Form CMS-10398 Performance Indicator Specification Template

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Overview

Instructions
Data Source Definitions
Call Centers (#1-3)
Applications (#5)
Transfers (#6)
Renewals (#7)
Enrollment (#8)
Eligible (#9)
Ineligible (#10)
Pending (#11)
Processing time (#12)

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Sheet 1: Instructions

OMB Control Number 0938-1148
Expiration date: 10/31/2014

Instructions

CMS is documenting the status of states' current capabilities to report the monthly Medicaid/CHIP performance indicators using the correct specifications and by the requested deadline, as well the time frame in which states not currently reporting to specification will be able to do so.

As a reminder, the detailed specifications for each indicator can be found in the Performance Indicators Data Dictionary at: http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/Performance-Indicators-DataDictionary.pdf. Other technical assistance resources, including FAQs, can be found on Medicaid.gov's Performance Indicator Technical Assistance page: http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/SDIS.html.

Within this document, each tab represents one of the 11 monthly performance indicators, with the exception of the first tab, which includes all three call center indicators. Please note that indicator #4, the weekly applications indicator, is no longer being collected and thus is not represented here. This document has been customized to reflect the data elements that your state is expected to report, based on whether you have a separate CHIP agency and whether marketplace applications are determined by a state-based marketplace (SBM) or determined or assessed by the federally-facilitated marketplace (FFM). "N.R." (not reported) values in Section A of the questionnaire indicate data elements within each indicator that your state is not expected to report.

On each tab, please provide information on the state data system(s) most immediately used to produce the performance indicator, including the name of the data source and the type of data (see Data Source Definitions tab). For each data element where "N/A" is not pre-populated, please answer each question about your state's capability to report the data on-time and to specification. Gray boxes indicate places where your response is required. If any data element within an indicator does not meet the specification or is not being reported on-time, you must answer all four questions in Section E of the tab. Your response in Section E should explain how your reported data deviates from the specification, how your state plans to address the deviation and the timeline for doing so.

Please submit your responses by MM/DD/YYYY to [email protected]. If you have any questions, please email them to [email protected].

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Sheet 2: Data Source Definitions

Definitions of Types of Data Sources
MMIS	Contains all or partial Medicaid and CHIP claims data from the additional claims data sources listed herein. MMIS is the primary state system that adjudicates claims. States can accept claims from providers using HIPAA EDI standard transactions electronically (i.e. 837 Professional, 837 Inpatient, 837 RX) or through HIPAA paper-based claims (e.g., CMS-1500 form).
Other claims systems	Contains claims data for specialized Medicaid or CHIP programs or providers.
Eligibility Determination System	Contains all data elements necessary to process and issue eligibility determinations for Medicaid and CHIP, and frequently the state maintains an integrated system with other public health assistance programs such as SNAP and TANF.
Data Warehouse	Contains an assortment of claims, eligibility, provider, encounter, and health plan data from one or many of the other data sources on this list.
Combination of systems	Combination of systems identified above (report each system if known based on the above list - on individual rows - or use this code to report a combination of other systems.
Other system	A system not listed above, or the source is not a system (e.g., manual, paper-based, etc.).

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Sheet 3: Call Centers (#1-3)

Indicators #1 - 3: Total Call Center Volume, Average Call Center Wait Time, and Average Call Center Abandonment Rate
Definition, Call Center Volume: The total number of calls received by each call center during the calendar month. The top-line total should equal the sum of the call volume at each individual call center reported.
Definition, Average Call Center Wait Time: The average wait time in whole minutes for calls received by each call center during the calendar month. If the state tracks wait time in seconds, round increments of 0 to 29 seconds down to the nearest whole minute, and round increments of 30 to 59 seconds up to the nearest whole minute. If the average wait time is less than 29 seconds, enter 0 and provide an explanation in the data limitations field. If average wait time cannot be provided, leave this field blank (missing) and provide an explanation in the data limitations field.The top-line total should be calculated as the weighted average of each individual call center’s wait time during the calendar month.
Definition, Average Call Center Abandonment Rate: For each call center or helpline reported in Indicator 1, the abandonment rate equals the number of calls abandoned by caller (numerator) divided by total call volume (denominator). The acceptable range for this number is between 0 and 1, with a zero value representing 0% (no calls abandoned), a value of 0.5 representing 50% (half of calls are abandoned), and a value of one representing 100% (all calls abandoned). The top-line total should be calculated as the weighted average of each individual call center’s abandonment rate during the calendar month.
Data source name(s) (name of state system or systems):	Please fill
State agencies responsible for data source(s) and reporting:	Please fill
Type of data (see definitions tab for more information):	MMIS/Other claims systems/Eligibility Determination System/Data Warehouse/Combination of systems/Other systems
If "type" is "combination of systems" or "other systems," please explain:	Please fill
Most recently-reported data limitations for these indicators:
Call Center Volume	pre-populated
Average Wait Time	pre-populated
Average Abandonment Rate	pre-populated
Please answer the following questions about your current reporting capabilities for each data element in these measures. Gray boxes indicate places where your response is required.
	Total Call Center Volume (1)	Average Call Center Wait Time (2)	Average Call Center Abandonment Rate (3)
a. Are you currently able to report the measure on the 8th of every month?	yes/no	yes/no	yes/no
b. The previous month's data does not need to be updated when reporting these measures.	N/A	N/A	N/A
c. Are you currently reporting the measure to exact specification?	yes/no	yes/no	yes/no
Please note yes/no for each requirement for each indicator:
1. Includes all or most calls to the state related to Medicaid/CHIP applications and enrollment	yes/no	yes/no	yes/no
2. Excludes calls to the call center operated by the SBM (these calls should not be included)	yes/no	yes/no	yes/no
3. Includes calls received outside of call center business hours	yes/no	yes/no	yes/no
4. Includes calls handled by automated system that are not transferred to a live agent	yes/no	yes/no	yes/no
5. Wait time is reported in whole minutes and not seconds	N/A	yes/no	N/A
6. Non-applicable data elements are left blank, and not reported as zero	yes/no	yes/no	yes/no
d. Other questions
1. In the June data, total overall call center volume is the sum of the volume reported for each call center	pre-populated
2. In the June data, average overall wait time and abandonment rate are weighted averages of each call center	pre-populated
[State-specific questions about known data issues, if any, here]	Please fill
e. If you reported "no" to any question above, or if any element is not being reported to specification for other reasons, please answer the following questions. Be sure to address each separate instance in which you answered "no" above:
1. If you are not currently reporting or regularly updating data, when do you expect to be able to report and/or regularly update data?	MM/YYYY
2. How does the reported data (or the data you plan to report) differ from the required specification? (If the only way it differs has been explained in most recent data limitation, please indicate that here.)	Please fill
3. What steps is the state taking to bring reporting in line with the specifications (or report data that has previously not been reported)?	Please fill
4. When do you expect the data to be reported to specification?	MM/YYYY

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Sheet 4: Applications (#5)

Indicator #5: Applications Received
Definition: Total number of applications received by any state agency with the authority to make Medicaid/CHIP eligibility determinations, including the Medicaid agency, a separate CHIP agency (if one exists in the state), and a state-based marketplace (if one exists in the state) during the calendar month. Applications for both MAGI and non-MAGI populations should be included. Report applications received through all doorways, including those received by a separate CHIP agency or state-based marketplace (SBM), and not just applications received directly by the Medicaid agency. Accounts transferred from the FFM are not included in this indicator, and should be instead be reported under indicator 6 (Number of Electronic Accounts Transferred).
Data source name(s) (name of state system or systems):	Please fill
State agencies responsible for data source(s) and reporting:	Please fill
Type of data: (see definitions tab for more information)	MMIS/Other claims systems/Eligibility Determination System/Data Warehouse/Combination of systems/Other systems
If "type" is "combination of systems" or "other systems," please explain:	Please fill
Most recently-reported data limitation for this indicator:	pre-populated
Please answer the following questions about your current reporting capabilities for each data element in this measure. Gray boxes indicate places where your response is required.
	Total applications (5a)	Applications received by Medicaid agency (5b)	Applications received by Medicaid agency, by channel (5c - 5g)	Applications received by CHIP agency (5h)	Applications received by CHIP agency, by channel (5i - 5m)	Applications received by state-based marketplace (5n)
a. Are you currently able to report the measure on the 8th of every month?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
b. Are you regularly updating the past month's data each month (e.g. updating March data when submitting April data)?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
If you are updating your data, are you only updating it when submitting the next month's data, and not updating again after that time?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
c. Are you currently reporting the measure to exact specification?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
Please note yes/no for each requirement for each indicator:
1. Includes applications from MAGI and non-MAGI populations	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
2. Applications received by separate CHIP agency reported only in 5a, and 5h-5m (and excluded from 5b-5g)	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
3. Includes all applications requesting financial assistance received by SBM	yes/no	N/A	N/A	N/A	N/A	yes/no
4. Excludes applications not requesting financial assistance received by SBM	yes/no	N/A	N/A	N/A	N/A	yes/no
5. Excludes account transfers from FFM (should not be included)	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
6. Includes all paper, online, and telephone applications	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
7. Includes applicants for partial-benefit programs	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
8. Excludes individuals administratively enrolled without filling out an application (such as SSI recipients who are auto-enrolled, or enrollments via Express Lane Eligibility)	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
9. Non-applicable data elements are left blank, and not reported as zero	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
d. Other questions
1. In the June data, applications received by Medicaid agency (5b), CHIP agency (5h), and SBM (5n) sum to total applications (5a)	pre-populated
2. In the June data, applications by channel (5c+5d+5e+5f+5g) sum to applications received by Medicaid agency (5b)	pre-populated
3. In the June data, applications by channel (5i+5j+5k+5l+5m) sum to applications received by CHIP agency (5h)	pre-populated
[State-specific questions about known data issues, if any, here]	Please fill
e. If you reported "no" to any question above, or if any element is not being reported to specification for other reasons, please answer the following questions. Be sure to address each separate instance in which you answered "no" above:
1. If you are not currently reporting or regularly updating data, when do you expect to be able to report and/or regularly update data?	MM/YYYY
2. How does the reported data (or the data you plan to report) differ from the required specification? (If the only way it differs has been explained in most recent data limitation, please indicate that here.)	Please fill
3. What steps is the state taking to bring reporting in line with the specifications (or report data that has previously not been reported)?	Please fill
4. When do you expect the data to be reported to specification?	MM/YYYY

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Sheet 5: Transfers (#6)

Indicator #6: Number of Electronic Accounts Transferred
Definition: Total number of accounts electronically transferred from the FFM to the Medicaid/CHIP agency during the calendar month. SBMs should not report transfers. Accounts moving between a new integrated system and a legacy system should not be included. An account is defined as the set of application and verification data necessary to make an eligibility determination for an insurance affordability program as required in §435.1200. Only electronic account transfers should be included; case referrals should not be included if an electronic account transfer is not made. This indicator should include both assessments and determinations of eligibility made by the FFM before transfer to the Medicaid/CHIP agency during the calendar month, as well as non-MAGI referrals and requests for a full Medicaid determination.This indicator should be left as blank (indicating “not applicable”) for all reports until the state begins to receive FFM account transfers. Accounts in the ‘flat file’ should not be counted (as the accounts will be subsequently transferred through electronic account transfer). Indicator 6a may be less than the sum of indicators 6e through 6h.
Data source name(s) (name of state system or systems):	Please fill
State agencies responsible for data source(s) and reporting:	Please fill
Type of data: (see definitions tab for more information)	MMIS/Other claims systems/Eligibility Determination System/Data Warehouse/Combination of systems/Other systems
If "type" is "combination of systems" or "other systems," please explain:	Please fill
Most recently-reported data limitation for this indicator:	pre-populated
Please answer the following questions about your current reporting capabilities for each data element in this measure. Gray boxes indicate places where your response is required.
	Total transfer accounts received (6a)	Total transfer accounts received, by transfer type (6e - 6h)	Total transfer accounts sent to FFM (6j)
a. Are you currently able to report the measure on the 8th of every month?	yes/no	yes/no	yes/no
b. Are you regularly updating the past month's data each month (e.g. updating March data when submitting April data)?	yes/no	yes/no	yes/no
If you are updating your data, are you only updating it when submitting the next month's data, and not updating again after that time?	yes/no	yes/no	yes/no
c. Are you currently reporting the measure to exact specification?	yes/no	yes/no	yes/no
Please note yes/no for each requirement for each indicator:
1. Includes all account transfers from FFM, including those later determined ineligible	yes/no	yes/no	N/A
2. Includes all account transfers from FFM, including those later determined eligible for partial benefits	yes/no	yes/no	N/A
3. Includes all accounts transferred to FFM	N/A	N/A	yes/no
4. Includes only electronic account transfers and excludes records submitted in the flat file	yes/no	yes/no	N/A
5. Excludes transfers between state's legacy and new eligibility systems (should not be included)	yes/no	yes/no	yes/no
6. Non-applicable data elements are left blank, and not reported as zero	yes/no	yes/no	yes/no
d. Other questions
[State-specific questions about known data issues, if any, here]	Please fill
e. If you reported "no" to any question above, or if any element is not being reported to specification for other reasons, please answer the following questions. Be sure to address each separate instance in which you answered "no" above:
1. If you are not currently reporting or regularly updating data, when do you expect to be able to report and/or regularly update data?	MM/YYYY
2. How does the reported data (or the data you plan to report) differ from the required specification? (If the only way it differs has been explained in most recent data limitation, please indicate that here.)	Please fill
3. What steps is the state taking to bring reporting in line with the specifications (or report data that has previously not been reported)?	Please fill
4. When do you expect the data to be reported to specification?	MM/YYYY

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Sheet 6: Renewals (#7)

Indicator #7: Number of Renewals
Definition: Total number of annual renewals that came up for redetermination by the Medicaid or CHIP agency during the calendar month. These data should include annual renewals only, and exclude beneficiaries redetermined due to a change in circumstances. All annual renewals that came up for redetermination should be included, regardless of the disposition (including pending, determined eligible, determined ineligible, and/or ineligible due to failure to return documentation). If a state has a waiver granted under section 1115 or section 1902(e)(14)(A) of the Social Security Act to delay renewals in 2013 and 2014, those renewals should be reported in the month in 2014 in which the renewal actually occurs, not in the month that the renewal would have occurred without the waiver.
Data source name(s) (name of state system or systems):	Please fill
State agencies responsible for data source(s) and reporting:	Please fill
Type of data: (see definitions tab for more information)	MMIS/Other claims systems/Eligibility Determination System/Data Warehouse/Combination of systems/Other systems
If "type" is "combination of systems" or "other systems," please explain:	Please fill
Most recently-reported data limitation for this indicator:	pre-populated
Please answer the following questions about your current reporting capabilities for each data element in this measure. Gray boxes indicate places where your response is required.
	Total number of renewals up for redetermination (7a)	Medicaid MAGI renewals (7b)	Medicaid non-MAGI renewals (7c)	CHIP renewals (7d)	Renewals of unknown type (7e)
a. Are you currently able to report the measure on the 8th of every month?	yes/no	yes/no	yes/no	yes/no	yes/no
b. Are you regularly updating the past month's data each month (e.g. updating March data when submitting April data)?	yes/no	yes/no	yes/no	yes/no	yes/no
If you are updating your data, are you only updating it when submitting the next month's data, and not updating again after that time?	yes/no	yes/no	yes/no	yes/no	yes/no
c. Are you currently reporting the measure to exact specification?	yes/no	yes/no	yes/no	yes/no	yes/no
Please note yes/no for each requirement for each indicator:
1. Excludes renewals occurring outside the annual redetermination process (including redeterminations based on change in circumstance)	yes/no	yes/no	yes/no	yes/no	yes/no
2. Includes all who are due for annual renewal in the month (regardless of the disposition of the renewal at the end of the month as currently pending, determined eligible, or determined ineligible)	yes/no	yes/no	yes/no	yes/no	yes/no
3. Includes renewals for beneficiaries in partial-benefit programs	yes/no	yes/no	yes/no	yes/no	yes/no
4. Includes renewals for all individuals funded under Title XXI in either M-CHIP or S-CHIP programs	yes/no	N/A	N/A	yes/no	N/A
5. Excludes renewals for all individuals funded under Title XXI in either M-CHIP or S-CHIP programs	N/A	yes/no	yes/no	N/A	N/A
6. Delayed renewals approved under a waiver are reported in month the renewal actually occurred, not in the month that the renewal would have occurred without the waiver	yes/no	yes/no	yes/no	yes/no	yes/no
7. Non-applicable data elements are left blank, and not reported as zero	yes/no	yes/no	yes/no	yes/no	yes/no
d. Other questions
1. In June data, renewals by determination type (7b+7c+7d+7e) sum to total renewals (7a)	pre-populated
2. Is this indicator reported at the individual or the household/case level?	Please fill
[State-specific questions about known data issues, if any, here]	Please fill
e. If you reported "no" to any question above, or if any element is not being reported to specification for other reasons, please answer the following questions. Be sure to address each separate instance in which you answered "no" above:
1. If you are not currently reporting or regularly updating data, when do you expect to be able to report and/or regularly update data?	MM/YYYY
2. How does the reported data (or the data you plan to report) differ from the required specification? (If the only way it differs has been explained in most recent data limitation, please indicate that here.)	Please fill
3. What steps is the state taking to bring reporting in line with the specifications (or report data that has previously not been reported)?	Please fill
4. When do you expect the data to be reported to specification?	MM/YYYY

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Sheet 7: Enrollment (#8)

Indicator #8: Total Enrollment
Definition, Medicaid enrollment: Total unduplicated number of individuals enrolled in Medicaid (i.e. funded under title XIX of the Social Security Act) as of the last day of the calendar month, including those with retroactive, conditional, and presumptive eligibility. This indicator is a point-in-time count of total program enrollment, and not solely a count of those newly enrolled during the calendar month. Include only those individuals who are eligible for comprehensive benefits (i.e., emergency Medicaid, family planning-only coverage and limited benefit dual eligible individuals should not be included). Medicaid 1115 Waiver populations should be included as long as the benefits are comprehensive. All individuals whose coverage is funded under title XXI of the Social Security Act, including through MCHIP programs are excluded from this indicator.
Definition, CHIP enrollment: Total unduplicated number of individuals enrolled in CHIP (i.e., funded under Title XXI of the Social Security Act, including through MCHIP programs) as of the last day of the calendar month, including those with retroactive, conditional, and presumptive eligibility. CHIP children in a premium grace period should be included, while CHIP children subject to a waiting period or premium lock-out period are considered eligible but not enrolled and should be excluded. Include only those individuals who are eligible for comprehensive benefits. This indicator is a point-in-time count of total program enrollment, and not solely a count of those newly enrolled during the calendar month.
Data source name(s) (name of state system or systems):	Please fill
State agencies responsible for data source(s) and reporting:	Please fill
Type of data: (see definitions tab for more information)	MMIS/Other claims systems/Eligibility Determination System/Data Warehouse/Combination of systems/Other systems
If "type" is "combination of systems" or "other systems," please explain:	Please fill
Most recently-reported data limitation for this indicator:	pre-populated
Please answer the following questions about your current reporting capabilities for each data element in this measure. Gray boxes indicate places where your response is required.
	Total Medicaid enrollees (8a)	Medicaid MAGI enrollees (8b)	Medicaid MAGI enrollees, by age group (8c - 8d)	Medicaid non-MAGI enrollees (8e)	Medicaid non-MAGI enrollees, by age group (8f - 8g)	CHIP enrollees (8h)
a. Are you currently able to report the measure on the 8th of every month?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
b. Are you regularly updating the past month's data each month (e.g. updating March data when submitting April data)?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
If you are updating your data, are you only updating it when submitting the next month's data, and not updating again after that time?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
c. Are you currently reporting the measure to exact specification?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
Please note yes/no for each requirement for each indicator:
1. Provides an unduplicated count	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
2. Count is of the last day of the month	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
3. Provides a point in time count of enrollment, and not a count of anyone enrolled at any point in the month	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
4. Excludes enrollees only eligible for partial benefits	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
5. Includes share-of-cost and 1115 waiver enrollees if they receive full benefits	yes/no	yes/no	yes/no	yes/no	yes/no	N/A
6. Includes only individuals funded under Title XIX (ie, excludes M-CHIP children)	yes/no	yes/no	yes/no	yes/no	yes/no	N/A
7. Includes all individuals funded under Title XXI (ie, includes M-CHIP children)	N/A	N/A	N/A	N/A	N/A	yes/no
8. MAGI-specific subindicators include all enrolled individuals who likely qualify for a MAGI group, even if the individual has not yet been subject to a MAGI determination	N/A	yes/no	yes/no	N/A	N/A	N/A
9. Non-applicable data elements are left blank, and not reported as zero	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
d. Other questions
1. In June data, Medicaid MAGI (8b) and non-MAGI (8e) enrollees sum to total Medicaid enrollees (8a)	pre-populated
2. In June data, Medicaid MAGI child (8c) and adult (8d) enrollees sum to total MAGI enrollees (8b)	pre-populated
3. In June data, Medicaid non-MAGI child (8f) and adult (8g) enrollees sum to total non-MAGI enrollees (8e)	pre-populated
[State-specific questions about known data issues, if any, here]	Please fill
e. If you reported "no" to any question above, or if any element is not being reported to specification for other reasons, please answer the following questions. Be sure to address each separate instance in which you answered "no" above:
1. If you are not currently reporting or regularly updating data, when do you expect to be able to report and/or regularly update data?	MM/YYYY
2. How does the reported data (or the data you plan to report) differ from the required specification? (If the only way it differs has been explained in most recent data limitation, please indicate that here.)	Please fill
3. What steps is the state taking to bring reporting in line with the specifications (or report data that has previously not been reported)?	Please fill
4. When do you expect the data to be reported to specification?	MM/YYYY

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Sheet 8: Eligible (#9)

Indicator #9: Total Number of Individuals Determined Eligible
Definition, Medicaid eligible: Total number of individuals determined eligible for Medicaid (i.e. funded under title XIX of the Social Security Act) under either MAGI or non-MAGI rules during the calendar month. This count should include determinations following an initial application as well as all redeterminations (triggered by either the annual renewal process or other change in circumstances). Individuals determined eligible for CHIP (i.e. funded under Title XXI of the Social Security Act, including through MCHIP programs) are not included in this indicator. All determinations made in the calendar month should be included, even if the individual will not be enrolled into the program during the calendar month or is found retroactively eligible. Include final determinations made by any state agency, including the Medicaid agency, a separate CHIP agency, and an SBM. Include determinations made on accounts assessed by the FFM and transferred to Medicaid for final determination. Do not include final eligibility determinations made by the FFM and transferred to Medicaid for enrollment. If an individual receives a MAGI and then a non-MAGI determination, both of these separate determinations should be counted.
Definition, CHIP eligible: Total number of individuals determined eligible for CHIP (i.e. funded under Title XXI of the Social Security Act, including through MCHIP programs) during the calendar month. This number should include determinations following an initial application as well as all redeterminations (triggered by either the annual renewal process or other change in circumstances). All determinations made in the calendar month should be included, even if the individual will not be enrolled into the program during the calendar month or is found retroactively eligible. Include determinations made by any state agency, including the Medicaid agency, a separate CHIP agency, and an SBM. Include determinations made on accounts assessed by the FFM and transferred to Medicaid for final determination. Do not include final eligibility determinations made by the FFM and transferred to Medicaid for enrollment.
Data source name(s) (name of state system or systems):	Please fill
State agencies responsible for data source(s) and reporting:	Please fill
Type of data: (see definitions tab for more information)	MMIS/Other claims systems/Eligibility Determination System/Data Warehouse/Combination of systems/Other systems
If "type" is "combination of systems" or "other systems," please explain:	Please fill
Most recently-reported data limitation for this indicator:	pre-populated
Please answer the following questions about your current reporting capabilities for each data element in this measure. Gray boxes indicate places where your response is required.
	Total Medicaid eligible (9a)	Medicaid MAGI eligible (9b)	Medicaid non-MAGI eligible (9c)	Medicaid eligible, by reason for determination (9d - 9i)	Total CHIP eligible (9j)	CHIP eligible, by reason for determination (9k - 9m)
a. Are you currently able to report the measure on the 8th of every month?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
b. Are you regularly updating the past month's data each month (e.g. updating March data when submitting April data)?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
If you are updating your data, are you only updating it when submitting the next month's data, and not updating again after that time?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
c. Are you currently reporting the measure to exact specification?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
Please note yes/no for each requirement for each indicator:
1. Includes individuals determined eligible at application and those redetermined eligible at renewal or after change in circumstance	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
2. Includes MAGI and non-MAGI determinations	yes/no	yes/no	yes/no	yes/no	N/A	N/A
3. Includes all individuals determined eligible in the month, even if they are not enrolled until later months or are retroactively eligible	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
4. Includes individuals determined eligible for partial benefit programs	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
5. Includes non-applicants determined eligible using information from other agencies	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
5a. Non-applicant determinations reported as "via administrative determination" (9h) only if using approved targeted enrollment strategy outlined in May 17, 2013 CMS guidance	N/A	N/A	N/A	yes/no	N/A	N/A
5b. Other non-applicant determinations (e.g. SSI or Express Lane Eligibility) reported as "via other methods" (9i)	N/A	N/A	N/A	yes/no	N/A	N/A
6. Includes individuals determined eligible for Medicaid or CHIP by the SBM	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
7. Includes individuals determined eligible for CHIP by the separate CHIP agency	N/A	N/A	N/A	N/A	yes/no	yes/no
8. Excludes individuals determined eligible by the FFM and transferred to state for enrollment	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
9. Includes individuals assessed eligible by the FFM and transferred to the state for a determination	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
10. Excludes presumptive eligibility determinations	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
11. Includes only determinations for Title XIX programs (ie, excludes M-CHIP children)	yes/no	yes/no	yes/no	yes/no	N/A	N/A
12. Includes all determinations for Title XXI programs (ie, includes M-CHIP children)	N/A	N/A	N/A	N/A	yes/no	yes/no
13. Non-applicable data elements are left blank, and not reported as zero	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
d. Other questions
1. In the June data, Medicaid MAGI (9b) and non-MAGI (9c) eligible sum to total Medicaid eligible (9a)	pre-populated
2. In the June data, determined Medicaid eligible by reason (9d+9g+9h+9i) sum to total Medicaid eligible (9a)	pre-populated
3. In the June data, determined MAGI eligible (9e) and non-MAGI eligible (9f) at application sum to total determined eligible at application (9d)	pre-populated
4. In the June data, determined CHIP eligible by reason (9k+9l+9m) sum to total CHIP eligible (9j)	pre-populated
[State-specific questions about known data issues, if any, here]	Please fill
e. If you reported "no" to any question above, or if any element is not being reported to specification for other reasons, please answer the following questions. Be sure to address each separate instance in which you answered "no" above:
1. If you are not currently reporting or regularly updating data, when do you expect to be able to report and/or regularly update data?	MM/YYYY
2. How does the reported data (or the data you plan to report) differ from the required specification? (If the only way it differs has been explained in most recent data limitation, please indicate that here.)	Please fill
3. What steps is the state taking to bring reporting in line with the specifications (or report data that has previously not been reported)?	Please fill
4. When do you expect the data to be reported to specification?	MM/YYYY

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Sheet 9: Ineligible (#10)

Indicator #10: Total Number of Individuals Determined Ineligible
Definition, Medicaid ineligible: Total number of individuals determined ineligible for Medicaid (i.e. funded under title XIX of the Social Security Act) under either MAGI or non-MAGI rules during the calendar month. This number should include determinations following an initial application as well as all redeterminations (triggered by either the annual renewal process or other change in circumstances). Include final determinations made by any state agency, including the Medicaid agency, a separate CHIP agency, and an SBM. Include individuals determined ineligible by a state agency after their account was assessed and transferred from the FFM. Do not include final eligibility determinations made by the FFM. Individuals who are determined ineligible for Medicaid and ineligible for CHIP should be counted both in the number of individuals determined ineligible for Medicaid under this indicator and in the number of individuals ineligible for CHIP under indicator 10g. Individuals who request disenrollment during the calendar month should not be included in this indicator.
Definition, CHIP ineligible: Total number of individuals determined ineligible for CHIP ((i.e. funded under Title XXI of the Social Security Act, including through MCHIP programs)) during the calendar month. This number should include determinations following an initial application as well as all redeterminations (triggered by either the annual renewal process or other change in circumstances). Include final determinations made by any state agency, including the Medicaid agency, a separate CHIP agency, and an SBM. Include individuals determined ineligible by a state agency after their account was assessed and transferred from the FFM. Do not include final eligibility determinations made by the FFM. Individuals who are determined ineligible for Medicaid and ineligible for CHIP should be counted both in the number of individuals determined ineligible for Medicaid and in the number of individuals ineligible for CHIP. Individuals determined eligible for Medicaid who do not receive a CHIP denial should not be included in this indicator.Individuals who request disenrollment or are disenrolled for failure to make premium payments during the calendar month should not be included in this indicator. Similarly, children subject to a waiting period or premium lock-out period are considered eligible but not enrolled and should also be excluded from this Indicator.
Data source name(s) (name of state system or systems):	Please fill
State agencies responsible for data source(s) and reporting:	Please fill
Type of data: (see definitions tab for more information)	MMIS/Other claims systems/Eligibility Determination System/Data Warehouse/Combination of systems/Other systems
If "type" is "combination of systems" or "other systems," please explain:	Please fill
Most recently-reported data limitation for this indicator:	pre-populated
Please answer the following questions about your current reporting capabilities for each data element in this measure. Gray boxes indicate places where your response is required.
	Total Medicaid ineligible (10a)	Medicaid ineligible, by reason for determination (10b - 10c)	Medicaid ineligible, by type of determination (10d - 10f)	Total CHIP ineligible (10g)	CHIP ineligible, by reason for determination (10h - 10i)	CHIP ineligible, by type of determination (10j - 10l)
a. Are you currently able to report the measure on the 8th of every month?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
b. Are you regularly updating the past month's data each month (e.g. updating March data when submitting April data)?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
If you are updating your data, are you only updating it when submitting the next month's data, and not updating again after that time?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
c. Are you currently reporting the measure to exact specification?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
Please note yes/no for each requirement for each indicator:
1. Includes individuals determined ineligible at application and those redetermined as ineligible at renewal or after change in circumstance	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
2. Includes MAGI and non-MAGI determinations	yes/no	yes/no	yes/no	N/A	N/A	N/A
3. Includes individuals determined ineligible for Medicaid or CHIP by the SBM	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
4. Includes only determinations for Title XIX programs (ie, excludes M-CHIP determinations)	yes/no	yes/no	yes/no	N/A	N/A	N/A
5. Includes all determinations for Title XXI programs (ie, includes M-CHIP determinations)	N/A	N/A	N/A	yes/no	yes/no	yes/no
6. Non-applicable data elements are left blank, and not reported as zero	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
d. Other questions
1. In the June data, determined Medicaid ineligible by reason (10b+10c) sums to total Medicaid ineligible (10a)	pre-populated
2. In the June data, determined Medicaid ineligible by type of determination (10d+10e+10f) sum to total Medicaid ineligible (10a)	pre-populated
3. In the June data, determined CHIP ineligible by reason (10h+10i) sum to total CHIP ineligible (10g)	pre-populated
4. In the June data, determined CHIP ineligible by type of determination (10j+10k+10l) sum to total CHIP ineligible (10g)	pre-populated
[State-specific questions about known data issues, if any, here]	Please fill
e. If you reported "no" to any question above, or if any element is not being reported to specification for other reasons, please answer the following questions. Be sure to address each separate instance in which you answered "no" above:
1. If you are not currently reporting or regularly updating data, when do you expect to be able to report and/or regularly update data?	MM/YYYY
2. How does the reported data (or the data you plan to report) differ from the required specification? (If the only way it differs has been explained in most recent data limitation, please indicate that here.)	Please fill
3. What steps is the state taking to bring reporting in line with the specifications (or report data that has previously not been reported)?	Please fill
4. When do you expect the data to be reported to specification?	MM/YYYY

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Sheet 10: Pending (#11)

Indicator #11: Number of Pending Applications or Redeterminations
Definition, for states with no separate CHIP agency: Total number of applications and redeterminations pending at Medicaid agency as of the last day of the month. This includes all applications that have been received by the agency (regardless of the date of application) and outstanding redeterminations (regardless of when the individual came up for renewal), but which have not yet been determined as of the last day of the month. Online applications that have been initiated but not yet submitted to the Medicaid agency should not be reported. If the Medicaid agency administers eligibility for the CHIP program, then pending CHIP applications and redeterminations should be included in this count.
CHIP definition, ONLY for states with separate CHIP agency: Total number of applications and redeterminations pending at the separate CHIP agency as of the last day of the month. This includes all applications that have been received by the agency (regardless of the date of application) and outstanding redeterminations (regardless of when the individual came up for renewal), but which have not yet been determined as of the last day of the month. Online applications that have been initiated but not yet submitted to the separate CHIP agency should not be reported.
Data source name(s) (name of state system or systems):	Please fill
State agencies responsible for data source(s) and reporting:	Please fill
Type of data: (see definitions tab for more information)	MMIS/Other claims systems/Eligibility Determination System/Data Warehouse/Combination of systems/Other systems
If "type" is "combination of systems" or "other systems," please explain:	Please fill
Most recently-reported data limitation for this indicator:	pre-populated
Please answer the following questions about your current reporting capabilities for each data element in this measure. Gray boxes indicate places where your response is required.
	Number pending at Medicaid agency (11a)	Number pending at separate CHIP agency (11c)
a. Are you currently able to report the measure on the 8th of every month?	yes/no	yes/no
b. Are you regularly updating the past month's data each month (e.g. updating March data when submitting April data)?	yes/no	yes/no
If you are updating your data, are you only updating it when submitting the next month's data, and not updating again after that time?	yes/no	yes/no
c. Are you currently reporting the measure to exact specification?	yes/no	yes/no
Please note yes/no for each requirement for each indicator:
1. Includes both pending applications and pending redeterminations still awaiting determination	yes/no	yes/no
2. Includes applications and redeterminations pending due to outstanding verification items due from applicant	yes/no	yes/no
3. Includes pending applications and redeterminations for both MAGI and non-MAGI populations	yes/no	N/A
4. Includes assessed transfers from the FFM that have not yet received a determination	yes/no	yes/no
5. Applications received by separate CHIP agency reported only in 11c and 11d (and excluded from 11a and 11b)	yes/no	yes/no
6. Non-applicable data elements are left blank, and not reported as zero	yes/no	yes/no
d. Other questions
[State-specific questions about known data issues, if any, here]	Please fill
e. If you reported "no" to any question above, or if any element is not being reported to specification for other reasons, please answer the following questions. Be sure to address each separate instance in which you answered "no" above:
1. If you are not currently reporting or regularly updating data, when do you expect to be able to report and/or regularly update data?	MM/YYYY
2. How does the reported data (or the data you plan to report) differ from the required specification? (If the only way it differs has been explained in most recent data limitation, please indicate that here.)	Please fill
3. What steps is the state taking to bring reporting in line with the specifications (or report data that has previously not been reported)?	Please fill
4. When do you expect the data to be reported to specification?	MM/YYYY

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Sheet 11: Processing time (#12)

Indicator #12: Processing Time for Determinations
Definition, median Medicaid processing time: For all applicants (regardless of date of application) who received a determination at application (as reported through indicators 9d and 10d) from the Medicaid agency in the calendar month, report the median number of calendar days elapsed between the date the Medicaid agency received the initial application (start date) and the day the determination at initial application was made (end date). The set of determinations included in the calculation of median processing time for this measure includes Medicaid and CHIP determinations made by the Medicaid agency;MAGI and non-MAGI determinations; and determinations where the applicant was considered eligible as well as those where the applicant was determined ineligible. All determinations within the calendar month should be included, regardless of when the application was submitted. If multiple household members applied on a single application, the processing time should be calculated and reported separately for each individual who received a determination. Individuals with presumptive eligibility should not be included in this Indicator, as they have not yet received a final determination. Determinations made by the Medicaid agency on transfer applications received from the FFM are included. The date that the Medicaid agency received the account transfer is the start date and the day of the determination is the end date.This indicator only applies to determinations at application, and does not apply to determinations at annual renewal, change in circumstance, or via other method.
Definition, number of Medicaid determinations, by processing time: The number of final determinations made by the Medicaid agency with each time category.
CHIP definition, median CHIP processing time, ONLY for states with a separate CHIP agency: For all applicants (regardless of date of application) who received a final determination from the separate CHIP agency in the calendar month, report the median number of calendar days elapsed between the date the agency received the application (start date) and the day the final determination was made (end date). The set of determinations included in the calculation of median processing time for this measure includes both determinations where the applicants was determined eligible as well as those where the applicant was determined ineligible. All determinations within the calendar month should be included, regardless of when the application was submitted. If multiple household members applied on a single application, the processing time should be calculated and reported separately for each individual who received a determination. Individuals with presumptive eligibility should not be included in this Indicator, as they have not yet received a final determination. This includes determinations made by the separate CHIP agency on transfer applications received from the FFM.This indicator only applies to determinations at application, and does not apply to determinations at annual renewal, change in circumstance, or via other method.In states without a separate CHIP agency, this indicator as well as indicators 12p and 12q should be left blank (not applicable).
Definition, number of CHIP determinations, by processing time, ONLY for states with a separate CHIP agency: The number of final determinations made by the CHIP agency with each time category.
Data source name(s) (name of state system or systems):	Please fill
State agencies responsible for data source(s) and reporting:	Please fill
Type of data: (see definitions tab for more information)	MMIS/Other claims systems/Eligibility Determination System/Data Warehouse/Combination of systems/Other systems
If "type" is "combination of systems" or "other systems," please explain:	Please fill
Most recently-reported data limitation for this indicator:	pre-populated
Please answer the following questions about your current reporting capabilities for each data element in this measure. Gray boxes indicate places where your response is required.
	Median processing time for Medicaid determinations (12a)	Median processing time, Medicaid MAGI and non-MAGI determinations (12b - 12c)	Median processing time, by source of Medicaid application (12d - 12e)	Number of Medicaid MAGI determinations, by processing time (12f - 12j)	Number of Medicaid non-MAGI determinations, by processing time (12k - 12n)	Median processing time for CHIP determinations (12o)	Median processing time, by source of CHIP application (12o - 12q)	Number of CHIP determinations, by processing time (12r - 12v)
a. Are you currently able to report the measure on the 8th of every month?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
b. Are you regularly updating the past month's data each month (e.g. updating March data when submitting April data)?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
If you are updating your data, are you only updating it when submitting the next month's data, and not updating again after that time?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
c. Are you currently reporting the measure to exact specification?	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
Please note yes/no for each requirement for each indicator:
1. Includes determinations at application only (excludes determinations at annual renewal or change in circumstance)	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
2. Includes determinations of eligiblity and determinations of ineligibilty	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
3. Includes both MAGI and non-MAGI determinations	yes/no	yes/no	yes/no	yes/no	yes/no	N/A	N/A	N/A
4. In assessment states, includes accounts transferred from FFM	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
5. For applications containing multiple individuals, the processing time for each determination for each individual is counted separately	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
6. Includes all days between application receipt and determination, including any delays caused by outstanding items due from applicant	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
7. Measure reported as the median and not mean days between application and determination	yes/no	yes/no	yes/no	N/A	N/A	yes/no	yes/no	N/A
8. Measure includes all determinations made by Medicaid agency at application (including determinations of CHIP eligibility or ineligibility)	yes/no	yes/no	yes/no	yes/no	yes/no	N/A	N/A	N/A
9. Measure includes all determinations made by CHIP agency at application	N/A	N/A	N/A	N/A	N/A	yes/no	yes/no	yes/no
10. Excludes individuals who have only received a presumptive eligibility determination, and have not yet received a final determination	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
11. Applications received by separate CHIP agency reported only in 12o-12v (and excluded from 12a-12n)	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
12. If median processing time is less than 12 hours, due to real time processing, then a zero is reported	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
13. Non-applicable data elements are left blank, and not reported as zero	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no	yes/no
d. Other questions
[State-specific questions about known data issues, if any, here]	Please fill
e. If you reported "no" to any question above, or if any element is not being reported to specification for other reasons, please answer the following questions. Be sure to address each separate instance in which you answered "no" above:
1. If you are not currently reporting or regularly updating data, when do you expect to be able to report and/or regularly update data?	MM/YYYY
2. How does the reported data (or the data you plan to report) differ from the required specification? (If the only way it differs has been explained in most recent data limitation, please indicate that here.)	Please fill
3. What steps is the state taking to bring reporting in line with the specifications (or report data that has previously not been reported)?	Please fill
4. When do you expect the data to be reported to specification?	MM/YYYY
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 0938-1148. The time required to complete this information collection is estimated to average 15 hours 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.