HOS 2025 MAO and FIDE SNP Survey Vendor Selection Form

HOS 2025 MAO and FIDE SNP 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 HEDIS® Medicare Health Outcomes Survey (HOS).

All Medicare Advantage Organizations (MAOs) must select a CMS-approved HOS vendor and notify NCQA of their survey vendor selection by submitting 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 Project Team (hos@ncqa.org) with the corresponding change.

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

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

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

Are you submitting survey vendor selections for Quality Reporting (Cohort 28 Baseline and/or Cohort 26 Follow-Up), FIDE SNP reporting, or both?*

Select all that apply.

Cohort 28 Baseline and/or Cohort 26 Follow-Up

FIDE SNP

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.

Cohort 28 Baseline and Cohort 26 Follow-Up Survey Vendor Selection

This section of the form is to submit a survey vendor selection for Cohort 28 Baseline and/or Cohort 26 Follow-Up ONLY.

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

Note: Please see Voluntary FIDE SNP section below to confirm FIDE SNP survey and survey vendor selections.

How many contracts are you submitting this form for?*

You may submit survey vendor selections for up to 9 MA contracts using this form. If you are selecting a survey vendor for more than 9 contracts, please submit an additional form.

Select

Contract 1

CMS Contract Number and Name*

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

Select

Cohort Administration*

Check all that apply.

Cohort 28 Baseline

Cohort 26 Follow-Up

Optional Oversampling Percentage

Provide oversampling requests in whole percentages (e.g., 33%).

Note: Oversampling can occur only at the contract level for Baseline only.

Contact Person*

Is the primary contact person for this contract the same as the person submitting this form?

Select

Contact Person Name*

First and Last Name

Telephone Number*

Email Address*

Contract 2

CMS Contract Number and Name*

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

Select

Cohort Administration*

Check all that apply.

Cohort 28 Baseline

Cohort 26 Follow-Up

Optional Oversampling Percentage

Provide oversampling requests in whole percentages (e.g., 33%).

Note: Oversampling can occur only at the contract level for Baseline only.

Contact Person*

Is the primary contact person for this contract the same as the person submitting this form?

Select

Contact Person*

Telephone Number*

Email Address*

Contract 3

CMS Contract Number and Name*

Select

Cohort Administration*

Check all that apply.

Cohort 28 Baseline

Cohort 26 Follow-Up

Optional Oversampling Percentage

Provide oversampling requests in whole percentages (e.g., 33%).

Note: Oversampling can occur only at the contract level for Baseline only.

Contact Person*

Is the primary contact person for this contract the same as the person submitting this form?

Select

Contact Person*

Telephone Number*

Email Address*

Contract 4

CMS Contract Number and Name*

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

Select

Cohort Administration*

Check all that apply.

Cohort 28 Baseline

Cohort 26 Follow-Up

Optional Oversampling Percentage

Provide oversampling requests in whole percentages (e.g., 33%).

Note: Oversampling can occur only at the contract level for Baseline only.

Contact Person*

Is the primary contact person for this contract the same as the person submitting this form?

Select

Contact Person*

Telephone Number*

Email Address*

Contract 5

CMS Contract Number and Name*

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

Select

Cohort Administration*

Check all that apply.

Cohort 28 Baseline

Cohort 26 Follow-Up

Optional Oversampling Percentage

Provide oversampling requests in whole percentages (e.g., 33%).

Note: Oversampling can occur only at the contract level for Baseline only.

Contact Person*

Is the primary contact person for this contract the same as the person submitting this form?

Select

Contact Person*

Telephone Number*

Email Address*

Contract 6

CMS Contract Number and Name*

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

Select

Cohort Administration*

Check all that apply.

Cohort 28 Baseline

Cohort 26 Follow-Up

Optional Oversampling Percentage

Provide oversampling requests in whole percentages (e.g., 33%).

Note: Oversampling can occur only at the contract level for Baseline only.

Contact Person*

Is the primary contact person for this contract the same as the person submitting this form?

Select

Contact Person*

First and Last Name

Telephone Number*

Email Address*

Contract 7

CMS Contract Number and Name*

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

Select

Cohort Administration*

Check all that apply.

Cohort 28 Baseline

Cohort 26 Follow-Up

Optional Oversampling Percentage

Provide oversampling requests in whole percentages (e.g., 33%).

Note: Oversampling can occur only at the contract level for Baseline only.

Contact Person*

Is the primary contact person for this contract the same as the person submitting this form?

Select

Contact Person*

Telephone Number*

Email Address*

Contract 8

CMS Contract Number and Name*

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

Select

Cohort Administration*

Check all that apply.

Cohort 28 Baseline

Cohort 26 Follow-Up

Optional Oversampling Percentage

Provide oversampling requests in whole percentages (e.g., 33%).

Note: Oversampling can occur only at the contract level for Baseline only.

Contact Person*

Is the primary contact person for this contract the same as the person submitting this form?

Select or enter value

Contact Person*

Telephone Number*

Email Address*

Contract 9

CMS Contract Number and Name*

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

Select

Cohort Administration*

Check all that apply.

Cohort 28 Baseline

Cohort 26 Follow-Up

Optional Oversampling Percentage

Provide oversampling requests in whole percentages (e.g., 33%).

Note: Oversampling can occur only at the contract level for Baseline only.

Contact Person*

Is the primary contact person for this contract the same as the person submitting this form?

Select

Contact Person*

Telephone Number*

Email Address*

Survey Vendor*

CMS Contract Number and FIDE SNP PBP ID*

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

Select

Frailty Survey*

Select

Survey Vendor*

Select or enter value

Survey Vendor*

Select

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