CMS-10333 Appendix 2

Appendix 2
Template for the Quarterly Progress Report
Consumer Contacts
I.

Estimate the number of consumers reached through outreach and public education efforts:
________
a. List all public education and outreach events by date.
b. Describe your plans for addressing consumers’ translation needs including, but
not limited to translating materials about health insurance coverage.
c. Is there anything else you would like to share with CCIIO about the CAP’s outreach and
public education efforts (e.g., brochures, toolkits and social media campaigns)?

Enforcement Actions
I.

II.

Number of cases referred for enforcement: ________
a. Of the number of cases referred for enforcement, note the number of cases
where enforcement action was taken: ________
Provide a brief narrative of the types of the cases referred for enforcement and of the types of
enforcement actions taken. Include any trends identified by your CAP in the types of cases
referred for enforcement or in the enforcement actions taken.

Expanded Capacity
Provide a brief summary of how the program used the grant to expand consumer assistance services
this past quarter.

Illustrative Examples
Provide at least one, but not more than three, examples of how your CAP helped a consumer with an
issue related to private health insurance coverage. Examples could include how your CAP helped a
consumer obtain or maintain coverage under a provision added by the ACA, or where a consumer’s case
was referred for enforcement and enforcement action was taken. (Note that under no circumstances
should any personally identifiable information (PII) be reported to CCIIO.)

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Instructions for the Quarterly Progress Report Template
Consumer Contacts
I.

Estimate the number of consumers reached through outreach and public education efforts –
Enter the approximate number of consumers reached through outreach and public education
efforts which can include, but are not limited to the number of views of an online educational
video; the number of attendees at outreach events; the number of consumers who received
educational materials; and the circulation of newspaper advertisements. It is at the State’s
discretion how to define what it means to “reach” a consumer. Note that the sum of participants
at all public education and outreach events listed under a. below will not necessarily equal the
number entered here.
a. List all public education and outreach events by date. – For each instance of a
public education and outreach event, include the following information:
Name of event
Date(s) of event
City where event was held
Location of event (e.g., library, municipal auditorium, shopping mall)
Specific populations reached at the event (e.g., members of the Springfield Lions Club,
members of the State Board of Home Health Aides, rural residents of Collins County,
working mothers, families in the Jackson Independent School District)
Estimated number of participants/readers/viewers directly impacted
Estimated number of participants/readers/viewers potentially impacted

Examples:
Healthy Families Expo
2012 November 9-11, 2012
Andersonville
Andersonville Conference Center
Adults and children from Andersonville and surrounding cities
Approximately 8,500 Expo participants
Approximately 200 brochures distributed to visitors to CAP booth and
125 attendees at CAP presentation
Advertisement in Springville Sun Times
December 2, 9, 16, 2012
Springville Sun Times newspaper
Readers of the Springville Sun Times
Approximately 5,000 readers directly impacted per day that the ad was placed
based on newspaper ad sales estimates, for a total of 15,000 readers over three
Sundays

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Approximate circulation of 45,000 copies per day that the ad was placed for a
total of 135,000 copies over three Sundays
b. Describe your plans for addressing consumers’ translation needs including, but not
limited to translating materials about health insurance coverage. – Describe your
CAP’s plans to address the needs of consumers with limited English proficiency.
c. Is there anything else you would like to share with CCIIO about the CAP’s
outreach and public education efforts? – Include information about your CAP’s
outreach and public education efforts that you would like to provide to CCIIO that are
not already captured in this report. Some examples of this information could include, but
are not limited to social media campaigns, toolkits, educational brochures, public service
announcements, and online educational videos.

Enforcement Actions
I.

Number of cases referred for enforcement – Enter the number of consumers’ cases that your CAP
referred to an agency for enforcement, not information, purposes. If your CAP is housed in an
agency that also has regulatory authority, these referrals reflect situations where the agency is asked
to intervene for enforcement purposes. For example, if a CAP is housed in a State’s Department of
Insurance.
a. Of the number of cases referred for enforcement, note the number of cases where
enforcement action was taken – Enter the number of consumers’ cases that your CAP
referred to an agency for enforcement and an enforcement action was taken on behalf of
the consumer. This number should be a portion of the number entered in Section I.
above.

II. Provide a brief narrative of the types of the cases referred for enforcement and of the types
of enforcement actions taken. – Describe the types of consumer cases that your CAP referred to
another agency for enforcement purposes and the types of enforcement actions taken by those
agencies. In providing this description, under no circumstances should any personally identifiable
information be reported to CCIIO. Include any trends identified by your CAP in the types of cases
referred for enforcement or in the enforcement actions taken.

Expanded Capacity
Provide a brief summary of how the program used the grant to expand consumer assistance
services this past quarter. – Describe how the CAP was able to expand the existing health insurance
consumer assistance services in the State, providing specific examples of how consumers have
benefitted from the CAP’s work. In providing this description, under no circumstances should any
personally identifiable information be reported to CCIIO.

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Illustrative Examples
Provide at least one, but not more than three, examples of how your CAP helped a consumer with
an issue related to private health insurance coverage. Examples could include how your CAP
helped a consumer obtain or maintain coverage under a provision added by the ACA, or where a
consumer’s case was referred for enforcement and enforcement action was taken. (Note that under
no circumstances should any personally identifiable information (PII) be reported to CCIIO.) –
Provide at least one, but not more than three, examples of how a consumer’s situation was positively
impacted by the assistance provided by or involvement of the CAP.
Under no circumstances should any personally identifiable information (PII) be reported to CCIIO. The
basic pieces of PII to avoid that could identify a consumer are the following: the consumer’s name
(instead refer to the consumer as “consumer,” “caller,” “writer,” etc. as appropriate) and the consumer’s
contact information. In some instances, what would otherwise not be considered PII may become PII
based on the consumer’s circumstances. For example if the consumer has a rare health condition, the
consumer’s health condition could be considered PII and should not be included by name in the
consumer story. Below please find an example of a de-identified consumer story.
Illustrative Example:
The consumer was successfully treated for lung cancer in 2008 and has follow-up
appointments every 6 months to check for recurrence. He is uninsured and seeking
coverage for follow up appointments and the peace of mind that treatment would be
covered in the case of recurrence. He works for a hospital and a community clinic as a
nurse; neither employer offers coverage. He is eligible to enroll in the guaranteed issue
individual market plan, but the $1,500/month premium is unaffordable and he would
face a pre-existing condition exclusion period. The CAP helped the consumer determine
that he was eligible for the Pre-existing Condition Insurance Plan (PCIP), and helped
him enroll. The $561 monthly PCIP premium will be a financial challenge, but he was
able to adjust his budget to allow for the added expense.

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