Form CMS-10371 Outcome Metric – SBM Exchange Metrics

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128

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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