Form CMS-10371 Outcome Metric – SBM Exchange Metrics

Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges

0938-1119. (Outcome Metric) SBM Exchange Metrics 20130829 pg layout.xlsx

Start-up Outcomes Metrics - Quarterly Reports

OMB: 0938-1119

Document [xlsx]
Download: xlsx | pdf

Overview

Table of Contents
Glossary of Breakouts
Crnt hth cvg
MCAID CHIP Elg
QHP App Elg
QHP Enr
Conversion
APTC
Fin Assist Det Time
Effectuated Time
QHP eligible-assist
Appeals
SHOP
Complaints


Sheet 1: Table of Contents

Outcomes Metrics: Draft Layout for State's Data Submission.








This document is the submission template for states with state based marketplaces to submit data to the federal government. This format does not require the submission of individual-level, granular data. The data will provide an overview of the applications submitted and eligibility determinations in the initial years of operations.




Data in this layout is specific to medical QHPs (not dental or vision) and coverage offered through the marketplaces (not Medicaid or CHIP coverage). The one exception is the SHOP-specific data elements which specify if the coverage is medical or dental.




If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.

Data that becomes reportable in the future should be reported beginning in the quarter in which the data are captured (and thus reportable). Data will not be reported retroactively.





Additional information about submission process will be sent separately. The first reporting date is February 1, 2014. Additional information about submission of test data and final data will be distributed separately at a later date. Questions should be directed to Christina Daw at [email protected].
























To populate data layout, first select from the following drop boxes:








State (please select)





Reference Period (please select)





Data Type: New or Modification (please select)

























Metric No. Tab Name Description of Tab Contents Reporting Frequency





n/a Glossary Glossary with detail about data breakouts n/a





1 Crnt. Hth cvg Current health insurance coverage at time of application (applications for financial assistance only) Quarterly





2 MCAID CHIP Elg Medicaid and CHIP eligibility assessments and determinations by the SBM Quarterly





3 QHP App Elg QHP Applications and Eligibility Quarterly





4 QHP Enr QHP Enrollment Quarterly





5 Conversion Allows for understanding of conversion rate from application to coverage Quarterly





6 APTC APTC eligible amount and percent APTC selected Quarterly





7 Fin Assist Det Time Median Time to Eligibility Determination for Financial Assistance Quarterly





8 Effectuated Time Median Time to Effectuated Enrollment Quarterly





9 QHP eligible-assist QHP eligible application submissions by type of assistance Quarterly





10 SHOP SHOP Quarterly





11 Appeals Efficiency of eligibility appeals Quarterly





12 Complaints Type and number of complaints submitted Quarterly















PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average [Insert Time (hours or minutes)] per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE.















































































Sheet 2: Glossary of Breakouts

Glossary of Data Breakout Terms for Marketplace Outcomes Metrics Reported by States
Age Age of individual as of most recent effective enrollment date:
<18 years
18-25
26-34
35-44
45-54
55-64
≥65
Application Assistance Describes whether individuals received assistance with either submission of application for QHP enrollment or with selection of a QHP.
1) Any (i.e. at least one type of the assistors list below)
2) None (i.e., no recorded assistance)

Detailed assistance data is collected on tab labeled "QHP eligible- assist." CCIIO recognizes that some assistance is provided but not recorded, and therefore cannot be reported. Also, not all states have each of these types of asssistance. We are not distinguishing between certified and non-certified assistors; they are considered equivalent for the purposes of this layout. Individuals may have more than one type of assistance.
- Navigator
- In-Person Assistor (IPA)
- Certified Application Councelor (CAC)
- Broker (includes Agents and Web Brokers)
- Authorized Representative
- Other (includes Community Health Center and other types of assistance not categorized above)
AV Level AV Level refers to the actuarial value of Cost-Sharing Reduction. Tribe members are eligibile for no cost-sharing and all other enrollees qualify for an AV level based on FPL. The categories are:
- ≥100 - ≤150% (not tribe member)
- >150 - ≤200% (not tribe member)
- >200 - ≤250% (not tribe member)
- >250- ≤400% (not tribe member)
- Tribe member (MAGI is <300% FPL)
- No CSR, APTC only
Channel Describes channel used to submit the enrollee's application. Applicants cannot have multiple channels for initial application submission. This metric does not collect data on other channels that may be used to provide assistance during the application process or to provide additional information in the verification process.
1) web (i.e. online submission by the applicant)
2) phone
3) paper (i.e. mailed or hand-delivered)
4) other/unknown (includes direct enrollment through an issuer, transfer from Medicaid program, applicants walking in and applying in-person. unknown in this case means it is not possible to distinguish between application submitted via web, phone, or in paper)

- scenario 1: applicant seeks assistance in person from IPA. IPA populates online application on behalf of the individual. this would be a web application
- scenario 2: applicant submits application online but the applicaiton requires follow-up before eligibility determination. additional info provided via the phone. this would be a web application
- scenario 3: applicant completes paper application, calling IPA for assistance before putting the application in the mail. this would be a paper application.
- scenario 4: applicant completes paper application, submits it to the state where it is entered into the system electronically. state does not track that initial application was in paper form. this would be other/unknown.
-scenario 5: applicant begins web application, calls call center with questions and ends up submitting application through the call center. this would be a phone application
Channel Roll-up Channel Roll-Up is based on the detailed Channel data breakout and used for metrics related to submission of incomplete applications.
- Electronic: Applications where data is provided through the web portal by the applicant or inputted into the system electronically by call center staff or other assistors.
- Paper: Applications which were submitted by hand or by mail on paper
- Other/Unknown: States that cannot determine the channel used to submit an incomplete application should use the unknown option.
FPL FPL (Federal Poverty Level) is calculated based on the projected, total, annual modified adjusted gross income (MAGI) for the taxpayer’s family. FPL is based on the same MAGI as the SBM uses to determine eligibility of APTC.
- MAGI includes the sum of the income of the taxpayer and the lawfully present individuals for whom the taxpayer properly claims a deduction for personal exemption for the taxable year. For additional information see Health Insurance Premium Tax Credit, 77 Fed. Reg. 30377 (amending 26 CFR pts. 1 and 602). May 23, 2012. (http://www.gpo.gov/fdsys/pkg/FR-2012-05-23/pdf/2012-12421.pdf).
- To report FPL, MAGI should be compared to the HHS poverty guidelines (current levels found here http://aspe.hhs.gov/poverty/13poverty.cfm), which is adjusted for the size of the family and state of residence.
- For the purposes of the SBM Supplemental Data Submission, MAGI may or may not be verified. States should report FPL based on incomes as of the most recent eligibility determination.
- For individuals that do not request an eligibility determination for financial assistance, MAGI may not be available. If MAGI is unavailable, populate the cell for the number of people with unknown FPL and enter -888 for each FPL category to signal data unavailable. Entering zero would signify no individuals at that income level.

The breakouts of FPL based on annual household income are:
1) <100%
2) ≥100 - ≤138%
3) >138 - ≤150%
4) >150 - ≤200%
5) >200 - ≤250%
6) >250 - ≤300%
7) >300- ≤400%
8) >400%
9) unknown
Group Size- Employees on Roster There are two group size breakouts. The "Group Size- Employees on Roster" is the number of employees on the roster/census that the employer submits when applying to the SHOP:
1 employee
2-5 employees
6-9 employees
10-24 employees
25-49 employees
50-74 employees
75-100 employees
Group Size- Enrolled Employees There are two group size breakouts. The "Group Size- Enrolleed Employees" is the number of employees that are enrolled in the SHOP as of the last day in the reference period:
1 employee
2-5 employees
6-9 employees
10-24 employees
25-49 employees
50-74 employees
75-100 employees
Policy Structure Describes the number individuals enrolled in QHP coverage within a single policy . This demographic variable does not reflect the number of individuals on the initial application or within the residential unit. The breakouts are:
1) single (adult policyholder)
2) single (adult policyholder) + 1 spouse/partner
3) single (adult policyholder) + 1 child
3) single (adult policyholder) + 2 or more dependents (spouse/partner or child)
4) child-only

- scenario 1: household includes two adults and two children (age 15 and 22). Father is covered through one QHP, mother and both children covered through another QHP. this is single and single + 2 or more dependents
- scenario 2: mother purchases child-only policy through marketplace for her 5 year old daughter. this is child-only policy
- scenario 3: mother seeks coverage for herself and daughter through the Marketplace. daughter is eligible for CHIP and enrolls. Mother purchases coverage through a QHP. This is single policy.
Metal Tier Metal tier associated with a health plan:
Catastrophic
Bronze
Silver
Gold
Platinum

Sheet 3: Crnt hth cvg

Current health insurance coverage at time of application (individuals found eligible for financial assistance only)






Description: Data used to report the health insurance coverage of individuals found eligible for financial assistance with QHP coverage (i.e., APTC/CSR). Insurance coverage is at the time that application is submitted. Individuals may have multiple types of insurance coverage on the application (particularly if submitting a family application) and can be included in multiple insurance categories.
Unit: Number of Individuals (i.e. number of covered lives)






Population Included: Individuals determined eligible for financial assistance (either provisional or final eligibility determination) during the reference period. Include individuals that have been determined eligible but may not have selected a QHP or paid an initial premium. Metric excludes individuals that were not determined eligible for financial assistance (i.e. determined ineligible or no determination took place)
Source for Data Breakouts: Most recent eligibility determination. If individual has not yet received final eligibility determination, report data from provisional eligibility determination.
First Reference Period: 10/1/2013-12/31/2013






Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.


















State
(please select)




Reference Period
(please select)




Data type
(please select)












# Data Element Data Element Description Data Breakouts
(for more info, see Glossary tab)
Data Element Name Data Type Data from State
Individual Marketplace (SBM)- Does not include SHOP
1 Individuals Not Enrolled in Any Coverage When Application Submitted Among individuals determined eligible for financial assistance with coverage through the SBM, number of individuals that did not have any of the types of coverage listed (i.e., likely uninsured) FPL <100% CURRENTCOV_UNINS_FPL1 Number
2 ≥100 - ≤138% CURRENTCOV_UNINS_FPL2 Number
3 >138 - ≤150% CURRENTCOV_UNINS_FPL3 Number
4 >150 - ≤200% CURRENTCOV_UNINS_FPL4 Number
5 >200 - ≤250% CURRENTCOV_UNINS_FPL5 Number
6 >250 - ≤300% CURRENTCOV_UNINS_FPL6 Number
7 >300- ≤400% CURRENTCOV_UNINS_FPL7 Number
8 unknown CURRENTCOV_UNINS_FPL9 Number
9 Total CURRENTCOV_UNINS_TOTAL Number
10 Individuals Enrolled in Employer-Based Coverage When Application Submitted Among individuals determined eligible for financial assistance with coverage through the SBM, number of individuals enrolled in employer-based coverage (aka employer-sponsored insurance or ESI) at the time the application was submitted FPL <100% CURRENTCOV_EMP_FPL1 Number
11 ≥100 - ≤138% CURRENTCOV_EMP_FPL2 Number
12 >138 - ≤150% CURRENTCOV_EMP_FPL3 Number
13 >150 - ≤200% CURRENTCOV_EMP_FPL4 Number
14 >200 - ≤250% CURRENTCOV_EMP_FPL5 Number
15 >250 - ≤300% CURRENTCOV_EMP_FPL6 Number
16 >300- ≤400% CURRENTCOV_EMP_FPL7 Number
17 unknown CURRENTCOV_EMP_FPL9 Number
18 Total CURRENTCOV_EMP_TOTAL Number
19 Individuals Enrolled in Medicaid/CHIP When Application Submitted Among individuals determined eligible for financial assistance with coverage through the SBM, number of individuals enrolled in Medicaid or CHIP at the time the application was submitted FPL <100% CURRENTCOV_MCAID_FPL1 Number
20 ≥100 - ≤138% CURRENTCOV_MCAID_FPL2 Number
21 >138 - ≤150% CURRENTCOV_MCAID_FPL3 Number
22 >150 - ≤200% CURRENTCOV_MCAID_FPL4 Number
23 >200 - ≤250% CURRENTCOV_MCAID_FPL5 Number
24 >250 - ≤300% CURRENTCOV_MCAID_FPL6 Number
25 >300- ≤400% CURRENTCOV_MCAID_FPL7 Number
26 unknown CURRENTCOV_MCAID_FPL9 Number
27 Total CURRENTCOV_MCAID_TOTAL Number
28 Individuals Enrolled in Medicare When Application Submitted Among individuals determined eligible for financial assistance with coverage through the SBM, number of individuals enrolled in Medicare at the time the application was submitted FPL <100% CURRENTCOV_MCARE_FPL1 Number
29 ≥100 - ≤138% CURRENTCOV_MCARE_FPL2 Number
30 >138 - ≤150% CURRENTCOV_MCARE_FPL3 Number
31 >150 - ≤200% CURRENTCOV_MCARE_FPL4 Number
32 >200 - ≤250% CURRENTCOV_MCARE_FPL5 Number
33 >250 - ≤300% CURRENTCOV_MCARE_FPL6 Number
34 >300- ≤400% CURRENTCOV_MCARE_FPL7 Number
35 unknown CURRENTCOV_MCARE_FPL9 Number
36 Total CURRENTCOV_MCARE_TOTAL Number
37 Individuals Enrolled in TRICARE When Application Submitted Among individuals determined eligible for financial assistance with coverage through the SBM, number of individuals enrolled in TRICARE at the time the application was submitted FPL <100% CURRENTCOV_TRI_FPL1 Number
38 ≥100 - ≤138% CURRENTCOV_TRI_FPL2 Number
39 >138 - ≤150% CURRENTCOV_TRI_FPL3 Number
40 >150 - ≤200% CURRENTCOV_TRI_FPL4 Number
41 >200 - ≤250% CURRENTCOV_TRI_FPL5 Number
42 >250 - ≤300% CURRENTCOV_TRI_FPL6 Number
43 >300- ≤400% CURRENTCOV_TRI_FPL7 Number
44 unknown CURRENTCOV_TRI_FPL9 Number
45 Total CURRENTCOV_TRI_TOTAL Number
46 Individuals Enrolled in Peace Corp coverage When Application Submitted Among individuals determined eligible for financial assistance with coverage through the SBM, number of individuals enrolled in Peace Corp coverage at the time the application was submitted FPL <100% CURRENTCOV_PEACE_FPL1 Number
47 ≥100 - ≤138% CURRENTCOV_PEACE_FPL2 Number
48 >138 - ≤150% CURRENTCOV_PEACE_FPL3 Number
49 >150 - ≤200% CURRENTCOV_PEACE_FPL4 Number
50 >200 - ≤250% CURRENTCOV_PEACE_FPL5 Number
51 >250 - ≤300% CURRENTCOV_PEACE_FPL6 Number
52 >300- ≤400% CURRENTCOV_PEACE_FPL7 Number
53 unknown CURRENTCOV_PEACE_FPL9 Number
54 Total CURRENTCOV_PEACE_TOTAL Number
55 Individuals Enrolled in VA coverage When Application Submitted Among individuals determined eligible for financial assistance with coverage through the SBM, number of individuals enrolled in VA coverage at the time the application was submitted FPL <100% CURRENTCOV_VA_FPL1 Number
56 ≥100 - ≤138% CURRENTCOV_VA_FPL2 Number
57 >138 - ≤150% CURRENTCOV_VA_FPL3 Number
58 >150 - ≤200% CURRENTCOV_VA_FPL4 Number
59 >200 - ≤250% CURRENTCOV_VA_FPL5 Number
60 >250 - ≤300% CURRENTCOV_VA_FPL6 Number
61 >300- ≤400% CURRENTCOV_VA_FPL7 Number
62 unknown CURRENTCOV_VA_FPL9 Number
63 Total CURRENTCOV_VA_TOTAL Number
64 Individuals Enrolled in Non-Group Coverage When Application Submitted Among individuals determined eligible for financial assistance with coverage through the SBM, number of individuals enrolled in non-group coverage at the time the application was submitted FPL <100% CURRENTCOV_NONGRP_FPL1 Number
65 ≥100 - ≤138% CURRENTCOV_NONGRP_FPL2 Number
66 >138 - ≤150% CURRENTCOV_NONGRP_FPL3 Number
67 >150 - ≤200% CURRENTCOV_NONGRP_FPL4 Number
68 >200 - ≤250% CURRENTCOV_NONGRP_FPL5 Number
69 >250 - ≤300% CURRENTCOV_NONGRP_FPL6 Number
70 >300- ≤400% CURRENTCOV_NONGRP_FPL7 Number
71 unknown CURRENTCOV_NONGRP_FPL9 Number
72 Total CURRENTCOV_NONGRP_TOTAL Number
73 Individuals With Unknown Coverage When Application Submitted Among individuals determined eligible for financial assistance with coverage through the SBM, number of individuals with unknown coverage at the time the application was submitted FPL <100% CURRENTCOV_UNKNOWN_FPL1 Number
74 ≥100 - ≤138% CURRENTCOV_UNKNOWN_FPL2 Number
75 >138 - ≤150% CURRENTCOV_UNKNOWN_FPL3 Number
76 >150 - ≤200% CURRENTCOV_UNKNOWN_FPL4 Number
77 >200 - ≤250% CURRENTCOV_UNKNOWN_FPL5 Number
78 >250 - ≤300% CURRENTCOV_UNKNOWN_FPL6 Number
79 >300- ≤400% CURRENTCOV_UNKNOWN_FPL7 Number
80 unknown CURRENTCOV_UNKNOWN_FPL8 Number
81 Total CURRENTCOV_UNKNOWN_TOTAL Number

Sheet 4: MCAID CHIP Elg

Transfers Between Marketplace and Medicaid/CHIP




Description: Data used to understand number of transfers between SBM and Medicaid/CHIP. Transfer means moving accounts from SBM to or from Medicaid/CHIP for the purposes of eligibility determination or transferring accounts to Medicaid/CHIP to perform nonMAGI eligibility determination.
Unit: Number of Individuals




Population Included: Individuals with accounts transferred during the reference period.
Source for Data Breakouts: N/A
First Reference Period: 10/1/2013-12/31/2013




Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.








State
(please select)


Reference Period
(please select)


Data type
(please select)








# Data Element Data Element Description Data Element Name Data Type Data from State
Individual Marketplace (SBM)- Does not include SHOP
1 Individuals assessed eligible for Medicaid based on MAGI For SBMs with eligibility systems that are integrated with Medicaid/CHIP eligibility systems, enter -999

For SBMs with eligibility systems that are not integrated with Medicaid eligibility systems, report the number of individuals assessed for Medicaid eligibility based on MAGI during the reference period. This data element includes all Medicaid MAGI assessments, whether the individuals are found to be eligible or ineligible.
ASSESS_MCAID_MAGI Number
2 Individuals assessed eligible for CHIP based on MAGI For SBMs with eligibility systems that are integrated with CHIP eligibility systems should enter -999

For SBMs with eligibility systems that are not integrated with CHIP eligibility systems, report the number of individuals assessed for CHIP eligibility based on MAGI during the reference period. This data element includes all CHIP MAGI assessments, whether the individuals are found to be eligible or ineligible.
ASSESS_CHIP_MAGI Number
3 Individuals assessed eligible for Medicaid based on NonMAGI Whether the SBM is integrated or not, teport the number of individuals assessed for Medicaid eligibility based on nonMAGI during the reference period. This data element includes all Medicaid NonMAGI assessments, whether the individuals are found likely to be eligible or ineligible. Please note: If the SBM has determined an individual to be eligible for Medicaid or CHIP, then the individual should not be counted as an assessment ASSESS_MCAID_NONMAGI Number
4 Individual determined eligible for Medicaid For SBM with eligibility systems that are integrated with Medicaid eligibility systems, report the number of individuals determined eligible for Medicaid by the SBM during the reference period.

For SBMs with eligibility systems that are not integrated with Medicaid eligibility systems, enter -999
DET_MCAID_ELG Number
5 Individual determined eligible for CHIP For SBM with eligibility systems that are integrated with CHIP eligibility systems, report the number of individuals determined eligible for CHIP by the SBM during the reference period.

For SBMs with eligibility systems that are not integrated with CHIP eligibility systems, enter -999
DET_CHIP_ELG Number
6 Individual determined ineligible for Medicaid For SBM with eligibility systems that are integrated with Medicaid eligibility systems, report the number of individuals determined ineligible for Medicaid by the SBM during the reference period.

For SBMs with eligibility systems that are not integrated with Medicaid eligibility systems, enter -999
DET_MCAID_INELG Number
7 Individual determined ineligible for CHIP For SBM with eligibility systems that are integrated with CHIP eligibility systems, report the number of individuals determined ineligible for CHIP by the SBM during the reference period.

For SBMs with eligibility systems that are not integrated with CHIP eligibility systems, enter -999
DET_CHIP_INELG Number
8 Individuals transferred from the SBM to Medicaid/CHIP agencies For SBMs with eligibility systems that are integrated with Medicaid/CHIP eligibility systems, report the number of individuals assessed to be eligible based on nonMAGI and transferred to the Medicaid/CHIP agencies during the reference period for the purposes of eligibility determination. Do not include individuals determined to be eligible and transferred for enrollment in Mediciad/CHIP.

For SBMs with eligibility systems that are not integrated with Medicaid/CHIP eligibility systems, report the number of individuals assessed to be eligible based on either MAGI or nonMAGI and transferred to the Medicaid/CHIP agencies during the reference period for the purposes of eligibility determination.
TRANSFER_TO_MCAID Number
9 Individuals transferred from the Medicaid/CHIP agencies to the SBM For SBMs with eligibility systems that are integrated with Medicaid/CHIP eligibility systems should enter -999

For SBMs with eligibility systems that are not integrated with Medicaid/CHIP eligibility systems, report the number of individuals who applied for coverage through the Medicaid/CHIP agencies as the "front door" and were deemed ineligible for Medicaid/CHIP and were transferred to the SBM for the purposes of QHP eligibility determination during the reference period.
TRANSFER_FROM_MCAID Number

Sheet 5: QHP App Elg

QHP Applications and Eligibility






Description: Data used to measure the number of individuals that applied to the SBM for coverage and were determined eligible or ineligible for QHP coverage with and without financial assistance
Unit: Number of Individuals






Population Included: Individuals with a completed, submitted application
Source for Data Breakouts: Most recent eligibility determination.
First Reference Period: 10/1/2013-12/31/2013






Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.












State
(please select)




Reference Period
(please select)




Data type
(please select)












# Data Element Data Element Description Data Breakouts
(for more info, see Glossary tab)
Data Element Name Data Type Data from State
Individual Marketplace (SBM)- Does not include SHOP
1 Applied for coverage through SBM Number of individuals that submitted a complete application for coverage to the SBM during the reference period.

A completed application is defined as an application with sufficient information to begin processing eligibility for any type of coverage (QHP or Medicaid/CHIP).

There are three possible outcomes of completed applications:
1) individual is determined eligible for Medicaid, CHIP or QHP (includes both provisional and final determination)
2) individual is determined ineligible for Medicaid, CHIP, or QHP; or
3) verification and additional documentation is required before eligibility can be determined.

Age <18 QHP_APP_AGE1 Number
2 18-25 QHP_APP_AGE2 Number
3 26-34 QHP_APP_AGE3 Number
4 35-44 QHP_APP_AGE4 Number
5 45-54 QHP_APP_AGE5 Number
6 55-64 QHP_APP_AGE6 Number
7 ≥65 QHP_APP_AGE7 Number
8 Channel web QHP_APP_WEB Number
9 phone QHP_APP_PHONE Number
10 paper QHP_APP_PAPER Number
11 other/unknown QHP_APP_UNK Number
12 Application Assistance Any QHP_APP_ANY Number
13 None QHP_APP_NONE Number
14 Total QHP_APP_TOTAL Number
15 Assessed Medicaid Eligible (NonMAGI) and APTC/CSR Eligible Number of individuals that were:
1. assessed to be Medicaid eligible based on NonMAGI
2. determined to be QHP eligible and
3. determined eligible for APTC/CSR during the reference period during the reference period
FPL <100% QHP_NONMAGI_APTC_FPL1 Number
16 ≥100 - ≤138% QHP_NONMAGI_APTC_FPL2 Number
17 >138 - ≤150% QHP_NONMAGI_APTC_FPL3 Number
18 >150 - ≤200% QHP_NONMAGI_APTC_FPL4 Number
19 >200 - ≤250% QHP_NONMAGI_APTC_FPL5 Number
20 >250 - ≤300% QHP_NONMAGI_APTC_FPL6 Number
21 >300- ≤400% QHP_NONMAGI_APTC_FPL7 Number
22 unknown QHP_NONMAGI_APTC_FPL9 Number
23 Age <18 QHP_NONMAGI_APTC_AGE1 Number
24 18-25 QHP_NONMAGI_APTC_AGE2 Number
25 26-34 QHP_NONMAGI_APTC_AGE3 Number
26 35-44 QHP_NONMAGI_APTC_AGE4 Number
27 45-54 QHP_NONMAGI_APTC_AGE5 Number
28 55-64 QHP_NONMAGI_APTC_AGE6 Number
29 ≥65 QHP_NONMAGI_APTC_AGE7 Number
30 Channel web QHP_NONMAGI_APTC_WEB Number
31 phone QHP_NONMAGI_APTC_PHONE Number
32 paper QHP_NONMAGI_APTC_PAPER Number
33 other/unknown QHP_NONMAGI_APTC_UNK Number
34 Application Assistance Any QHP_NONMAGI_APTC_ANY Number
35 None QHP_NONMAGI_APTC_NONE Number
36 AV Level ≥100 - ≤150% QHP_NONMAGI_APTC_AV1 Number
37 >150 - ≤200% QHP_NONMAGI_APTC_AV2 Number
38 >200 - ≤250% QHP_NONMAGI_APTC_AV3 Number
39 >250- ≤400% QHP_NONMAGI_APTC_AV1 Number
40 tribal member QHP_NONMAGI_APTC_AV4 Number
41 No CSR, APTC eligibility only QHP_NONMAGI_APTC_AV5 Number
42 Total QHP_NONMAGI_APTC_TOTAL Number
43 Assessed Medicaid Eligible (NonMAGI) and APTC/CSR Ineligible Number of individuals that were:
1. assessed to be Medicaid eligible based on NonMAGI
2. determined to be QHP eligible
3. determined ineligible for APTC/CSR during the reference period
FPL <100% QHP_NONMAGI_INELGAPTC_FPL1 Number
44 ≥100 - ≤138% QHP_NONMAGI_INELGAPTC_FPL2 Number
45 >138 - ≤150% QHP_NONMAGI_INELGAPTC_FPL3 Number
46 >150 - ≤200% QHP_NONMAGI_INELGAPTC_FPL4 Number
47 >200 - ≤250% QHP_NONMAGI_INELGAPTC_FPL5 Number
48 >250 - ≤300% QHP_NONMAGI_INELGAPTC_FPL6 Number
49 >300- ≤400% QHP_NONMAGI_INELGAPTC_FPL7 Number
50 >400% QHP_NONMAGI_INELGAPTC_FPL8 Number
51 unknown QHP_NONMAGI_INELGAPTC_FPL9 Number
52 Age <18 QHP_NONMAGI_INELGAPTC_AGE1 Number
53 18-25 QHP_NONMAGI_INELGAPTC_AGE2 Number
54 26-34 QHP_NONMAGI_INELGAPTC_AGE3 Number
55 35-44 QHP_NONMAGI_INELGAPTC_AGE4 Number
56 45-54 QHP_NONMAGI_INELGAPTC_AGE5 Number
57 55-64 QHP_NONMAGI_INELGAPTC_AGE6 Number
58 ≥65 QHP_NONMAGI_INELGAPTC_AGE7 Number
59 Channel web QHP_NONMAGI_INELGAPTC_WEB Number
60 phone QHP_NONMAGI_INELGAPTC_PHONE Number
61 paper QHP_NONMAGI_INELGAPTC_PAPER Number
62 other/unknown QHP_NONMAGI_INELGAPTC_UNK Number
63 Application Assistance Any QHP_NONMAGI_INELGAPTC_ANY Number
64 None QHP_NONMAGI_INELGAPTC_NONE Number
65 Total QHP_NONMAGI_INELGAPTC_TOTAL Number
66 Eligible for QHP and eligible for APTC/CSR Number of individuals that were:
1. determined/assessed to be ineligible for Medicaid/CHIP (based on MAGI or nonMAGI)
2. determined QHP eligible
3. determined eligible for financial assistance (APTC/CSR) during the reference period
FPL <100% QHP_APTC_FPL1 Number
67 ≥100 - ≤138% QHP_APTC_FPL2 Number
68 >138 - ≤150% QHP_APTC_FPL3 Number
69 >150 - ≤200% QHP_APTC_FPL4 Number
70 >200 - ≤250% QHP_APTC_FPL5 Number
71 >250 - ≤300% QHP_APTC_FPL6 Number
72 >300- ≤400% QHP_APTC_FPL7 Number
73 unknown QHP_APTC_FPL9 Number
74 Age <18 QHP_APTC_AGE1 Number
75 18-25 QHP_APTC_AGE2 Number
76 26-34 QHP_APTC_AGE3 Number
77 35-44 QHP_APTC_AGE4 Number
78 45-54 QHP_APTC_AGE5 Number
79 55-64 QHP_APTC_AGE6 Number
80 ≥65 QHP_APTC_AGE7 Number
81 Channel web QHP_APTC_WEB Number
82 phone QHP_APTC_PHONE Number
83 paper QHP_APTC_PAPER Number
84 other/unknown QHP_APTC_UNK Number
85 Application Assistance Any QHP_APTC_ANY Number
86 None QHP_APTC_NONE Number
87 AV Level ≥100 - ≤150% QHP_APTC_AV1 Number
88 >150 - ≤200% QHP_APTC_AV2 Number
89 >200 - ≤250% QHP_APTC_AV3 Number
90 >250- ≤400% QHP_APTC_AV1 Number
91 tribal member QHP_APTC_AV4 Number
92 No CSR, APTC eligibility only QHP_APTC_AV5 Number
93 Total QHP_APTC_TOTAL Number
94 Eligible for QHP but ineligible for APTC/CSR Number of individuals that were:
1. determined/assessed to be ineligible for Medicaid/CHIP (based on MAGI or nonMAGI)
2. determined QHP eligible
3. determined ineligible for financial assistance (APTC/CSR) during the reference period
FPL <100% QHP_INELGAPTC_FPL1 Number
95 ≥100 - ≤138% QHP_INELGAPTC_FPL2 Number
96 >138 - ≤150% QHP_INELGAPTC_FPL3 Number
97 >150 - ≤200% QHP_INELGAPTC_FPL4 Number
98 >200 - ≤250% QHP_INELGAPTC_FPL5 Number
99 >250 - ≤300% QHP_INELGAPTC_FPL6 Number
100 >300- ≤400% QHP_INELGAPTC_FPL7 Number
101 >400% QHP_INELGAPTC_FPL8 Number
102 unknown QHP_INELGAPTC_FPL9 Number
103 Age <18 QHP_INELGAPTC_AGE1 Number
104 18-25 QHP_INELGAPTC_AGE2 Number
105 26-34 QHP_INELGAPTC_AGE3 Number
106 35-44 QHP_INELGAPTC_AGE4 Number
107 45-54 QHP_INELGAPTC_AGE5 Number
108 55-64 QHP_INELGAPTC_AGE6 Number
109 ≥65 QHP_INELGAPTC_AGE7 Number
110 Channel web QHP_INELGAPTC_WEB Number
111 phone QHP_INELGAPTC_PHONE Number
112 paper QHP_INELGAPTC_PAPER Number
113 other/unknown QHP_INELGAPTC_UNK Number
114 Application Assistance Any QHP_INELGAPTC_ANY Number
115 None QHP_INELGAPTC_NONE Number
116 Total QHP_INELGAPTC_TOTAL Number
117 Eligible for QHP but no request for financial assistance Number of individuals that:
1. did not request financial assistance of any kind (Medicaid, CHIP, APTC, or CSR) and
2. were determined QHP eligible during the reference period
Age <18 QHP_NOREQ_AGE1 Number
118 18-25 QHP_NOREQ_AGE2 Number
119 26-34 QHP_NOREQ_AGE3 Number
120 35-44 QHP_NOREQ_AGE4 Number
121 45-54 QHP_NOREQ_AGE5 Number
122 55-64 QHP_NOREQ_AGE6 Number
123 ≥65 QHP_NOREQ_AGE7 Number
124 Channel web QHP_NOREQ_WEB Number
125 phone QHP_NOREQ_PHONE Number
126 paper QHP_NOREQ_PAPER Number
127 other/unknown QHP_NOREQ_UNK Number
128 Application Assistance Any QHP_NOREQ_ANY Number
129 None QHP_NOREQ_NONE Number
130 Total QHP_NOREQ_TOTAL Number
131 QHP Eligible Number of individuals determined QHP eligible during the reference period.

Include all individuals were or were not assessed Medicaid eligible based on nonMAGI, were or were not determined eligible for APTC/CSR, did or did not request financial assistance. For example: QHP_ELG_TOTAL= QHP_NONMAGI_APTC_TOTAL + QHP_NONMAGI_INELGAPTC_TOTAL + QHP_APTC_TOTAL + QHP_INELGAPTC_TOTAL + QHP_NOREQ_TOTAL
Age <18 QHP_ELG_TOTAL Number
132 18-25 QHP_ELG_TOTAL Number
133 26-34 QHP_ELG_TOTAL Number
134 35-44 QHP_ELG_TOTAL Number
135 45-54 QHP_ELG_TOTAL Number
136 55-64 QHP_ELG_TOTAL Number
137 ≥65 QHP_ELG_TOTAL Number
138 Channel web QHP_ELG_TOTAL Number
139 phone QHP_ELG_TOTAL Number
140 paper QHP_ELG_TOTAL Number
141 other/unknown QHP_ELG_TOTAL Number
142 Application Assistance Any QHP_ELG_TOTAL Number
143 None QHP_ELG_TOTAL Number
144 Total QHP_ELG_TOTAL Number
145 Ineligible for QHP Number of individuals determined ineligible for QHP coverage during the reference period. Includes individual that requested financial assistance and did not request financial assistance Age <18 QHP_ELG_TOTAL Number
146 18-25 QHP_INELG_TOTAL Number
147 26-34 QHP_INELG_TOTAL Number
148 35-44 QHP_INELG_TOTAL Number
149 45-54 QHP_INELG_TOTAL Number
150 55-64 QHP_INELG_TOTAL Number
151 ≥65 QHP_INELG_TOTAL Number
152 Channel web QHP_INELG_TOTAL Number
153 phone QHP_INELG_TOTAL Number
154 paper QHP_INELG_TOTAL Number
155 other/unknown QHP_INELG_TOTAL Number
156 Application Assistance Any QHP_INELG_TOTAL Number
157 None QHP_INELG_TOTAL Number
158 Total QHP_INELG_TOTAL Number

Sheet 6: QHP Enr

QHP Enrollment






Description: Data used to measure the number of individuals that reached various stages in application, eligibility, and enrollment during the reference period.
Unit: Number of Individuals






Population Included: Individuals determined eligible for QHP coverage
Source for Data Breakouts: Most recent eligibility determination.
First Reference Period: 10/1/2013-12/31/2013






Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.












State
(please select)




Reference Period
(please select)




Data type
(please select)












# Data Element Data Element Description Data Breakouts
(for more info, see Glossary tab)
Data Element Name Data Type Data from State
Individual Marketplace (SBM)- Does not include SHOP
1 Canceled for Non-Payment Number of individuals that cancelled for non-payment during the reference period. These individuals would be deemed QHP eligible and selected a QHP, the SBM approved QHP selection, but the individual was disenrolled during the reference period and before the effective enrollment date (i.e. coverage canceled) due to non-payment FPL <100% QHP_NONPYMT_FPL1 Number
2 ≥100 - ≤138% QHP_NONPYMT_FPL2 Number
3 >138 - ≤150% QHP_NONPYMT_FPL3 Number
4 >150 - ≤200% QHP_NONPYMT_FPL4 Number
5 >200 - ≤250% QHP_NONPYMT_FPL5 Number
6 >250 - ≤300% QHP_NONPYMT_FPL6 Number
7 >300- ≤400% QHP_NONPYMT_FPL7 Number
8 >400% QHP_NONPYMT_FPL8 Number
9 unknown QHP_NONPYMT_FPL9 Number
10 Age <18 QHP_NONPYMT_AGE1 Number
11 18-25 QHP_NONPYMT_AGE2 Number
12 26-34 QHP_NONPYMT_AGE3 Number
13 35-44 QHP_NONPYMT_AGE4 Number
14 45-54 QHP_NONPYMT_AGE5 Number
15 55-64 QHP_NONPYMT_AGE6 Number
16 ≥65 QHP_NONPYMT_AGE7 Number
17 Channel web QHP_NONPYMT_WEB Number
18 phone QHP_NONPYMT_PHONE Number
19 paper QHP_NONPYMT_PAPER Number
20 other/unknown QHP_NONPYMT_OTHER Number
21 Application Assistance Any QHP_NONPYMT_ANY Number
22 None QHP_NONPYMT_NONE Number
23 Policy Structure Single QHP_NONPYMT_PS1 Number
24 Single + 1 spouse/partner QHP_NONPYMT_PS2 Number
25 Single + 1 child QHP_NONPYMT_PS3 Number
26 Single + 2 or more dependents QHP_NONPYMT_PS4 Number
27 Child-only QHP_NONPYMT_PS5 Number
28 Total QHP_NONPYMT_TOTAL Number
29 Canceled for Other Reason Number of individuals that cancelled for reasons other than non-payment during the reference period. These individuals would be deemed QHP eligible and selected a QHP, the SBM approved QHP selection, but the individual was disenrolled during the reference period and before the effective enrollment date (i.e. coverage canceled) due for reasons other than non-payment Total QHP_OTHCANCEL_TOTAL Number
30 Effective Enrollment-
Financial Assistance
Number of individuals that received effective enrollment with financial assistance (APTC/CSR) during the reference period. These individuals were deemed QHP eligibile with financial assistance, selected a QHP and a financial assistance amount, and the SBM approved the QHP selection during the reference period. Includes individuals with either provisional or final eligibility determination. FPL <100% QHP_EFFECTIVE_APTC_FPL1 Number
31 ≥100 - ≤138% QHP_EFFECTIVE_APTC_FPL2 Number
32 >138 - ≤150% QHP_EFFECTIVE_APTC_FPL3 Number
33 >150 - ≤200% QHP_EFFECTIVE_APTC_FPL4 Number
34 >200 - ≤250% QHP_EFFECTIVE_APTC_FPL5 Number
35 >250 - ≤300% QHP_EFFECTIVE_APTC_FPL6 Number
36 >300- ≤400% QHP_EFFECTIVE_APTC_FPL7 Number
37 unknown QHP_EFFECTIVE_APTC_FPL9 Number
38 Age <18 QHP_EFFECTIVE_APTC_AGE1 Number
39 18-25 QHP_EFFECTIVE_APTC_AGE2 Number
40 26-34 QHP_EFFECTIVE_APTC_AGE3 Number
41 35-44 QHP_EFFECTIVE_APTC_AGE4 Number
42 45-54 QHP_EFFECTIVE_APTC_AGE5 Number
43 55-64 QHP_EFFECTIVE_APTC_AGE6 Number
44 ≥65 QHP_EFFECTIVE_APTC_AGE7 Number
45 Channel web QHP_EFFECTIVE_APTC_WEB Number
46 phone QHP_EFFECTIVE_APTC_PHONE Number
47 paper QHP_EFFECTIVE_APTC_PAPER Number
48 other/unknown QHP_EFFECTIVE_APTC_UNK Number
49 Application Assistance Any QHP_EFFECTIVE_APTC_ANY Number
50 None QHP_EFFECTIVE_APTC_NONE Number
51 Total QHP_EFFECTIVE_APTC_TOTAL Number
52 Effective Enrollment-
NO Financial Assistance
Number of individuals that received effective enrollment without financial assistance (APTC/CSR) during the reference period. These individuals were deemed QHP eligibile with financial assistance, selected a QHP, and the SBM approved the QHP selection during the reference period. Includes individuals with either provisional or final eligibility determination.

Includes all of the following: (1) individuals deemed ineligible for QHP coverage with financial assistance (APTC and/or CSR); (2) individuals that requested their application not be considered for financial assistance; and (3) individuals deemed eligible for QHP coverage with financial assistance (APTC and/or CSR) and did not select financial assistance.
FPL <100% QHP_EFFECTIVE_NOAPTC_FPL1 Number
53 ≥100 - ≤138% QHP_EFFECTIVE_NOAPTC_FPL2 Number
54 >138 - ≤150% QHP_EFFECTIVE_NOAPTC_FPL3 Number
55 >150 - ≤200% QHP_EFFECTIVE_NOAPTC_FPL4 Number
56 >200 - ≤250% QHP_EFFECTIVE_NOAPTC_FPL5 Number
57 >250 - ≤300% QHP_EFFECTIVE_NOAPTC_FPL6 Number
58 >300- ≤400% QHP_EFFECTIVE_NOAPTC_FPL7 Number
59 >400% QHP_EFFECTIVE_NOAPTC_FPL8 Number
60 unknown QHP_EFFECTIVE_NOAPTC_FPL9 Number
61 Age <18 QHP_EFFECTIVE_NOAPTC_AGE1 Number
62 18-25 QHP_EFFECTIVE_NOAPTC_AGE2 Number
63 26-34 QHP_EFFECTIVE_NOAPTC_AGE3 Number
64 35-44 QHP_EFFECTIVE_NOAPTC_AGE4 Number
65 45-54 QHP_EFFECTIVE_NOAPTC_AGE5 Number
66 55-64 QHP_EFFECTIVE_NOAPTC_AGE6 Number
67 ≥65 QHP_EFFECTIVE_NOAPTC_AGE7 Number
68 Channel web QHP_EFFECTIVE_NOAPTC_WEB Number
69 phone QHP_EFFECTIVE_NOAPTC_PHONE Number
70 paper QHP_EFFECTIVE_NOAPTC_PAPER Number
71 other/unknown QHP_EFFECTIVE_NOAPTC_UNK Number
72 Application Assistance Any QHP_EFFECTIVE_NOAPTC_ANY Number
73 None QHP_EFFECTIVE_NOAPTC_NONE Number
74 Total QHP_EFFECTIVE_NOAPTC_TOTAL Number
75 Effectuated Enrollment-
Financial Assistance
Number of individuals that received effectuated enrollment with financial assistance (APTC/CSR) during the reference period. These individuals were deemed QHP eligibile with financial assistance, selected a QHP and a financial assistance amount, the SBM approved the QHP selection, and the individual made the first premium payment during the reference period.

Includes individuals with either provisional or final eligibility determination.
FPL <100% QHP_EFFECTUATED_FIN_FPL1 Number
76 ≥100 - ≤138% QHP_EFFECTUATED_FIN_FPL2 Number
77 >138 - ≤150% QHP_EFFECTUATED_FIN_FPL3 Number
78 >150 - ≤200% QHP_EFFECTUATED_FIN_FPL4 Number
79 >200 - ≤250% QHP_EFFECTUATED_FIN_FPL5 Number
80 >250 - ≤300% QHP_EFFECTUATED_FIN_FPL6 Number
81 >300- ≤400% QHP_EFFECTUATED_FIN_FPL7 Number
82 unknown QHP_EFFECTUATED_FIN_FPL9 Number
83 Age <18 QHP_EFFECTUATED_FIN_AGE1 Number
84 18-25 QHP_EFFECTUATED_FIN_AGE2 Number
85 26-34 QHP_EFFECTUATED_FIN_AGE3 Number
86 35-44 QHP_EFFECTUATED_FIN_AGE4 Number
87 45-54 QHP_EFFECTUATED_FIN_AGE5 Number
88 55-64 QHP_EFFECTUATED_FIN_AGE6 Number
89 ≥65 QHP_EFFECTUATED_FIN_AGE7 Number
90 Channel web QHP_EFFECTUATED_FIN_WEB Number
91 phone QHP_EFFECTUATED_FIN_PHONE Number
92 paper QHP_EFFECTUATED_FIN_PAPER Number
93 other/unknown QHP_EFFECTUATED_FIN_OTHER Number
94 Application Assistance Any QHP_EFFECTUATED_FIN_ANY Number
95 None QHP_EFFECTUATED_FIN_NONE Number
96 Policy Structure Single QHP_EFFECTUATED_FIN_PS1 Number
97 Single + 1 spouse/partner QHP_EFFECTUATED_FIN_PS2 Number
98 Single + 1 child QHP_EFFECTUATED_FIN_PS3 Number
99 Single + 2 or more dependents QHP_EFFECTUATED_FIN_PS4 Number
100 Child-only QHP_EFFECTUATED_FIN_PS5 Number
101 Total QHP_EFFECTUATED_FIN_TOTAL Number
102 Effectuated Enrollment-
NO Financial Assistance
Number of individuals that received effectuated enrollment without financial assistance (APTC/CSR) during the reference period. These individuals were deemed QHP eligibile with financial assistance, selected a QHP, the SBM approved the QHP selection, and the individual made the first premium payment during the reference period

Includes all of the following: (1) individuals deemed ineligible for QHP coverage with financial assistance (APTC and/or CSR); (2) individuals that requested their application not be considered for financial assistance; and (3) individuals deemed eligible for QHP coverage with financial assistance (APTC and/or CSR) and did not select financial assistance.


Includes individuals with either provisional or final eligibility determination.
Age <18 QHP_EFFECTUATED_NOFIN_AGE1 Number
103 18-25 QHP_EFFECTUATED_NOFIN_AGE2 Number
104 26-34 QHP_EFFECTUATED_NOFIN_AGE3 Number
105 35-44 QHP_EFFECTUATED_NOFIN_AGE4 Number
106 45-54 QHP_EFFECTUATED_NOFIN_AGE5 Number
107 55-64 QHP_EFFECTUATED_NOFIN_AGE6 Number
108 ≥65 QHP_EFFECTUATED_NOFIN_AGE7 Number
109 Channel web QHP_EFFECTUATED_NOFIN_WEB Number
110 phone QHP_EFFECTUATED_NOFIN_PHONE Number
111 paper QHP_EFFECTUATED_NOFIN_PAPER Number
112 other/unknown QHP_EFFECTUATED_NOFIN_OTHER Number
113 Application Assistance Any QHP_EFFECTUATED_NOFIN_ANY Number
114 None QHP_EFFECTUATED_NOFIN_NONE Number
115 Policy Structure Single QHP_EFFECTUATED_NOFIN_PS1 Number
116 Single + 1 spouse/partner QHP_EFFECTUATED_NOFIN_PS2 Number
117 Single + 1 child QHP_EFFECTUATED_NOFIN_PS3 Number
118 Single + 2 or more dependents QHP_EFFECTUATED_NOFIN_PS4 Number
119 Child-only QHP_EFFECTUATED_NOFIN_PS5 Number
120 Total QHP_EFFECTUATED_NOFIN_TOTAL Number

Sheet 7: Conversion

Conversion






Description: Data allows for an understanding the conversation rate from a submitted application to enrollment. This metric includes all applications submitted for all types of coverage during the reference period. For states with integrated eligibility determination systems, please report number of applications in the individual market (inclusive of Medicaid, CHIP, and/or QHP coverage) and excluding employer and employee applications to the SHOP. For states that do not have integrated eligibility determination systems, please report the number of applications submitted to the SBM (excluding employer and employee applications to the SHOP).
Unit: Number of applications, number of policies with effectuated coverage, number of Medicaid/CHIP accounts






Population Included: Completed applications submitted during the reference period. One application may results in multiple QHP policies or Medicaid/CHIP accounts
Source for Data Breakouts: Most recent eligibility determination.
First Reference Period: 10/1/2013-12/31/2013






Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.










State
(please select)




Reference Period
(please select)




Data type
(please select)












# Data Element Data Element Description Data Breakouts
(for more info, see Glossary tab)
Data Element Name Data Type Data from State
Individual Marketplace (SBM)- Does not include SHOP
1 Incomplete Application Number of incomplete applications initiated during the reference period and remain incomplete as of the last day in the reference period. Applications initiated in previous reference periods should not be included in these data elements, even if there was some activity on the application.

An incomplete application submitted via electronic channels includes applications where data is provided through the web portal by the applicant or inputted into the system electronically by call center staff or other assistors. The applicant must have a registered account, started the application, and provided enough information to hit "save," but not yet have submitted a complete application with enough information to begin processing eligibility for coverage (QHP or Medicaid/CHIP).

An incomplete application submitted via paper channels includes applications which were submitted by hand or by mail on paper and where there is at least a signature but the information necessary to begin processing eligibility is incomplete (e.g., these fields on the application are left blank). At a minimum, an incomplete paper application would have a signature only.

States that cannot determin the channel used to submit an incomplete application should use the unknown option.
Channel Roll-Up Electronic INCOMPLETE_ELEC Number
2 Paper INCOMPLETE_PAPER Number
3 Unknown INCOMPLETE_UNK Number
4 Total INCOMPELTE_TOTAL Number
5 Submitted and Completed Applications Number of completed applications for any type of coverage submitted during the reference period. (QHP or Medicaid/CHIP).

A completed application is defined as an application with sufficient information to begin processing eligibility for any type of coverage (QHP or Medicaid/CHIP).

There are three possible outcomes of completed applications:
1) individual is determined eligible for Medicaid, CHIP or QHP (includes both provisional and final determination); or
2) individual is determined ineligible for Medicaid, CHIP, or QHP; or
3) verification and additional documentation is required before eligibility can be determined.
FPL <100% APPLICATIONS_FPL1 Number
6 ≥100 - ≤138% APPLICATIONS_FPL2 Number
7 >138 - ≤150% APPLICATIONS_FPL3 Number
8 >150 - ≤200% APPLICATIONS_FPL4 Number
9 >200 - ≤250% APPLICATIONS_FPL5 Number
10 >250 - ≤300% APPLICATIONS_FPL6 Number
11 >300- ≤400% APPLICATIONS_FPL7 Number
12 >400% APPLICATIONS_FPL8 Number
13 unknown APPLICATIONS_FPL9 Number
14 Channel web APPLICATIONS_WEB Number
15 phone APPLICATIONS_PHONE Number
16 paper APPLICATIONS_PAPER Number
17 other/unknown APPLICATIONS_OTHER Number
18 Application Assistance Any APPLICATIONS_ANY Number
19 None APPLICATIONS_NONE Number
20 Total APPLICATIONS_TOTAL Number
21 Submitted Applications with Verification Issues Number of completed applications that were submitted but require additional documentation to resolve verification issues. Includes applications that required verification before eligibility could be determined and applications which resulted in provisional eligibility determination but need additional follow-up before determination of final eligibility.

Channel Roll-Up Electronic VERIFICATION_ELEC Number
22 Paper VERIFICATION_PAPER Number
23 Unknown VERIFICATION_UNK Number
24 Total VERIFICATION_TOTAL Number
25 Effectuated Policies for QHP Coverage

Financial Assistance
Number of effectuated policies for QHP enrollment issued during the reference period.

Includes only policies for individuals receiving QHP coverage with financial assistance (APTC and/or CSR)

Effectuated enrollment is defined as when an individual is determined eligible for QHP enrollment, the SBM approved the QHP selection, and the first premium payment has been made.
FPL ≤100% POLICIES_FIN_FPL1 Number
26 >100 - ≤138% POLICIES_FIN_FPL2 Number
27 >138 - ≤150% POLICIES_FIN_FPL3 Number
28 >150 - ≤200% POLICIES_FIN_FPL4 Number
29 >200 - ≤250% POLICIES_FIN_FPL5 Number
30 >250 - ≤300% POLICIES_FIN_FPL6 Number
31 >300- ≤400% POLICIES_FIN_FPL7 Number
32 >400% POLICIES_FIN_FPL8 Number
33 unknown POLICIES_FIN_FPL9 Number
34 Channel web POLICIES_FIN_WEB Number
35 phone POLICIES_FIN_PHONE Number
36 paper POLICIES_FIN_PAPER Number
37 other/unknown POLICIES_FIN_OTHER Number
38 Application Assistance Any POLICIES_FIN_ANY Number
39 None POLICIES_FIN_NONE Number
40 Policy Structure Single POLICIES_FIN_PS1 Number
41 Single + 1 spouse/partner POLICIES_FIN_PS2 Number
42 Single + 1 child POLICIES_FIN_PS3 Number
43 Single + 2 or more dependents POLICIES_FIN_PS4 Number
44 Child-only POLICIES_FIN_PS5 Number
45 Total POLICIES_FIN_TOTAL Number
46 Effectuated Policies for QHP Coverage

NO Financial Assistance
Number of effectuated policies for QHP enrollment issued during the reference period.

Includes only policies for individuals receiving QHP coverage without financial assistance (APTC and/or CSR). Includes all of the following: (1) individuals deemed ineligible for QHP coverage with financial assistance (APTC and/or CSR); (2) individuals that requested their application not be considered for financial assistance; and (3) individuals deemed eligible for QHP coverage with financial assistance (APTC and/or CSR) and did not select financial assistance.


Effectuated enrollment is defined as when an individual is determined eligible for QHP enrollment, the SBM approved the QHP selection, and the first premium payment has been made.
Channel web POLICIES_NOFIN_WEB Number
47 phone POLICIES_NOFIN_PHONE Number
48 paper POLICIES_NOFIN_PAPER Number
49 other/unknown POLICIES_NOFIN_OTHER Number
50 Application Assistance Any POLICIES_NOFIN_ANY Number
51 None POLICIES_NOFIN_NONE Number
52 Policy Structure Single POLICIES_NOFIN_PS1 Number
53 Single + 1 spouse/partner POLICIES_NOFIN_PS2 Number
54 Single + 1 child POLICIES_NOFIN_PS3 Number
55 Single + 2 or more dependents POLICIES_NOFIN_PS4 Number
56 Child-only POLICIES_NOFIN_PS5 Number
57 Total POLICIES_NOFIN_TOTAL Number

Sheet 8: APTC

APTC






Description: Data use to understand the amount of Advanced Premium Tax Credit (APTC) that enrollees were deeemed eligible to receive and the percentage selected during the reference period. All calculations are median across tax households.
Unit: Tax households deemed eligibile for APTC






Population Included: Policies in which the individuals received effectuated coverage.
Source for Data Breakouts: Most recent eligibility determination
First Reference Period: 10/1/2013-12/31/2013






Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.










State
(please select)




Reference Period
(please select)




Data type
(please select)












# Data Element Data Element Description Data Breakouts
(for more info, see Glossary tab)
Data Element Name Data Type Data from State
Individual Marketplace (SBM)- Does not include SHOP
1 Median APTC Eligible Amount Among individuals that are deemed eligible for APTC assistance within the reference period, monthly maximum APTC amount that enrollees were deemed eligible to receive. Report median per tax household

Include individuals that are QHP Eligible, meaning deemed eligible for QHP coverage with APTC assistance during the reference period, but may or may not have selected a QHP.
FPL <100% APTC_AMT_FPL1 Number
2 ≥100 - ≤138% APTC_AMT_FPL2 Number
3 >138- ≤150% APTC_AMT_FPL3 Number
4 >150 - ≤250% APTC_AMT_FPL4 Number
5 >250- ≤400% APTC_AMT_FPL5 Number
6 Application Assistance Any APTC_AMT_ANY Number
7 None APTC_AMT_NONE Number
8 Median across all tax households APTC_AMT_TOTAL Number
9 Median APTC Selected Amount Among individuals that recieve effective enrollment with APTC assistance within the reference period, the median amount of APTC selected. Report median per tax household.

Include individuals that are have effective enrollment, meaning deemed eligible for QHP coverage with APTC assistance and selected a QHP during the reference period, but may or may not have selected have paid the first premium.
FPL <100% APTC_SELECT_FPL1 Number
10 ≥100 - ≤138% APTC_SELECT_FPL2 Number
11 >138- ≤150% APTC_SELECT_FPL3 Number
12 >150 - ≤250% APTC_SELECT_FPL4 Number
13 >250- ≤400% APTC_SELECT_FPL5 Number
14 Application Assistance Any APTC_SELECT_ANY Number
15 None APTC_SELECT_NONE Number
16 Median across all tax households APTC_SELECT_TOTAL Number
17 Median Percentage APTC Selected Among individuals that recieve effective enrollment with APTC assistance within the reference period, the percentage of offered APTC that enrollees selected.
Report median per tax household (no decimals).

Include individuals that are have effective enrollment, meaning deemed eligible for QHP coverage with APTC assistance and selected a QHP during the reference period, but may or may not have selected have paid the first premium
FPL <100% APTC_PCTSELECT_FPL1 Number
18 ≥100 - ≤138% APTC_PCTSELECT_FPL2 Number
19 >138- ≤150% APTC_PCTSELECT_FPL3 Number
20 >150 - ≤250% APTC_PCTSELECT_FPL4 Number
21 >250- ≤400% APTC_PCTSELECT_FPL5 Number
22 Application Assistance Any APTC_PCTSELECT_ANY Number
23 None APTC_PCTSELECT_NONE Number
24 Median across all tax households APTC_PCTSELECT_TOTAL Number

Sheet 9: Fin Assist Det Time

Time to Determine Eligibility for QHP Financial Assistance (APTC/CSR)






Description: Data reflects median number of days (calendar days, not working days) to determine eligibility for financial assistance with QHP enrollment (APTC/CSR). For individuals that received final eligibility determination, look back to calculate the number of days since submission of the completed application. A completed application is defined as an application with sufficient information to begin processing eligibility for any type of coverage (QHP or Medicaid/CHIP).
Unit: Number of individuals that received final eligibility determination for financial assistance






Population Included: Individuals that had final eligibility determination for financial assistance (APTC/CSR) within the reference period. Includes individuals determined eligibile and ineligible. Metric excludes individuals where final eligibility determination has not taken place (e.g., the individual is in the midst of verification and only have provisional eligibility determination or they did not request financial assistance eligibility determination)
Source for Data Breakouts: Final eligibility determination.
First Reference Period: 10/1/2013-12/31/2013






Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.










State
(please select)




Reference Period
(please select)




Data type
(please select)












# Data Element Data Element Description Data Breakouts
(for more info, see Glossary tab)
Data Element Name Data Type Data from State
Individual Marketplace (SBM)- Does not include SHOP
1 Eligibility Determinations- Median Time Median number of calendar days between submission of completed application and final eligibility determination for financial assistance (no decimals) FPL <100% DET_MEDIAN_FPL1 Number
2 ≥100 - ≤138% DET_MEDIAN_FPL2 Number
3 >138 - ≤150% DET_MEDIAN_FPL3 Number
4 >150 - ≤200% DET_MEDIAN_FPL4 Number
5 >200 - ≤250% DET_MEDIAN_FPL5 Number
6 >250 - ≤300% DET_MEDIAN_FPL6 Number
7 >300- ≤400% DET_MEDIAN_FPL7 Number
8 >400% DET_MEDIAN_FPL8 Number
9 unknown DET_MEDIAN_FPL9 Number
10 Channel web DET_MEDIAN_WEB Number
11 phone DET_MEDIAN_PHONE Number
12 paper DET_MEDIAN_MAIL Number
13 other/unknown DET_MEDIAN_OTHER Number
14 Application Assistance Any DET_MEDIAN_ANY Number
15 None DET_MEDIAN_NONE Number
16 Financial Assistance
Eligiblity
APTC only DET_MEDIAN_APTC Number
17 Both APTC and CSR DET_MEDIAN_BOTH Number
18 Ineligible for APTC and CSR DET_MEDIAN_NEITHER Number
19 Total DET_MEDIAN_TOTAL Number

Sheet 10: Effectuated Time

Time to Effectuated Enrollment






Description: Data reflects median number of days (calendar days, not working days) for an individual to have effectuated enrollment. Effectuated enrollment is defined as when an individual is determined eligible for QHP enrollment, the SBM approved the QHP selection, and the individual has made the first premium payment. To identify the amount time involved, look back to calculate the number of days between submission of the completed application and first date of effectuated enrollment. A completed application is defined as an application with sufficient information to begin processing eligibility for any type of coverage (QHP or Medicaid/CHIP).
Unit: Number of individuals






Population Included: Individuals with effectuated enrollment that begins within the reference period. Metric excludes individuals that do not yet have effectuated enrollment or first had effectuated enrollment in the previous quarter (and have not changed QHP selection). If individuals changed QHP selection within the reference period, time should be calculated based on the number of days between when the marketplace recieves notification of the new QHP selection and effective enrollment in the new QHP.
Source for Data Breakouts: Most recent eligibility determination
First Reference Period: 10/1/2013-12/31/2013






Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.










State
(please select)




Reference Period
(please select)




Data type
(please select)












# Data Element Data Element Description Data Breakouts
(for more info, see Glossary tab)
Data Element Name Data Type Data from State
Individual Marketplace (SBM)- Does not include SHOP
1 Effectuated Enrollment- Median Time

Financial Assistance
Median number of calendar days between submission of completed application and effectuated enrollment (no decimals).

Includes only individuals receiving QHP coverage with financial assistance (APTC and/or CSR)
FPL <100% EFFECT_FIN_MEDIAN_FPL1 Number
2 ≥100 - ≤138% EFFECT_FIN_MEDIAN_FPL2 Number
3 >138 - ≤150% EFFECT_FIN_MEDIAN_FPL3 Number
4 >150 - ≤200% EFFECT_FIN_MEDIAN_FPL4 Number
5 >200 - ≤250% EFFECT_FIN_MEDIAN_FPL5 Number
6 >250 - ≤300% EFFECT_FIN_MEDIAN_FPL6 Number
7 >300- ≤400% EFFECT_FIN_MEDIAN_FPL7 Number
8 >400% EFFECT_FIN_MEDIAN_FPL8 Number
9 unknown EFFECT_FIN_MEDIAN_FPL9 Number
10 Channel web EFFECT_FIN_MEDIAN_WEB Number
11 phone EFFECT_FIN_MEDIAN_PHONE Number
12 paper EFFECT_FIN_MEDIAN_MAIL Number
13 other/unknown EFFECT_FIN_MEDIAN_OTHER Number
14 Application Assistance Any EFFECT_FIN_MEDIAN_ANY Number
15 None EFFECT_FIN_MEDIAN_NONE Number
16 Total EFFECT_FIN_MEDIAN_TOTAL Number
17 Effectuated Enrollment- Median Time

NO Financial Assistance
Median number of calendar days between submission of completed application and effectuated enrollment (no decimals).

Includes only individuals receiving QHP coverage without financial assistance (APTC and/or CSR)
Channel web EFFECT_NOFIN_MEDIAN_WEB Number
18 phone EFFECT_NOFIN_MEDIAN_PHONE Number
19 paper EFFECT_NOFIN_MEDIAN_MAIL Number
20 other/unknown EFFECT_NOFIN_MEDIAN_OTHER Number
21 Application Assistance Any EFFECT_NOFIN_MEDIAN_ANY Number
22 None EFFECT_NOFIN_MEDIAN_NONE Number
23 Total EFFECT_NOFIN_MEDIAN_TOTAL Number

Sheet 11: QHP eligible-assist

QHP Eligible Application Submission- By Type of Assistance






Description: Data used to report on QHP eligibles (both subsidized and unsubsidized) in the SBM (not SHOP) by type of assistance. This metric is intended to capture all recorded types of assistance either with submission of application for QHP enrollment or with selection of a QHP. CCIIO recognizes that some assistance is provided but not recorded, and therefore cannot be reported. Also, not all states have each of these types of asssistance. CCIIO does not distinguishing between certified and non-certified assistors; they are considered equivelent for the purposes of this layout. Individuals may have more than one type of assistance. If so, report all types of assistance for each individual. Additional information about assistance types in the glossary.

QHP Eligible-Any Assistance + QHP Eligible- No Assistance= Together these data elements should describe the universe individuals determined QHP eligible by the SBM during the reference period
Unit: Number of Individuals determined QHP eligilble during the reference period






Population Included: Any individual considered eligible for QHP enrollment (either provisional or final eligibility determination) during the reference period. Include individuals that have been determined eligible but may not have selected a QHP or paid an initial premium.
Source for Data Breakouts: Most recent eligibility determination. If individual has not yet received final eligibility determination, report data from provisional eligibility determination.
First Reference Period: 10/1/2013-12/31/2013






Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.










State
(please select)




Reference Period
(please select)




Data type
(please select)












# Data Element Data Element Description Data Breakouts
(for more info, see Glossary tab)
Data Element Name Data Type Data from State
Individual Marketplace (SBM)- Does not include SHOP
1 QHP eligible -Any assistance Number of QHP eligible individuals in the reference period that received any assistance FPL <100% ASSIST_ANY_FPL1 Number
2 ≥100 - ≤138% ASSIST_ANY_FPL2 Number
3 >138 - ≤150% ASSIST_ANY_FPL3 Number
4 >150 - ≤200% ASSIST_ANY_FPL4 Number
5 >200 - ≤250% ASSIST_ANY_FPL5 Number
6 >250 - ≤300% ASSIST_ANY_FPL6 Number
7 >300- ≤400% ASSIST_ANY_FPL7 Number
8 >400% ASSIST_ANY_FPL8 Number
9 unknown ASSIST_ANY_FPL9 Number
10 Channel web ASSIST_ANY_WEB Number
11 phone ASSIST_ANY_PHONE Number
12 paper ASSIST_ANY_PAPER Number
13 other/unknown ASSIST_ANY_OTHER Number
14 Total ASSIST_ANY_TOTAL Number
15 QHP eligible -No assistance Number of QHP eligible individuals in the reference period that did not receive any assistance FPL <100% ASSIST_NONE_FPL1 Number
16 ≥100 - ≤138% ASSIST_NONE_FPL2 Number
17 >138 - ≤150% ASSIST_NONE_FPL3 Number
18 >150 - ≤200% ASSIST_NONE_FPL4 Number
19 >200 - ≤250% ASSIST_NONE_FPL5 Number
20 >250 - ≤300% ASSIST_NONE_FPL6 Number
21 >300- ≤400% ASSIST_NONE_FPL7 Number
22 >400% ASSIST_NONE_FPL8 Number
23 unknown ASSIST_NONE_FPL9 Number
24 Channel web ASSIST_NONE_WEB Number
25 phone ASSIST_NONE_PHONE Number
26 paper ASSIST_NONE_PAPER Number
27 other/unknown ASSIST_NONE_OTHER Number
28 Total ASSIST_NONE_TOTAL Number
29 QHP eligible -Navigator Number of QHP eligible individuals in the reference period with assistance from a navigator FPL <100% ASSIST_NAV_FPL1 Number
30 ≥100 - ≤138% ASSIST_NAV_FPL2 Number
31 >138 - ≤150% ASSIST_NAV_FPL3 Number
32 >150 - ≤200% ASSIST_NAV_FPL4 Number
33 >200 - ≤250% ASSIST_NAV_FPL5 Number
34 >250 - ≤300% ASSIST_NAV_FPL6 Number
35 >300- ≤400% ASSIST_NAV_FPL7 Number
36 >400% ASSIST_NAV_FPL8 Number
37 unknown ASSIST_NAV_FPL9 Number
38 Channel web ASSIST_NAV_WEB Number
39 phone ASSIST_NAV_PHONE Number
40 paper ASSIST_NAV_PAPER Number
41 other/unknown ASSIST_NAV_OTHER Number
42 Total ASSIST_NAV_TOTAL Number
43 QHP eligible-IPA Number of QHP eligible individuals in the reference period with assistance from an In-Person Assister (IPA) FPL <100% ASSIST_IPA_FPL1 Number
44 ≥100 - ≤138% ASSIST_IPA_FPL2 Number
45 >138 - ≤150% ASSIST_IPA_FPL3 Number
46 >150 - ≤200% ASSIST_IPA_FPL4 Number
47 >200 - ≤250% ASSIST_IPA_FPL5 Number
48 >250 - ≤300% ASSIST_IPA_FPL6 Number
49 >300- ≤400% ASSIST_IPA_FPL7 Number
50 >400% ASSIST_IPA_FPL8 Number
51 unknown ASSIST_IPA_FPL9 Number
52 Channel web ASSIST_IPA_WEB Number
53 phone ASSIST_IPA_PHONE Number
54 paper ASSIST_IPA_PAPER Number
55 other/unknown ASSIST_IPA_OTHER Number
56 Total ASSIST_IPA_TOTAL Number
57 QHP eligible-CAC Number of QHP eligible individuals in the reference period with assistance from a Certified Application Councelor (CAC) FPL <100% ASSIST_CAC_FPL1 Number
58 ≥100 - ≤138% ASSIST_CAC_FPL2 Number
59 >138 - ≤150% ASSIST_CAC_FPL3 Number
60 >150 - ≤200% ASSIST_CAC_FPL4 Number
61 >200 - ≤250% ASSIST_CAC_FPL5 Number
62 >250 - ≤300% ASSIST_CAC_FPL6 Number
63 >300- ≤400% ASSIST_CAC_FPL7 Number
64 >400% ASSIST_CAC_FPL8 Number
65 unknown ASSIST_CAC_FPL9 Number
66 Channel web ASSIST_CAC_WEB Number
67 phone ASSIST_CAC_PHONE Number
68 paper ASSIST_CAC_PAPER Number
69 other/unknown ASSIST_CAC_OTHER Number
70 Total ASSIST_CAC_TOTAL Number
71 QHP eligible-Broker Number of QHP eligible individuals in the reference period with assistance from an Agent or a Broker (includes web broker) FPL <100% ASSIST_BKR_FPL1 Number
72 ≥100 - ≤138% ASSIST_BKR_FPL2 Number
73 >138 - ≤150% ASSIST_BKR_FPL3 Number
74 >150 - ≤200% ASSIST_BKR_FPL4 Number
75 >200 - ≤250% ASSIST_BKR_FPL5 Number
76 >250 - ≤300% ASSIST_BKR_FPL6 Number
77 >300- ≤400% ASSIST_BKR_FPL7 Number
78 >400% ASSIST_BKR_FPL8 Number
79 unknown ASSIST_BKR_FPL9 Number
80 Channel web ASSIST_BKR_WEB Number
81 phone ASSIST_BKR_PHONE Number
82 paper ASSIST_BKR_PAPER Number
83 other/unknown ASSIST_BKR_OTHER Number
84 Total ASSIST_BKR_TOTAL Number
85 QHP eligible-Authorized Rep Number of QHP eligible individuals in the reference period with assistance from an Authorized Representative FPL <100% ASSIST_AUTHREP_FPL1 Number
86 ≥100 - ≤138% ASSIST_AUTHREP_FPL2 Number
87 >138 - ≤150% ASSIST_AUTHREP_FPL3 Number
88 >150 - ≤200% ASSIST_AUTHREP_FPL4 Number
89 >200 - ≤250% ASSIST_AUTHREP_FPL5 Number
90 >250 - ≤300% ASSIST_AUTHREP_FPL6 Number
91 >300- ≤400% ASSIST_AUTHREP_FPL7 Number
92 >400% ASSIST_AUTHREP_FPL8 Number
93 unknown ASSIST_AUTHREP_FPL9 Number
94 Channel web ASSIST_AUTHREP_WEB Number
95 phone ASSIST_AUTHREP_PHONE Number
96 paper ASSIST_AUTHREP_PAPER Number
97 other/unknown ASSIST_AUTHREP_OTHER Number
98 Total ASSIST_AUTHREP_TOTAL Number
99 QHP eligible-other assistance Number of QHP eligible individuals in the reference period with assistance from an entity or person not in the list (e.g., Community Health Centers) FPL <100% ASSIST_OTHER_FPL1 Number
100 ≥100 - ≤138% ASSIST_OTHER_FPL2 Number
101 >138 - ≤150% ASSIST_OTHER_FPL3 Number
102 >150 - ≤200% ASSIST_OTHER_FPL4 Number
103 >200 - ≤250% ASSIST_OTHER_FPL5 Number
104 >250 - ≤300% ASSIST_OTHER_FPL6 Number
105 >300- ≤400% ASSIST_OTHER_FPL7 Number
106 >400% ASSIST_OTHER_FPL8 Number
107 unknown ASSIST_OTHER_FPL9 Number
108 Channel web ASSIST_OTHER_WEB Number
109 phone ASSIST_OTHER_PHONE Number
110 paper ASSIST_OTHER_PAPER Number
111 other/unknown ASSIST_OTHER_OTHER Number
112 Total ASSIST_OTHER_TOTAL Number

Sheet 12: Appeals

Appeals







Description: Data used to understand status of appeals and report median time to resolve appeals. Appeals of all types related to the SBM or SHOP marketplace are included in this metric (e.g., exemption from coverage, eligibility for financial assistance, level of assistance, special enrollment period, small employer eligibility for SHOP, etc). Data breakouts are specific to individual-level appeals. SHOP appeals may be included in the total but not in the data breakouts. Channel in data breakout related to the submission of the application not the appeal (for more information see the Glossary).

For appeals in which the marketplace's decision is contested and the appeal receives second consideration (for example, by an adminsitrative law judge), count the appeal once and based most recent decision. Scenario: An appeal is denied by the marketplace. The individual contests the decision and the appeal is in the process of being reviewed by an administrative law judge but the decision has not been made. For the purposes of the SBM supplemental data submission, the appeal should be considered "unresolved."

Unit: Number of Appeals







Population Included: Appeals submitted within the reference period. If date of submission is unavailable, use date of initiation of appeal. Includes only appeals managed by the state; excludes appeals managed by federal government (level 3).

Source for Data Breakouts: Most recent eligibility determination.

First Reference Period: 10/1/2013-12/31/2013







Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.












State
(please select)





Reference Period
(please select)





Data type
(please select)














# Data Element Data Element Description Data Breakouts
(for more info, see Glossary tab)
Data Element Name Data Type Data from State
Combined SBM and SHOP
1 Appeals-
Upheld
Number of appeals that were submitted during the reference period and upheld FPL <100% APPEAL_UPHLD_FPL1 Number

2 ≥100 - ≤138% APPEAL_UPHLD_FPL2 Number

3 >138 - ≤150% APPEAL_UPHLD_FPL3 Number

4 >150 - ≤200% APPEAL_UPHLD_FPL4 Number

5 >200 - ≤250% APPEAL_UPHLD_FPL5 Number

6 >250 - ≤300% APPEAL_UPHLD_FPL6 Number

7 >300- ≤400% APPEAL_UPHLD_FPL7 Number

8 >400% APPEAL_UPHLD_FPL8 Number

9 unknown APPEAL_UPHLD_FPL9 Number

10 Channel web APPEAL_UPHLD_WEB Number

11 phone APPEAL_UPHLD_PHONE Number

12 paper APPEAL_UPHLD_MAIL Number

13 other/unknown APPEAL_UPHLD_OTHER Number

14 Application Assistance Any APPEAL_UPHLD_ANY Number

15 None APPEAL_UPHLD_NONE Number

16 Total APPEAL_UPHLD_TOTAL Number

17 Appeals- Reversed Number of appeals that were submitted during the reference period and reversed FPL <100% APPEAL_RVSD_FPL1 Number

18 ≥100 - ≤138% APPEAL_RVSD_FPL2 Number

19 >138 - ≤150% APPEAL_RVSD_FPL3 Number

20 >150 - ≤200% APPEAL_RVSD_FPL4 Number

21 >200 - ≤250% APPEAL_RVSD_FPL5 Number

22 >250 - ≤300% APPEAL_RVSD_FPL6 Number

23 >300- ≤400% APPEAL_RVSD_FPL7 Number

24 >400% APPEAL_RVSD_FPL8 Number

25 unknown APPEAL_RVSD_FPL9 Number

26 Channel web APPEAL_RVSD_WEB Number

27 phone APPEAL_RVSD_PHONE Number

28 paper APPEAL_RVSD_MAIL Number

29 other/unknown APPEAL_RVSD_OTHER Number

30 Application Assistance Any APPEAL_RVSD_ANY Number

31 None APPEAL_RVSD_NONE Number

32 Total APPEAL_RVSD_TOTAL Number

33 Appeals- Withdrawn, Dismissed, or Halted Number of appeals that were submitted during the reference period and withdrawn, dismissed, or halted FPL <100% APPEAL_WDH_FPL1 Number

34 ≥100 - ≤138% APPEAL_WDH_FPL2 Number

35 >138 - ≤150% APPEAL_WDH_FPL3 Number

36 >150 - ≤200% APPEAL_WDH_FPL4 Number

37 >200 - ≤250% APPEAL_WDH_FPL5 Number

38 >250 - ≤300% APPEAL_WDH_FPL6 Number

39 >300- ≤400% APPEAL_WDH_FPL7 Number

40 >400% APPEAL_WDH_FPL8 Number

41 unknown APPEAL_WDH_FPL9 Number

42 Channel web APPEAL_WDH_WEB Number

43 phone APPEAL_WDH_PHONE Number

44 paper APPEAL_WDH_MAIL Number

45 other/unknown APPEAL_WDH_OTHER Number

46 Application Assistance Any APPEAL_WDH_ANY Number

47 None APPEAL_WDH_NONE Number

48 Total APPEAL_WDH_TOTAL Number

49 Appeals- unresolved Number of appeals that were submitted during the reference period and remain unresolved (meaning in progress or pending and not halted) FPL <100% APPEAL_UNRES_FPL1 Number

50 ≥100 - ≤138% APPEAL_UNRES_FPL2 Number

51 >138 - ≤150% APPEAL_UNRES_FPL3 Number

52 >150 - ≤200% APPEAL_UNRES_FPL4 Number

53 >200 - ≤250% APPEAL_UNRES_FPL5 Number

54 >250 - ≤300% APPEAL_UNRES_FPL6 Number

55 >300- ≤400% APPEAL_UNRES_FPL7 Number

56 >400% APPEAL_UNRES_FPL8 Number

57 unknown APPEAL_UNRES_FPL9 Number

58 Channel web APPEAL_UNRES_WEB Number

59 phone APPEAL_UNRES_PHONE Number

60 paper APPEAL_UNRES_MAIL Number

61 other/unknown APPEAL_UNRES_OTHER Number

62 Application Assistance Any APPEAL_UNRES_ANY Number

63 None APPEAL_UNRES_NONE Number

64 Total APPEAL_UNRES_TOTAL Number

65 Appeals-
Median Time
Median number of calendar days to resolve appeals that were submitted during the reference period. Only include appeals that were upheld or reversed. (no decimals) FPL <100% APPEAL_MEDIAN_FPL1 Number

66 ≥100 - ≤138% APPEAL_MEDIAN_FPL2 Number

67 >138 - ≤150% APPEAL_MEDIAN_FPL3 Number

68 >150 - ≤200% APPEAL_MEDIAN_FPL4 Number
69 >200 - ≤250% APPEAL_MEDIAN_FPL5 Number

70 >250 - ≤300% APPEAL_MEDIAN_FPL6 Number

71 >300- ≤400% APPEAL_MEDIAN_FPL7 Number

72 >400% APPEAL_MEDIAN_FPL8 Number

73 unknown APPEAL_MEDIAN_FPL9 Number

74 Channel web APPEAL_MEDIAN_WEB Number

75 phone APPEAL_MEDIAN_PHONE Number

76 paper APPEAL_MEDIAN_MAIL Number

77 other/unknown APPEAL_MEDIAN_OTHER Number

78 Application Assistance Any APPEAL_MEDIAN_ANY Number

79 None APPEAL_MEDIAN_NONE Number

80 Total APPEAL_MEDIAN_TOTAL Number


Sheet 13: SHOP

SHOP






Description: Data used to report employer and employee SHOP activity. This is the only metric to include data elements about dental coverage. Data elements about dependents includes both spouse/partner and children (≤25 yrs). Enrolled means first premium payment by employer and employee submitted.
Unit: Varies by data element






Population Included: Varies by data element
Source for Data Breakouts: Group size is the only data breakout and refers to number of employees on census submitted by the employer to the SHOP
First Reference Period: 10/1/2013-12/31/2013






Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.










State
(please select)




Reference Period
(please select)




Data type
(please select)












# Data Element Data Element Description Data Breakouts Data Element Name Data Type Data from State
SHOP






1 Employers Total number of employers that submitted a complete application for enrollment in the SHOP during the reference period Total SHOP_EMP_APP Number
2 Total number of employers enrolled in SHOP during the reference period, by group size Group Size- Enrolled Employees Employees=1 SHOP_EMP_ENR1 Number
3 2<=Employees<=5 SHOP_EMP_ENR2 Number
4 6<=Employees<=9 SHOP_EMP_ENR6 Number
5 10<=Employees<=24 SHOP_EMP_ENR10 Number
6 25<=Employees<=49 SHOP_EMP_ENR25 Number
7 50<=Employees<=74 SHOP_EMP_ENR50 Number
8 75<=Employees<=100 SHOP_EMP_ENR75 Number
9 Total SHOP_EMP_ENRTOT Number
10 Average group size of enrolled employees among all employers enrolled in SHOP during the reference period Average across all employers SHOP_EMP_ENRAVG Number
11 Total number of employers offering dependent medical coverage at some point during the reference period Total SHOP_EMP_DEP Number
12 Total number of employers offering stand-alone dental coverage at some point during the reference period Total SHOP_EMP_DENTAL Number
13 Employee Choice Total number of employers offering one choice of medical QHPs to employees Total SHOP_EMP_CHOICE1 Number
14 Total number of employers offering two or more medical QHPs to employees Total SHOP_EMP_CHOICE2 Number
15 Total number of employers offering all QHPs at a single metal level of coverage (states where employers cannot offer more than one QHP should enter -999 for not applicable) Total SHOP_EMP_CHOICE3 Number
16 Total number of employers offering all QHPs at all metal levels of coverage (states where employers cannot offer more than one QHP should enter -999 for not applicable) Total SHOP_EMP_CHOICE4 Number
17 Total number of employers offering QHPs from a single insurance carrier across all metal levels of coverage (states where employers cannot offer more than one QHP should enter -999 for not applicable) Total SHOP_EMP_CHOICE5 Number
18 Total number of employers offering all insurance carriers across two contiguous metal levels of coverage (states where employers cannot offer more than one QHP should enter -999 for not applicable) Total SHOP_EMP_CHOICE6 Number
19 Employees Total number of employees on the roster/census submitted by employers as of the last day in reference period- medical coverage only (excluding dependents) Group Size- Employees on Roster Employees=1 SHOP_EE_ROSTER1 Number
20 2<=Employees<=5 SHOP_EE_ROSTER2 Number
21 6<=Employees<=9 SHOP_EE_ROSTER6 Number
22 10<=Employees<=24 SHOP_EE_ROSTER10 Number
23 25<=Employees<=49 SHOP_EE_ROSTER25 Number
24 50<=Employees<=74 SHOP_EE_ROSTER50 Number
25 75<=Employees<=100 SHOP_EE_ROSTER75 Number
26 Total SHOP_EE_ROSTERTOT Number
27 Average number of employees on the roster/census submitted by employers as of the last day in the reference period- medical coverage only (excluding dependents) Average across all employers SHOP_EE_ROSTERAVG Number
28 Among employers that submitted a roster during the reference period, total number of enrolled employees as of the last day in the reference period - medical coverage only Group Size- Enrolled Employees Employees=1 SHOP_EE_ENR1 Number
29 2<=Employees<=5 SHOP_EE_ENR2 Number
30 6<=Employees<=9 SHOP_EE_ENR6 Number
31 10<=Employees<=24 SHOP_EE_ENR10 Number
32 25<=Employees<=49 SHOP_EE_ENR25 Number
33 50<=Employees<=74 SHOP_EE_ENR50 Number
34 75<=Employees<=100 SHOP_EE_ENR75 Number
35 Total SHOP_EE_ENR Number
36 Among employers that submitted a roster during the reference period, average number of enrolled employees per employer as of the last day of the reference period- medical coverage only Group Size- Enrolled Employees Employees=1 SHOP_EE_ENRAVG1 Number
37 2<=Employees<=5 SHOP_EE_ENRAVG2 Number
38 6<=Employees<=9 SHOP_EE_ENRAVG6 Number
39 10<=Employees<=24 SHOP_EE_ENRAVG10 Number
40 25<=Employees<=49 SHOP_EE_ENRAVG25 Number
41 50<=Employees<=74 SHOP_EE_ENRAVG50 Number
42 75<=Employees<=100 SHOP_EE_ENRAVG75 Number
43 Total SHOP_EE_ENRAVG Number
44 Average participation rate in medical QHPs per employer as of the last day in the reference period.

Participation rate in medical QHPs is the number of qualified employees accepting coverage under the employer's group health plan, divided by the number of qualified employees offered coverage. Excluded from the calculation are any employee who, at the time the employer submits the SHOP application, is enrolled in coverage through another employer's group health plan or through a governmental plan such as Medicare, Medicaid, or TRICARE. Retirees and COBRA enrollees that are included on the employer’s roster are included in the denominator of the participation rate calculation.
Average across all employers SHOP_EE_PARTICIPATION Number
45 Contribution Average percent employer premium contribution for employees that enrolled in medical coverage through SHOP as of the last day in the reference period Group Size- Enrolled Employees Employees=1 SHOP_CONT_EEMED1 Number
46 2<=Employees<=5 SHOP_CONT_EEMED2 Number
47 6<=Employees<=9 SHOP_CONT_EEMED6 Number
48 10<=Employees<=24 SHOP_CONT_EEMED10 Number
49 25<=Employees<=49 SHOP_CONT_EEMED25 Number
50 50<=Employees<=74 SHOP_CONT_EEMED50 Number
51 75<=Employees<=100 SHOP_CONT_EEMED75 Number
52 Average across all employers SHOP_CONT_EEMED Number
53 Assistance-
Employers
Total number of agents/brokers registered for SHOP (including web brokers or related organizations such as third party assistors).

Some states may not register agents/broker with the SHOP only, but instead register agents/broker with the marketplace (individual and SHOP combined). In that case, please report the number of agents/brokers registered with the marketplace
Total SHOP_ASSIST_TOTBKR Number
54 Total number of employer applications submitted with agent/broker assistance (including web brokers or related organizations such as third party assistors) as of the last day in the reference period Group Size- Enrolled Employees Employees=1 SHOP_ASSIST_BKR1 Number
55 2<=Employees<=5 SHOP_ASSIST_BKR2 Number
56 6<=Employees<=9 SHOP_ASSIST_BKR6 Number
57 10<=Employees<=24 SHOP_ASSIST_BKR10 Number
58 25<=Employees<=49 SHOP_ASSIST_BKR25 Number
59 50<=Employees<=74 SHOP_ASSIST_BKR50 Number
60 75<=Employees<=100 SHOP_ASSIST_BKR75 Number
61 Total SHOP_ASSIST_BKR Number
62 Total number of employer applications submitted with Navigator assistance Total SHOP_ASSIST_NAV Number
63 Total number of employer applications submitted with a assistance other than from agent/broker or navigator Total SHOP_ASSIST_OTHER Number
64 Total number of employer applications submitted without any recorded assistance Total SHOP_ASSIST_NONE Number
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Sheet 14: Complaints

Complaints






Description: Data used to understand number, type, and resolution time of complaints about the marketplace that were submitted during the reference period. Include only complaints that were accepted by the SBM (e.g., considered actionable by the SBM) and not transferred to a different organization (e.g., an insurance carrier or regulator with authority formally investigate).
Unit: Number of complaints or number of calendar days






Population Included: Includes all complaints associated with both the SBM and the SHOP that were submitted during the reference period and accepted by the SBM. Average time calculation excludes complaints that are unresolved at the end of the reference period.
Source for Data Breakouts: N/A
First Reference Period: 10/1/2013-12/31/2013






Notes: If no data matches the restrictions of a particular data element, enter "0" (zero). If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.










State
(please select)




Reference Period
(please select)




Data type
(please select)












# Data Element Data Element Description Data Breakouts
(for more info, see Glossary tab)
Data Element Name Data Type Data from State
Combined SBM and SHOP
1 Number of Complaints Number of complaints submitted during the reference period that were resolved or unresolved as of the last day in the reference period Complaint Status Resolved COMPLAINTS_RESOLVED Number
2 Unresolved COMPLAINTS_UNRESOLVED Number
3 Total Number of Complaints
COMPLAINTS_TOTAL Number
4 Time to Resolve Complaints Among complaints submitted during the reference period, average time to resolve complaint. Exclude complaints that were unresolved as of the last day of the reference period.

Report average calendar days, no decimals
Average Number of Days COMPLAINTS_RESOLVEDTIME Number
5 Complaints by Topic Number of complaints submitted during the reference period and associated with the following topics Difficulties with website COMPLAINTS_WEB Text
6 Difficulties with phone contact COMPLAINTS_PHONE Text
7 Problem with plan/benefit COMPLAINTS_PLAN Text
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

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