Last updated 2026-07-09

TL;DR
The Family Child Care Environment Rating Scale (FCCERS-3) is a 38-item observation tool that scores home daycare quality on a 1 to 7 scale across space, materials, routines, language, activities, and interactions. States use FCCERS scores in Quality Rating and Improvement Systems (QRIS), tiered subsidy rates, and grant eligibility. A 5.0 or above counts as "good" quality.
What is the Family Child Care Environment Rating Scale?
The Family Child Care Environment Rating Scale, almost always called FCCERS, is a standardized observation tool built for home-based child care. A trained assessor spends roughly two to three hours in your home, watches what actually happens, then scores what they saw across 38 items. Each item gets a score from 1 (inadequate) to 7 (excellent), and those scores average into subscale and total scores. [1]
The tool came out of the Frank Porter Graham Child Development Institute at the University of North Carolina at Chapel Hill. The current version, FCCERS-3, was published in 2015 by Thelma Harms, Debby Cryer, Richard Clifford, and Noreen Yazejian. It replaced FCCERS-R (revised edition, 2007). If your state or QRIS program still references FCCERS-R, you may see slightly different subscale labels, but the 1 to 7 scoring structure is the same. [1]
This is not a licensing inspection. FCCERS is not hunting for code violations or ratio problems. It measures the lived quality of a child's day: whether the space is set up for learning, whether caregivers talk with children in rich ways, whether routines feel safe and predictable. That distinction matters. A provider can pass every licensing inspection and still score a 2 on FCCERS. The reverse happens too. A plainly decorated home with warm, responsive caregiving can score a 6.
Frank Porter Graham licenses FCCERS through Teachers College Press. The scale, the training materials, and the scoring anchor videos are all commercial products. Your state's QRIS program or Child Care Resource and Referral (CCR&R) agency almost certainly owns copies and trains assessors, so most providers access it through those programs rather than buying it. [1]
What does FCCERS actually measure? The 38 items and subscales
FCCERS-3 sorts its 38 items into six subscales. Knowing what each one covers tells you where a morning observation will actually land.
| Subscale | Number of Items | What It Covers |
|---|---|---|
| Space and Furnishings | 6 | Indoor/outdoor play space, furniture fit for children, display of children's work, privacy, child-related display |
| Personal Care Routines | 7 | Greeting/departing, meals/snacks, nap/rest, diapering/toileting, health practices, safety practices |
| Listening and Talking | 3 | Helping children understand language, helping children use language, using books |
| Activities | 10 | Fine motor, art, music/movement, blocks, dramatic play, math/number, nature/science, technology, promoting acceptance of diversity, gross motor |
| Interaction | 5 | Supervision of children, provider-child interaction, discipline, interactions among children, provider-family interaction |
| Program Structure | 4 | Schedule, free play, group time, provisions for children with disabilities |
Activities carries 10 items, the most of any subscale, so it has the biggest pull on your total average. Providers who run a morning of free play in a well-arranged space with rich materials tend to beat those running tightly structured, teacher-directed days. That is by design. The research behind FCCERS links child-initiated, materials-rich play to language and cognitive gains in preschool-age children. [2]
Interaction is the hardest subscale to "prepare" for, because it captures the texture of how you actually talk with and respond to children. Assessors watch whether you get down to a child's level, whether you follow the child's conversational lead, and whether your discipline leans on redirection instead of commands or punishment. [1]
Here is the anchor logic. A score of 1 means the minimum requirements are not met. A 3 means minimal quality: basic safety, little more. A 5 is "good" and represents developmentally appropriate practice. A 7 is "excellent" and demands evidence of individualization, intentional planning, and active enrichment. Most programs land between 3 and 5 on a first formal assessment. [1]
How does FCCERS scoring work and what score is considered good?
FCCERS scoring is anchored at odd numbers: 1, 3, 5, and 7. Each anchor has specific observable indicators printed in the scale. The assessor marks "Yes" or "No" for each indicator, then assigns the item score based on the pattern of answers. Even scores (2, 4, 6) get assigned when an item clears one anchor but not the next. [1]
Your total score is the arithmetic mean of all 38 items. Because subscales hold different numbers of items, they weigh unequally. Activities (10 items) pulls harder than Listening and Talking (3 items).
The benchmarks people cite:
- 1.0 to 2.9: Inadequate
- 3.0 to 3.9: Minimal
- 4.0 to 4.9: Approaching good (some programs call this "developmental" or "basic")
- 5.0 to 5.9: Good
- 6.0 to 7.0: Excellent
QRIS research summarized by Child Trends puts the average FCCERS-R score across participating family child care homes around 4.0 to 4.3, meaning most homes sit near the line between minimal and approaching good. [3] A 5.0 genuinely sets a program apart.
Assessors are trained to fight the "halo effect," where a warm, likable provider picks up inflated scores because the assessor liked her. The Yes/No anchor system exists to make scoring behavioral instead of impressionistic. Even so, inter-rater reliability is imperfect. A NICHD study of home-based care reported intraclass correlations for FCCERS-R subscales in the range of roughly 0.72 to 0.89. That is acceptable, but do not be shocked by a 0.3 to 0.5 point swing between two trained assessors watching the same morning. [8]
How do states use FCCERS in licensing and QRIS programs?
States mostly use FCCERS inside their Quality Rating and Improvement Systems, and those ratings then feed subsidy rates and grant eligibility. The federal Child Care and Development Fund (CCDF) requires states to describe how they support quality improvement. The 2016 CCDF final rule stopped short of mandating QRIS but named quality rating as a strategy states use to hit their CCDF quality goals, and most states built QRIS programs around that. [4] FCCERS is the most common quality tool for family child care inside those systems.
The consequences vary by state but usually include:
Tiered subsidy reimbursement. Many states pay higher Child Care and Development Block Grant (CCDBG) reimbursement rates to providers at higher QRIS levels. If your QRIS level depends partly on an FCCERS score, a higher score turns straight into more dollars per subsidized child per day. [4]
Star ratings and public listing. Some states publish star ratings online for parents to see. FCCERS thresholds map to star levels. A 5.0 instead of a 4.8 can be the gap between a 3-star and a 4-star designation.
Grant eligibility. Quality improvement grants, equipment grants, and professional development funds often sit behind a minimum QRIS level, which may require a minimum FCCERS score. Read your state's QRIS manual before applying for any state grant. It takes ten minutes.
Licensing preferences. A smaller set of states use FCCERS results to reduce monitoring frequency for high-scoring homes. This is the exception, not the rule.
Child Care Aware of America reports that 38 states plus D.C. operate a voluntary or mandatory QRIS, and most of those serving family child care homes use FCCERS or FCCERS-R as the environmental tool. [5] Not sure whether your state uses it? Your CCR&R agency is the fastest way to find out. Child Care Aware keeps a national CCR&R directory at childcareaware.org. [5]
For providers working through michigan daycare licensing or any other state that ties QRIS participation to subsidy access, your FCCERS score is not optional. It moves your cash flow.
How is a FCCERS observation conducted? What should you expect?
A certified assessor schedules the visit for a typical morning of care and watches for two to three hours. The assessor holds a current reliability certificate, moves around the space taking notes, and usually does not interact with the children. Do not rearrange your program for the visit. Assessors are trained to spot artificial setups, and a room that looks curated but runs differently every other day falls apart once they watch the interactions.
At the end of the observation, many QRIS programs (not all) offer a feedback conference where the assessor walks through item-by-item scores. Some states hold that conference on a separate day. Ask ahead of time.
The assessor is not there to catch you. They document what they see. A few things carry more weight than providers expect:
- Transitions. How you handle the gap between activities. Waiting time is scored.
- Mealtime conversation. Meals are rich territory for the Listening and Talking subscale.
- What is on the walls. Not the decor quality. Whether children's own work hangs at their eye level, and whether the display reflects the children actually enrolled.
- Materials access. Anything in a locked cabinet or on a high shelf that a child cannot reach without asking does not count as available.
- Your tone during conflict. The assessor notes what you say, and how, when a child hits, cries, or refuses to comply.
Providers who have been through it say the feedback conference is the best part, even when the scores sting. A 3.4 with specific item-level notes hands you a real roadmap. A 5.1 with vague praise gives you nothing to work with.
What is the difference between FCCERS-R and FCCERS-3?
FCCERS-R (2007) had 38 items in 7 subscales. FCCERS-3 (2015) also has 38 items but reorganized them into 6 subscales, dropped the separate Provisions for Parents subscale and folded family engagement into Interaction, and updated several items around technology, STEM, and diversity. [1]
The change that matters most for scoring is the adjustment of the anchor indicators. Some items that earned a 5 under FCCERS-R now need more evidence to reach a 5 under FCCERS-3. Providers assessed under the old version and re-assessed under the new one sometimes see lower scores even though their practice never changed. That is a real source of frustration, and it is worth raising with your QRIS coordinator.
As of 2024, most states have moved to FCCERS-3 or have a transition plan underway, though the pace varies. A handful still use FCCERS-R for ongoing assessments of programs that entered QRIS under that version. If you are unsure which version applies to you, ask your CCR&R or QRIS office in writing so the answer is documented.
The 1 to 7 scale, the two-to-three-hour observation format, and the general scoring logic are identical across versions. Understand FCCERS-3 and you understand the older one well enough to prepare for either.
How can you actually improve your FCCERS score?
Raising your score is genuinely doable, and it does not take an expensive renovation. QRIS quality improvement research points to a few moves that reliably shift scores.
Get a practice assessment first. Many CCR&R agencies run coaching-based assessments that do not touch your official QRIS level. A practice run with feedback shows you your real scores before they count. This is the single highest-leverage move most home providers have, and it is usually free or heavily subsidized through state quality funds.
Fix materials organization and access. Activities has 10 items, and a lot of them turn on whether materials are organized, labeled, and reachable during free choice. Clear bins at child height, sorted by category (building materials, art supplies, nature objects), cost maybe $40 at a discount store and can move several items at once. This is one place where a small equipment spend pays back in score points.
Add open-ended art and science materials. The Art item and the Nature/Science item both reward child-directed exploration. Playdough children mix themselves, magnifying glasses with real objects, a small tray of sand or soil: these score based on availability, so having them out matters even on days no child picks them.
Record yourself during meals and transitions. Ten minutes of watching your own language patterns is uncomfortable and useful. Assessors score whether you use extended conversation (following up on what a child said, asking open questions, adding new vocabulary) against task-directed talk ("sit down," "eat your food"). Most providers talk more directively than they think.
Pursue a CDA credential or more coursework. Studies find an association between provider education and FCCERS scores, though the relationship is not linear and credential type matters. The Child Development Associate (CDA) credential covers the intentional practice FCCERS rewards. [6]
Providers who work with quality improvement coaching have shown average score gains of 0.3 to 0.8 points over a year of active engagement, per QRIS program evaluations. [3] That sounds small until you realize a 0.5 gain from 4.5 to 5.0 can trigger a higher subsidy tier or a star-level bump.
If you are tracking quality improvement alongside your compliance picture, the ChildCareComp compliance toolkit has checklists mapped to common QRIS requirements to help you line up FCCERS prep with your licensing documentation.
A structured preschool curriculum helps too. A written plan gives assessors evidence of intentional planning, which feeds the Program Structure subscale directly.
Does FCCERS affect child care subsidies and parent assistance programs?
Yes, and the link runs more directly than most providers realize. The Child Care and Development Block Grant (CCDBG) Act of 2014 requires states to reserve at least 8% of their CCDF funds for quality improvement. [4] States decide how to structure those activities, and many tie the dollars to QRIS participation, which often requires FCCERS assessment. So FCCERS sits upstream of subsidy policy twice: it helps set your QRIS tier, and your QRIS tier sets your reimbursement rate.
The reimbursement differential swings hard by state. Some states pay 5% more for a high QRIS tier. Others pay 20% or 25% more. In a home serving six children with four on subsidies, a 20% bump can add $8,000 to $15,000 in yearly revenue, depending on the state's base rate and age mix. Nobody has a clean national aggregate for this, but your state's CCDF plan (public and searchable at childcare.gov) lists the tiered rate differentials. [7]
For families, childcare subsidy access sometimes requires the provider to hold a minimum QRIS level. If your FCCERS score keeps you under that minimum, subsidized families may not be able to use their certificates with you. That is a direct enrollment and revenue hit.
The childcare tax credit for families is not FCCERS-gated. Provider quality ratings do increasingly show up in state-level tax credit and child care grant programs that run parallel to the federal credit.
How does FCCERS compare to other childcare quality tools?
FCCERS belongs to a family of Environment Rating Scales developed at Frank Porter Graham. The others are ECERS-3 (for center-based preschool classrooms), ITERS-3 (for center-based infant and toddler rooms), and SACERS-Updated (for school-age programs). [1]
| Tool | Setting | Age Range | Items |
|---|---|---|---|
| FCCERS-3 | Family child care home | Birth to 12 years | 38 |
| ECERS-3 | Center preschool classroom | 3 to 5 years | 35 |
| ITERS-3 | Center infant/toddler room | Birth to 36 months | 33 |
| SACERS-Updated | School-age program | 5 to 12 years | 49 |
FCCERS is the only one built for a mixed-age, home-based setting. A center with both an infant room and a preschool room needs ITERS-3 and ECERS-3 scored separately. A family child care home with infants, toddlers, and school-agers all present uses FCCERS-3 alone.
Some QRIS programs pair FCCERS with CLASS (Classroom Assessment Scoring System). CLASS looks only at interaction quality across three domains (Emotional Support, Classroom Organization, Instructional Support) and picks up teaching differences at the high end of the scale better than FCCERS does. FCCERS is broader, covering the physical environment and structural features CLASS ignores. The two tools work together, and some research suggests using both predicts child outcomes better than either alone. [2]
For providers running a formal creative curriculum for preschool, the fit between curriculum documentation and FCCERS Program Structure items is strong. Planning forms, daily schedules, and activity logs all give assessors evidence they can observe or request.
What is the research evidence behind FCCERS and child outcomes?
Do higher scores actually predict better outcomes for children? For FCCERS the evidence is supportive but more modest than the tool's wide adoption might suggest.
A 2014 meta-analysis in Early Childhood Research Quarterly looked at the link between Environment Rating Scale scores (ECERS-R, ITERS, and FCCERS together) and child outcomes. The authors found statistically significant positive associations between ERS scores and child language, literacy, and social competence, but the effect sizes were small (standardized effects roughly 0.10 to 0.25). [2] That does not make the tool invalid. Small effects in observational studies of real-world program variation are normal. It means a 1-point FCCERS gain alone will not dramatically bend a child's trajectory.
The NICHD Study of Early Child Care and Youth Development, which followed a large sample of children from birth into adolescence, used FCCERS as one quality measure for home-based care. Higher quality home care (measured partly by FCCERS) was associated with better language and pre-academic skills at 24 and 36 months, though family income and parenting quality carried substantially more weight. [8]
The practical read: FCCERS gains that come from real changes in practice (better language modeling, richer materials, more responsive interaction) are likely to help children. Gains from physical setup alone, with no shift in practice, are less likely to move outcomes. That is why good quality improvement coaches spend as much time on language and interaction as on the room.
The scale does not claim to measure everything. It cannot capture individual provider-child attachment, cultural responsiveness beyond how the tool operationalizes it, or the specific relationship between a provider and a family. Those limits are real, and the authors say so. [1]
Where can you get FCCERS training or access a certified assessor?
FCCERS reliability training is required for anyone conducting an official assessment, and it runs through the Environment Rating Scales Institute (ERSI) at Frank Porter Graham. [9] Assessors complete online training, practice scoring with anchor videos, and pass a reliability test before any official assessment. Training costs are usually covered by state agencies or CCR&R networks, not individual providers.
As a provider, your access points are:
Your state CCR&R agency. The fastest route. Most CCR&R agencies keep a roster of certified FCCERS assessors and can schedule an assessment, often free to the provider, as part of QRIS enrollment. Child Care Aware of America maintains a state CCR&R directory at childcareaware.org. [5]
Your state's QRIS office. Some states run QRIS assessments centrally instead of through CCR&R. Your state licensing agency (often inside the Department of Health, Education, or Human Services) can tell you who manages QRIS assessments.
QRIS coaching programs. Many states fund quality improvement coaches who are also certified FCCERS assessors. A coaching relationship usually includes practice assessments, item-level goal-setting, and follow-up. This format moves scores far better than a one-time visit.
Higher education partnerships. Some community colleges and universities with early childhood programs have faculty who hold FCCERS reliability and offer assessments for practicum or research. These are usually not QRIS-official but work well for practice.
If you are in a state where FCCERS drives subsidy rate increases, get on the calendar early. Wait times for formal assessments run 4 to 12 weeks in high-demand states with limited assessor capacity, and they spike in the fall when QRIS renewal cycles peak.
Building a solid free preschool curriculum into your daily schedule before the visit pays off. Documented planning supports several Program Structure items and shows the intentionality assessors can verify.
Common FCCERS misconceptions home providers should stop believing
"I need a perfect setup before I request an assessment." You do not. Many QRIS programs require an initial baseline assessment before you can touch improvement funds. Waiting until you feel ready means waiting on the resources built to help you improve. Request the assessment and treat the scores as your improvement plan.
"More toys means a higher score." Wrong in a specific way. FCCERS scores materials for organization, variety, age-appropriateness, and accessibility, not sheer volume. A cluttered room with 200 toys in bins children cannot reach scores lower than a tidy room with 40 well-organized, accessible materials across several categories.
"A high score means I'm a good person." FCCERS measures observable, behavioral quality of the environment and interactions. A provider can score a 6.0 and still be hard to work with. A provider can score a 3.5 and be deeply caring. The tool measures what it measures.
"Infants don't affect my score much." Personal Care Routines (7 items) leans heavily on diapering, feeding, and sleep safety. If you serve infants, those items carry major score weight and demand careful hygiene procedures, safe sleep positioning, and responsive feeding.
"The assessor just doesn't like me." Inter-rater reliability, imperfect as it is, is real. If you disagree with a score, most QRIS programs have a formal appeal or re-assessment process. Ask about it. The ERSI training process addresses observer bias head-on, and most assessors take the reliability requirement seriously.
Providers who treat FCCERS as feedback rather than a verdict tend to do better over time, in both their scores and their own satisfaction with the work.
Frequently asked questions
How long does a FCCERS observation take?
A formal FCCERS observation usually runs two to three hours, covering a complete morning of care. The assessor watches arrival, free play, structured activities, meals, transitions, and outdoor time if applicable. Some programs schedule a separate feedback conference afterward; others build 20 to 30 minutes of discussion into the same visit. Plan for a full half-day.
What is a passing FCCERS score?
There is no universal passing score, because FCCERS is not a pass/fail test. Most QRIS programs require a minimum of 3.5 to 4.0 to qualify for higher subsidy reimbursement tiers, and a 5.0 is widely cited as the threshold for "good" quality. A score below 3.0 on any subscale usually triggers a required improvement plan in QRIS programs.
Is FCCERS required for family child care licensing?
In most states, no. Basic home daycare licensing does not require FCCERS. It comes into play when you join your state's Quality Rating and Improvement System (QRIS), apply for quality-based grants, or want higher subsidy reimbursement rates. A handful of states made QRIS participation mandatory for subsidy-accepting providers, which makes FCCERS effectively required for those programs.
Can I do a FCCERS self-assessment?
You can buy a copy of FCCERS-3 through Teachers College Press and score your own environment as a learning exercise. Self-assessments do not count toward official QRIS ratings. Self-scoring helps you spot weak items before an official visit, but research consistently shows providers score themselves higher than trained assessors do, especially on interaction items.
How often do I need to be re-assessed with FCCERS?
Re-assessment frequency is set by your state's QRIS program, not by FCCERS itself. Most programs require re-assessment every one to three years to maintain your QRIS level and its benefits. Some states reassess annually if a provider received quality improvement funding. Check your state's QRIS participation agreement for the exact cycle.
Does FCCERS-3 cover mixed-age groups including infants and school-agers?
Yes. FCCERS-3 is built specifically for home-based programs serving children from birth through age 12 in mixed-age groups. It is the only Environment Rating Scale designed for this setting. Items address age-specific needs: safe sleep and diapering for infants, fine motor and literacy activities for preschoolers, and homework and peer interaction for school-agers.
What materials or changes should I make before a FCCERS assessment?
Focus on access and variety, not quantity. Organize materials into labeled, reachable bins at child height. Make sure art, blocks, dramatic play props, science materials, and books are all available during free play. Display children's work at their eye level. Check that your outdoor space has both active and quiet options. Do not rearrange for the visit and then revert; assessors come back for re-assessments.
Does my education level affect my FCCERS score?
Not directly. FCCERS scores observable behaviors and the environment, not your credentials. But research does find that providers with more early childhood education tend to score higher, especially on Interaction and Listening and Talking. Pursuing a CDA credential or child development coursework improves the practices that drive those scores. The credential itself never appears on the scoring sheet.
How does FCCERS relate to CCDF and federal child care funding?
The Child Care and Development Fund requires states to support quality improvement, and most states use QRIS as the mechanism. QRIS programs commonly use FCCERS as the assessment tool for family child care. Higher FCCERS scores drive higher QRIS tiers, and many states pay higher CCDBG reimbursement rates for higher tiers. The 2014 CCDBG reauthorization reinforced this by requiring states to reserve at least 8% of CCDF funds for quality activities.
What is the difference between FCCERS and CLASS?
FCCERS covers the full environment: physical space, materials, routines, activities, interactions, and program structure. CLASS measures only interaction quality across Emotional Support, Classroom Organization, and Instructional Support. CLASS picks up teaching quality differences at the high end better. Some states require both. FCCERS is broader; CLASS goes deeper on the instructional and emotional side of adult-child interaction.
Does a higher FCCERS score affect what I can charge parents?
Indirectly, yes. A higher QRIS level, driven partly by FCCERS scores, signals quality to parents in markets where ratings are public. Some providers charge modestly higher private-pay rates alongside higher ratings, though no required rate schedule ties to FCCERS. The more concrete financial effect runs through higher subsidy reimbursement in states with tiered rates.
Can an assessor score me lower because my home looks different from a center?
No. FCCERS-3 was written specifically for home settings. Items are calibrated for domestic spaces, not classroom architecture. A kitchen table used for meals and art is expected. A couch in the care space is fine. The tool assesses whether the home is arranged and used in ways that support children's development, not whether it looks like a school building.
What happens if I disagree with my FCCERS score?
Most QRIS programs have an appeal or re-assessment process. Ask your QRIS coordinator or CCR&R contact for the written appeal policy before the visit so you know your options. Common grounds include assessor error in recording indicators, items scored during an atypical event, or inter-rater reliability concerns. Having a second certified assessor score the same observation is the most common resolution.
Sources
- Frank Porter Graham Child Development Institute, UNC Chapel Hill: Environment Rating Scales: FCCERS-3 has 38 items scored 1–7 across 6 subscales; published 2015 by Harms, Cryer, Clifford, and Yazejian; licensed through Teachers College Press
- Brunsek et al. / Early Childhood Research Quarterly meta-analysis of Environment Rating Scales and child outcomes: Meta-analysis found statistically significant positive associations between ERS scores and child language, literacy, and social competence, with small standardized effects of 0.10–0.25
- Child Trends: Quality Rating and Improvement Systems (QRIS) Research and Evaluation: Average FCCERS-R scores in QRIS-participating family child care homes were approximately 4.0–4.3; coaching engagement associated with score gains of 0.3–0.8 points over one year
- Office of Child Care, HHS: Child Care and Development Fund (CCDF) Program Final Rule 2016: CCDBG Act of 2014 requires states to reserve at least 8% of CCDF funds for quality improvement; CCDF final rule named quality rating as a quality improvement strategy; tiered reimbursement rates for higher QRIS levels
- Child Care Aware of America: State Child Care Licensing and QRIS Overview: 38 states plus D.C. operate a voluntary or mandatory QRIS; majority of those serving family child care homes use FCCERS or FCCERS-R as the environmental assessment tool
- Council for Professional Recognition: CDA Credential and Child Care Quality: Multiple studies find association between provider education level including CDA credential and higher ERS scores, particularly on interaction subscales
- Office of Child Care, HHS: Child Care and Development Fund State Plans: State CCDF plans are publicly available and list tiered reimbursement rate differentials for QRIS participation
- NICHD Study of Early Child Care and Youth Development (SECCYD), NIH: NICHD SECCYD used FCCERS as a quality measure for home-based care; higher quality home care associated with better language and pre-academic skills at 24 and 36 months; FCCERS-R subscale intraclass correlations reported around 0.72–0.89
- Environment Rating Scales Institute (ERSI), Frank Porter Graham: Assessor Training and Reliability: ERSI requires online training, practice scoring with anchor videos, and reliability test passage before assessors conduct official FCCERS assessments
- U.S. Department of Health and Human Services, Office of Child Care: CCDBG Reauthorization 2014: CCDBG Act of 2014 reauthorization reinforced quality improvement requirements and tiered reimbursement structures linked to QRIS participation