: case review and health care quality improvement support. Both functions are carried out through four initiatives:

• Two Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs) help people with Medicare and their families exercise their right to high-quality health care. They do this by managing quality of care concerns, conducting immediate advocacy and reviewing appeals of discharge or decisions to end Medicare-covered services. (May 2024 – April 2029)
• Seven Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) work directly with nursing homes, hospitals, and physician offices to improve the quality and safety of care for people with Medicare. (May 2025 – May 2030)
• The American Indian Alaska Native Healthcare Quality Initiative (AIANHQI) works directly with Indian Health Service (IHS) hospitals to improve the quality of health care for people with Medicare who are American Indian or Alaska Native. (January 2025 – May 2030)
• The Opioid Prescriber Safety & Support (OPSS) initiative provides national outreach and education to eligible providers to promote safe opioid prescribing practices and to spread knowledge of non-opioid pain management therapies.

Services Provided:

• Direct technical assistance and resources
• Advanced data analytics support
• Evidence-based intervention recommendations
• Customized training and education

Focus Areas: Disease prevention, quality and patient safety, chronic conditions management, behavioral health, emergency preparedness, care coordination, and workforce challenges.

How do QIOs improve health delivery, status, and cost?

Nationally, the QIO Program partners with leading organizations like the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and many others. QIOs also work with state, local, and tribal agencies, engaging them as partners in learning and action networks and improvement collaboratives that rapidly effect large-scale change for the better.

CMS QIN-QIO 13^th Scope of Work Contractors (2025 – 2030)

Quality Evaluation and Improvement Contracts Descriptions

CMS carries out important evaluation and improvement activities for public benefit and services programs to ensure Medicare and Medicaid beneficiaries receive cost effective high quality, evidence-based services, consistent with the principle of beneficence. CMS and the quality improvement contractors use patient identifiable information for program planning and outcomes assessment. Although the primary purpose of the Quality Improvement Organizations (QIO) program is to improve healthcare quality, evaluation activities sometimes produce generalizable knowledge (which might be interpreted by some as meeting the definition of human subjects’ research).

All of CMS’s QIO program contractors comply with strict privacy protection standards to safeguard identifiable information, including those related to the Federal Information Security Management Acts of 2002 and 2014, the Health Insurance Portability and Accountability Act, and regulations specific to the Quality Improvement Organization program (42 CFR 480).
 

The following QI project listing includes only QI projects that potentially qualify as human subjects research but qualify for an exemption and the corresponding common rule exemption for each such QI project:

• The work conducted under the contract, Network of Quality Improvement and Innovation Contractors (NQIIC) Independent Evaluation Contractor, for the 12th Statement of Work (12SoW). This contract collects data, conducts analysis, and develops reports to monitor progress toward 12SoW program goals and impact of program outcomes. This activity studies, evaluates, and improves a public benefit program and thereby falls under the 45 CFR 46.104(d)(5) exemption from human subjects research requirements.

For quality improvement projects that include human subjects research and do not meet the criteria for a common rule exemption, CMS will comply with Institutional Review Board (IRB) requirements.