Crosswalk document

APPENDIX B: Reporting Requirements Crosswalk
Data Collection template in 80 FR 16687; May 30,2015

Data Collection template - CHANGES
to the proposed performance measures

Weekly Progress Report
Number of federally trained Assisters who are awaiting any applicable state
certification

Number of federally trained Assisters who are awaiting any applicable state
certification

Number of consumers who have been assisted with general inquiries about
health coverage

Number of consumers who have been assisted with general inquiries about
health coverage

Number of consumers who have sought enrollment assistance from an
Assister

Number of consumers who have sought enrollment assistance from an
Assister

Of the total number of consumers who have sought enrollment assistance
from an Assister, provide the number of consumers who have been assisted
with:
o Providing education only (no enrollment)
o Selecting a QHP
o Applying for Medicaid/CHIP
o Enrolling into SHOP
o Referrals to:
 Medicaid/CHIP
 Agents/brokers for SHOP assistance
o Taxes
o Filing exemptions
o Other __________

Of the total number of consumers who have sought enrollment assistance
from an Assister, provide the number of consumers who have been assisted
with:
o Providing education only (no enrollment)
o Selecting a QHP
o Applying for Medicaid/CHIP
o Enrolling into SHOP
o Referrals to:
 Medicaid/CHIP
 Agents/brokers for SHOP assistance
o Taxes
o Filing exemptions
o Other __________

Number of consumers who have sought post-enrollment assistance from an
Assister

Number of consumers who have sought post-enrollment assistance from an
Assister

If the consumer resides in a non-Medicaid expansion state, indicate the
number of consumers assisted who fall in the coverage gap

If the consumer resides in a non-Medicaid expansion state, indicate the
number of consumers assisted who fall in the coverage gap

Outreach, Education, and Marketing spreadsheet
List of outreach, education, and marketing events (including date, type of
event {outreach, education, or marketing}, event name, sponsor/partner,

Outreach, Education, and Marketing
List of outreach, education, and marketing events (including date, type of
event {outreach, education, or marketing}, event name, sponsor/partner,
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event description, location, number of consumers targeted, type of
population-based event, point of contact information)

event description, location, number of consumers targeted, number of
Marketplace applications started, type of population-based event, point of
contact information)

Monthly Progress Report
Estimate the amount of grant funds spent during the previous month for:
Grant Year 2014-2015______ (if applicable)
Grant Year 2015-2016______

Estimate the amount of grant funds spent during the previous month for:
Grant Year 2014-2015______ (if applicable)
Grant Year 2015-2016______

Estimate the amount of grant funds remaining as of the last day of the
previous month for:
Grant Year 2014-2015______ (if applicable)
Grant Year 2015-2016______

Estimate the amount of grant funds remaining as of the last day of the
previous month for:
Grant Year 2014-2015______ (if applicable)
Grant Year 2015-2016______

Please indicate the activity that you have done this month, as applicable:
• Number of site visits conducted with sub-grantees/sub-recipients
• Number of internal assister training with staff and subgrantees/sub-recipients
• Number of background checks for Assisters
• Number of breaches with protocols for collecting PII or retaining
consent forms

Please indicate the activity that you have done this month, as applicable:
• Number of site visits conducted with sub-grantees/sub-recipients
• Number of internal assister training with staff and sub-grantees/subrecipients
• Number of background checks for Assisters
• Number of breaches with protocols for collecting PII or retaining
consent forms

Please explain how you ensure successful performance of your subgrantees/sub-recipients.

Please explain how you ensure successful performance of your subgrantees/sub-recipients.

Describe how you have collaborated with the HHS regional office and CMS
regional office this month. Please note what is working well and any
challenges you face.

Describe how you have collaborated with the HHS regional office and CMS
regional office this month. Please note what is working well and any
challenges you face.

Provide at least one example of a best practice this month in each of the
categories:
• successful outreach and education tactics
• collaboration with others in the community, including partnering
organizations, local businesses, etc.
• other

Provide at least one example of a best practice this month in each of the
categories:
• successful outreach and education tactics
• collaboration with others in the community, including partnering
organizations, local businesses, etc.
• other
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Estimate the percentage of people whose primary language is not English
this month.

Estimate the percentage of people whose primary language is not English this
month.

Provide an updated list of the organizations you are supporting with your
Navigator grant funds.
Quarterly Progress Report
Provide at least one example of a best practice describing how your
organization has adhered to Culturally and Linguistically Appropriate
Services (CLAS) standards this quarter.

Provide an updated list of the organizations you are supporting with your
Navigator grant funds.

Provide at least one example of a best practice describing how your
organization has ensured that consumers with disabilities have reasonable
modifications and accommodations to access your Marketplace assistance
services this quarter.

Provide at least one example of a best practice describing how your
organization has ensured that consumers with disabilities have reasonable
modifications and accommodations to access your Marketplace assistance
services this quarter.

List five most common languages, other than English, spoken by consumers
you have assisted this quarter.

List five most common languages, other than English, spoken by consumers
you have assisted this quarter.

Provide at least one example of a best practice describing how your
organization has collected, retained, and protected consumers’ Personally
Identifiable Information (PII) this quarter.

Provide at least one example of a best practice describing how your
organization has collected, retained, and protected consumers’ Personally
Identifiable Information (PII) this quarter.

Upload a copy of your consent form (only required for quarter 1, unless
modified) and describe how your organization has retained consent forms
this quarter.

Upload a copy of your consent form (only required for quarter 1, unless
modified) and describe how your organization has retained consent forms
this quarter.

Final Progress Report
The data collection for the Annual Progress Report will capture submitted
updates from each quarterly report.

The data collection for the Annual Progress Report will capture submitted
updates from each quarterly report.

Provide at least one example of a best practice describing how your
organization has adhered to Culturally and Linguistically Appropriate Services
(CLAS) standards this quarter.

ADDITIONAL INFORMATION COLLECTION: Assister organizations will be required to make any updates or corrections to Assister organization
information submitted to CMS.

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