Staff for Enrollment Data Collection

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Overview

1.X.New Enrollment, Demos
2.X. Retention

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Sheet 1: 1.X.New Enrollment, Demos

Table 1.X: New [Medicaid/CHIP] Enrollees by Month, [Simplified/Traditional Enrollment Procedures]
		START 12-Months pre-simplified enrollment procedure		Simplified enrollment procedure implementation				END
		Month 1	Month 2…	…Month 13	Month 14	Month 15	Month 16+ (as needed)	Dec 20122
Number New Enrollees
By Subgroup
Demographic Characteristics
Age of Child at start of Month
	Younger than 1
	1-5
	6-12
	13-18
	19-21
	Unknown
Race/Ethnicity
	Hispanic
	Non-Hispanic American Indian and Non-Hispanic Alaska Native
	Non-Hispanic Asian, Non-Hispanic Native Hawaiian and Other Pacific Islander
	Non-Hispanic Black
	Non-Hispanic White
	Other
	Unknown
Gender
	Female
	Male
	Unknown/ other
Primary Language
	English
	Spanish
	Other non-English
	Unknown
US Citizenship
	Citizen
	Qualified non-citizen
	Non-qualified non-citizen
	Awaiting confirmation
	Other
	Unknown
Household Income by FPL
	<100%
	100 - <133
	133-<185
	185-<200
	200- <300
	300+
	Unknown
Residence
	Urban
	Rural
	Unknown
Family Size
	2
	3
	4
	5
	6 or more
	Unknown
Number of Children in household
	1
	2
	3
	4 or more
	Unknown
Number with a TANF Flag
Number with Parent/Caregiver employment
Private Insurance Coverage
	Number with Third Party Coverage
	Number with coverage available from employer (if available)
	Number with a recent loss of private coverage (if available)
Prior Public Coverage
	Number with a previous spell of public coverage, past 3-months
	Number with a previous spell of public coverage, past 6-months
	Number with a previous spell of public coverage, past 12 months
ELE = Express Lane Eligibility; FPL = federal poverty level; TANF = Temporary Assistance for Needy Families.

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Sheet 2: 2.X. Retention

Table 2.X: New [Medicaid/CHIP] Enrollees Retention Measures, [Simplified/Traditional Enrollment Procedures]
		START 12-Months pre-simplified enrollment procedure		Simplified enrollment procedure implementation				END
		Month 1	Month 2…	…Month 13	Month 14	Month 15	Month 16+ (as needed)	Dec 20122
Number New Enrollees
Likelihood of retention
	Number still enrolled 6 months from enrollment
	Number still enrolled 12 months from enrollment
	Number still enrolled 13 months from enrollment
	Number still enrolled 18 months from enrollment
	Number still enrolled 24 months from enrollment
Disenrollment/Reenrollment Measures
	Number disenrolled (within 6 months)
	Number disenrolled (within 12 months)
	Number disenrolled (within 13 months)
	Number disenrolled (within 18 months)
	Number disenrolled (within 24 months)
	Number of disenrollees within 13 months that reenrolled within 3 months
	Number of disenrollees within 13 months that reenrolled within 6 months
	Number of disenrollees within 13 months that reenrolled within 12 months
	Number of disenrollees within 13 months that reenrolled within 3 months via simplified enrollment procedure
	Number of disenrollees within 13 months that reenrolled within 6 months via simplified enrollment procedure
	Number of disenrollees within 13 months that reenrolled within 12 months via simplified enrollment procedure
Transfers
	Number of enrollees that transferred to [CHIP/Medicaid] within 6 months
	Number of enrollees that transferred to [CHIP/Medicaid] within 12 months
	Number of enrollees that transferred to [CHIP/Medicaid] within 13 months
	Number of enrollees that transferred to [CHIP/Medicaid] within 18 months
	Number of enrollees that transferred to [CHIP/Medicaid] within 24 months
	Number of enrollees that transferred to [CHIP/Medicaid] within 6 months via simplified enrollment procedure
	Number of enrollees that transferred to [CHIP/Medicaid] within 12 months via simplified enrollment procedure
	Number of enrollees that transferred to [CHIP/Medicaid] within 13 months via simplified enrollment procedure
	Number of enrollees that transferred to [CHIP/Medicaid] within 18 months via simplified enrollment procedure
	Number of enrollees that transferred to [CHIP/Medicaid] within 24 months via simplified enrollment procedure
CHIP = Children's Health Insurance Program; ELE = Express Lane Eligibility