HOS-M 2025 PACE Organization Survey Vendor Selection Form

HOS-M 2025 PACE Organization

Survey Vendor Selection Form

The Centers for Medicare & Medicaid Services (CMS) is contracted with the National Committee for Quality Assurance (NCQA) to oversee the administration of the Medicare Health Outcomes Survey—Modified (HOS-M) for Programs of All-Inclusive Care for the Elderly (PACE) organizations. CMS has also contracted with RTI International (RTI) to provide additional survey support in the administration of HOS-M, as well as data analysis.

All PACE organizations must select a CMS-approved HOS-M vendor and notify NCQA of their survey vendor selection by completing this form by Friday, April 25, 2025.

If you need to make changes after you have submitted this form, please do not submit a new form; contact the HOS-M Project Team (hos@ncqa.org) with the corresponding change.

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A list of CMS-approved HOS-M survey vendors can be found on the HOS website (https://www.hosonline.org/en/program-overview/hos-m-survey-vendors/).

For additional information on HOS-M 2025 survey administration requirements, please review the HOS-M 2025 Survey Administration Memo (https://www.hosonline.org/en/program-overview/survey-administration/).

Please contact the HOS-M Project Team (hos@ncqa.org) if you have any questions or difficulties with this form.

First and Last Name*

Enter the first and last name of the person submitting this form.

Telephone Number*

Enter the telephone number for the person submitting this form.

Email Address*

Enter the email address for the person submitting this form.

Instructions

Complete the fields below by selecting your PACE organization contract number, contact information, and survey vendor selection.

If you believe your PACE organization contract number is missing from this form in error, please contact the HOS-M Project Team (hos@ncqa.org).

How many PACE organizations are you submitting this form for?*

You may submit survey vendor selections for up to 5 PACE organizations using this form. If you are selecting a survey vendor for more than 5 PACE organizations, please submit an additional form.

Select

PACE Organization 1

CMS Contract Number and Name*

Click the field below to select or type your contract number from the dropdown menu.

Select

Contact Person*

Select

Contact Person at PACE Organization*

First and Last Name

Telephone Number of Contact Person at PACE Organization*

Email Address of Contact Person at PACE Organization*

PACE Organization 2

CMS Contract Number and Name*

Click the field below to select or type your contract number from the dropdown menu.

Select

Contact Person*

Select

Contact Person at PACE Organization*

First and Last Name

Telephone Number of Contact Person at PACE Organization*

Email Address of Contact Person at PACE Organization*

PACE Organization 3

CMS Contract Number and Name*

Click the field below to select or type your contract number from the dropdown menu.

Select

Contact Person*

Select

Contact Person at PACE Organization*

First and Last Name

Telephone Number of Contact Person at PACE Organization*

Email Address of Contact Person at PACE Organization*

PACE Organization 4

CMS Contract Number and Name*

Click the field below to select or type your contract number from the dropdown menu.

Select

Contact Person*

Select

Contact Person at PACE Organization*

First and Last Name

Telephone Number of Contact Person at PACE Organization*

Email Address of Contact Person at PACE Organization*

PACE Organization 5

CMS Contract Number and Name*

Click the field below to select or type your contract number from the dropdown menu.

Select

Contact Person*

Select

Contact Person at PACE Organization*

First and Last Name

Telephone Number of Contact Person at PACE Organization*

Email Address of Contact Person at PACE Organization*

Survey Vendor Selection

Survey Vendor*

Click on the field below to select a survey vendor.

Select

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