Form CMS-10295 State Report on the Transitional Medical Assistance Sect

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Overview

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Sheet 1: Page 1

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
I. Introduction
The American Recovery and Reinvestment Act of 2009 section 5004(d) includes requirements that States report to CMS information relating to participation in Transitional Medical Assistance. The purpose of this form is to define the data to be submitted and to provide a format for that submission.
II. State Information:
1. State:			XX
2. State Organizational Component:
3. State Contact Info:		Name:
		Address:
		E-Mail:
		Telephone:
4. Date Submitted:
5. Report Period:			From (mm/dd/yyyy):	mm/dd/20yy
			To (mm/dd/yyyy):	mm/dd//20yy
6. Attestation (signature):
The data elements to be reported are defined on the following pages.
File: ARRA-Sec-5004-State-Report-3.xlsx				Date Last Revised: 8/20/2009

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Sheet 2: Page 2

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
State:	XX					Report Period:
						From (mm/dd/yyyy):	mm/dd/20yy
						To (mm/dd/yyyy):	mm/dd//20yy
III. ARRA Section 5004(d) Data Collection Elements
Average Monthly Enrollment-Adults			The total unduplicated number of adults enrolled in the TMA category for each month being reported, divided by the number of months being reported.
Average Monthly Enrollment-Children			The total unduplicated number of children enrolled in the TMA category for each month being reported, divided by the number of months being reported.
Average Monthly Participation Rate- Adults			The average monthly number of adults enrolled in the TMA category who receive Medicaid services, divided by the average monthly number of adults enrolled in TMA.
Average Monthly Participation Rate- Children			The average monthly number of children enrolled in the TMA category who receive Medicaid services, divided by the average monthly number of children enrolled in TMA.
Number of Children Continued in Another Title XIX Category			The number of children eligible under title XIX in a category other than TMA, including Medicaid expansions, who were eligible under TMA in the month immediately preceding.
Percentage of Children Continued in Another Title XIX Category			The number of children eligible under title XIX in a category other than TMA, including Medicaid expansions, who were eligible under TMA in the month immediately preceding eligibility in the other category, divided by the number of children eligible under TMA in the immediately preceding month.
Number of Children continued in a Title XXI Category			The number of children eligible under title XXI who were eligible under TMA in the month immediately preceding eligibility under title XXI.
Percentage of Children Continued in a Title XXI Category			The number of children eligible under title XXI who were eligible under TMA in the month immediately preceding eligibility under title XXI, divided by the number of children eligible under TMA in the immediately preceding month
The elements defined above are to be reported quarterly on the following tables.
Include individuals who were eligible for any portion of the reporting period.
Individuals eligible in more than one eligibility category during a month should be reported in the category that occurred first.
Use unduplicated counts.
Define children as specified in your state plan.
Transitional Medical Assistance (TMA) is defined as coverage under sections 1902(a)(52), 1902(e)(1) and 1925 of the Social Security Act

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Sheet 3: Page 3

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
State:	XX							Report Period:
								From (mm/dd/yyyy):	mm/dd/20yy
								To (mm/dd/yyyy):	mm/dd//20yy
IV. ARRA Section 5004(d) Data Collection
Table 1. Transitional Medical Assistance Enrollment Data- Adults
Number of Adults Enrolled during the Reporting Period (Fill-in)		Number of Enrollment Months in Reporting Period (Fill-in)		Average Monthly Enrollment (Col B/3)		Average Enrollment Months Per Enrollee (Col B/Col A)		Number of Enrolled Adults Who Received Services (Fill-in)		Average Monthly Participation Rate (Col E/Col A)
A		B		C		D		E		F
				0
A -This is the total number of unduplicated number of adults enrolled in TMA at any time during each month of the reporting period.
B - This is the total number of enrollment months for the entire reporting period.
C- This is the number of enrollment months for adults in Column B divided by 3 to obtain the average monthly enrollment for adults
D - This is the number of enrollment months for adults in Column B divided by the unduplicated number adults in Column A, representing the average number of enrollment months for the reporting period
E - This is the total unduplicated number of adults enrolled in TMA at any time during the reporting period who received Medicaid services during the reporting period.
F - This is the number of enrolled adults who received services in Column E divided by the total number of adults in Column A, representing the average monthly participation rate for adults

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Sheet 4: Page 4

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
State:	XX							Report Period:
								From (mm/dd/yyyy):	mm/dd/20yy
								To (mm/dd/yyyy):	mm/dd//20yy
IV. ARRA Section 5004(d) Data Collection (Cont'd)
Table 2. Transitional Medical Assistance Enrollment Data- Children
Number of Children Enrolled during the Reporting Period (Fill-in)		Number of Enrollment Months in Reporting Period (Fill-in)		Average Monthly Enrollment (Col B/3)		Average Enrollment Months Per Enrollee (Col B/Col A)		Number of Enrolled Children Who Received Services (Fill-in)		Average Monthly Participation Rate (Col E/Col A)
A		B		C		D		E		F
				0
A -This is the total number of unduplicated number of children enrolled in TMA at any time during each month of the reporting period.
B - This is the total number of enrollment months for the entire reporting period.
C- This is the number of enrollment months for children in Column B divided by 3 to obtain the average monthly enrollment for children
D - This is the number of enrollment months for children in Column B divided by the unduplicated number adults in Column A, representing the average number of enrollment months for the reporting period
E - This is the total unduplicated number of children enrolled in TMA at any time during the reporting period who received Medicaid services during the reporting period.
F - This is the number of enrolled children who received services in Column E divided by the total number of adults in Column A, representing the average monthly participation rate for children

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Sheet 5: Page 5

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
State:	XX							Report Period:
								From (mm/dd/yyyy):	mm/dd/20yy
								To (mm/dd/yyyy):	mm/dd//20yy
IV. ARRA Section 5004(d) Data Collection (Cont'd)
Table 3. Transitional Medical Assistance - Children Continued Eligibility Under Title XIX or Title XXI
Number of Children Previously Enrolled in TMA (Fill-in)		Number of Children Continued in Title XIX (Fill-in)		Percentage of Children Continued in Title XIX (Col B/Col A)		Number of Children Continued in Title XXI (Fill-in)		Percentage of Children Continued in Title XXI (Col D/Col A)
A		B		C		D		E
A –This is the total unduplicated number of children who were enrolled in TMA during the month immediately preceding the reporting period, or during either or both of the first two months of the reporting period
B - This is the total unduplicated number of those children reported in A who were enrolled in a title XIX eligibility group other than TMA, including expansions under title XXI, at any time during the reporting period.
C- This is the percentage of children enrolled in a title XIX eligibility group other than TMA at any time during the reporting period who were enrolled in TMA in the month immediately preceding other title XIX eligibility (Col. B/Col. A)
D- This is the total unduplicated number of those children reported in A who were enrolled in title XXI at any time during the reporting period.
E- This the percentage of children enrolled in title XXI at any time during the reporting period who were enrolled in TMA in the month immediately preceding title XXI eligibility (Col. D/Col. A)

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Sheet 6: Page 6

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
State:	XX							Report Period:
								From (mm/dd/yyyy):	mm/dd/20yy
								To (mm/dd/yyyy):	mm/dd//20yy
V. Comments