Appendix B - Data elements for 155 Subpart M

Appendix B – Data Elements Related to the General Program Integrity and
Oversight Requirements

The following appendix lays out the data elements associated with the proposed §155.1200.
Data Element
Exchange Name

Data Specifics
Name of Exchange

Exchange Address

Exchange address, state, and zip code

Financial Statements

Financial Statement presented in accordance with GAAP

External Audits

Performance of external financial and programmatic audit

Corrective Actions

Actions that Exchange needs to take to address issues in audit

Performance Monitoring Data
The data elements below are associated with the information collection requirement proposed in
§155.1200(b)(3) that provides that State Exchanges must submit and information on performance
monitoring data.
Data Element
Current health insurance coverage
(APTC applicants only)

Data Specifics
Number and percent of individuals applying for APTC who are
currently enrolled in: COBRA, Retiree health plan, Veterans
health program, Medicare, TRICARE, Peace Corps,
Medicaid/CHIP, IHS, Other Federal Programs, ESI, Uninsured

Retention of coverage

Distribution of longevity of coverage (continuous coverage
within SBM/SBM-SHOP from initiation), by month

Health plan renewal rate in
Marketplace

Number of QHP contract renewals during open season/all
policies in force in December of that year

Marketplace revenues by category
Marketplace expenditures
Marketplace reserves

SBM revenues by category (see glossary)
SBM expenditures by category (see glossary)
Cash on hand and other liquid financial instruments to fund
SBM operations, by number of months

Assistance with QHP enrollment
submission

Percent and number by web, phone, mail, in person, multiple
channels; by assistance (Navigators, In-person assistors, CACs,
Agents/Brokers, Web Brokers, Medicaid authorized reps, Other
Assistant); Number of requests for language assistance/Number
fulfilled; Time taken to provide language assistance; Form of
language assistance (e.g., translated forms, individual
assistance, etc)
1

Number and proportion of “real-time”
eligibility determinations as percent of
completed applications for eligibility
determination (see glossary for
provisional eligibilty determinations)

Percent of eligibility determinations made within the month
that were completed in a single application session or within
24 hours; percent resolved within 7 days of intake; median time
for eligibility determination per month

Number of customer complaints and
grievances about eligibility and
enrollment problems in Marketplace

Number of individuals and families submitting eligiblity
application/enrollees in QHPs; Customer complaints per capita
regarding enrollment (see glossary)

Number of QHP eligibility
determination appeals per application

Number of QHP eligibility determination appeals/Number of
QHP eligibility determinations

Percentage of initial QHP eligibility
determinations upheld or reversed in
an appeal

Upheld or reversed appeals/All appeals

Median time to resolve appeal for
QHP eligibility determination

Median time to resolve from date of filing appeal to date of
final disposition

Percent with NCQA/URAC
accreditation [for issuers] on the
Marketplace compared to nonparticipating issuers; Percent on the
path to accreditation

Unweighted and weighted by enrollment, separately for
individual and small groups

2