Form CMS-10295 State Report on the Transitional Medical Assistance

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
I. Introduction
The American Recovery and Reinvestment Act of 2009 section 5004(d) includes
requirements that States report to CMS information relating to participation in Transitional
Medical Assistance. The purpose of this form is to define the data to be submitted and to
provide a format for that submission.
II. State Information:
1. State:
XX
2. State Organizational Component:
3. State Contact Info:

Name:
Address:
E-Mail:
Telephone:

4. Date Submitted:
5. Report Period:

From (mm/dd/yyyy): mm/dd/20yy
To (mm/dd/yyyy): mm/dd//20yy

6. Attestation (signature):

The data elements to be reported are defined on the following pages.
File: ARRA-Sec-5004-State-Report-3.xlsx

CMS-10295
OMB Control Number: 0938-1073
Expires: TBD

Date Last Revised: 8/20/2009

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
State:

Report Period:
From (mm/dd/yyyy): mm/dd/20yy
To (mm/dd/yyyy): mm/dd//20yy

XX

III. ARRA Section 5004(d) Data Collection Elements

Average Monthly EnrollmentAdults

The total unduplicated number of adults enrolled in the
TMA category for each month being reported, divided by
the number of months being reported.

Average Monthly EnrollmentChildren

The total unduplicated number of children enrolled in the
TMA category for each month being reported, divided by
the number of months being reported.

Average Monthly Participation
Rate- Adults

The average monthly number of adults enrolled in the
TMA category who receive Medicaid services, divided by
the average monthly number of adults enrolled in TMA.

Average Monthly Participation
Rate- Children
Number of Children Continued
in Another Title XIX Category
Percentage of Children
Continued in Another Title XIX
Category
Number of Children continued
in a Title XXI Category

The average monthly number of children enrolled in the
TMA category who receive Medicaid services, divided by
the average monthly number of children enrolled in
TMA.
The number of children eligible under title XIX in a
category other than TMA, including Medicaid
expansions, who were eligible under TMA in the month
immediately preceding.
The number of children eligible under title XIX in a
category other than TMA, including Medicaid
expansions, who were eligible under TMA in the month
immediately preceding eligibility in the other category,
divided by the number of children eligible under TMA in
the immediately preceding month.
The number of children eligible under title XXI who were
eligible under TMA in the month immediately preceding
eligibility under title XXI.

The number of children eligible under title XXI who were
eligible under TMA in the month immediately preceding
Percentage of Children
eligibility under title XXI, divided by the number of
Continued in a Title XXI Category children eligible under TMA in the immediately
preceding month

The elements defined above are to be reported quarterly on the following tables.
Include individuals who were eligible for any portion of the reporting period.
Individuals eligible in more than one eligibility category during a month should be
reported in the category that occurred first.
Use unduplicated counts.
Define children as specified in your state plan.
Transitional Medical Assistance (TMA) is defined as coverage under sections 1902(a)(52),
1902(e)(1) and 1925 of the Social Security Act

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
State:

XX

Report Period:
From (mm/dd/yyyy): mm/dd/20yy
To (mm/dd/yyyy): mm/dd//20yy

IV. ARRA Section 5004(d) Data Collection
Table 1. Transitional Medical Assistance Enrollment Data- Adults
Number of Adults Enrolled
during the Reporting Period
(Fill-in)

Number of Enrollment
Months in Reporting Period
(Fill-in)

A

B

Average Monthly Enrollment
(Col B/3)

Average Enrollment Months
Per Enrollee (Col B/Col A)

Number of Enrolled Adults Who
Received Services (Fill-in)

Average Monthly
Participation Rate (Col E/Col
A)

C
0

D

E

F

A -This is the total number of unduplicated number of adults enrolled in TMA at any time during each month of the reporting period.
B - This is the total number of enrollment months for the entire reporting period.
C- This is the number of enrollment months for adults in Column B divided by 3 to obtain the average monthly enrollment for adults
D - This is the number of enrollment months for adults in Column B divided by the unduplicated number adults in Column A, representing
the average number of enrollment months for the reporting period
E - This is the total unduplicated number of adults enrolled in TMA at any time during the reporting period who received Medicaid
services during the reporting period.
F - This is the number of enrolled adults who received services in Column E divided by the total number of adults in Column A,
representing the average monthly participation rate for adults

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
State:

XX

Report Period:
From (mm/dd/yyyy): mm/dd/20yy
To (mm/dd/yyyy): mm/dd//20yy

IV. ARRA Section 5004(d) Data Collection (Cont'd)
Table 2. Transitional Medical Assistance Enrollment Data- Children
Number of Children Enrolled
during the Reporting Period
(Fill-in)

Number of Enrollment
Months in Reporting Period
(Fill-in)

A

B

Average Monthly Enrollment
(Col B/3)

Average Enrollment Months
Per Enrollee (Col B/Col A)

Number of Enrolled Children
Who Received Services (Fill-in)

Average Monthly
Participation Rate (Col E/Col
A)

C
0

D

E

F

A -This is the total number of unduplicated number of children enrolled in TMA at any time during each month of the reporting period.
B - This is the total number of enrollment months for the entire reporting period.
C- This is the number of enrollment months for children in Column B divided by 3 to obtain the average monthly enrollment for children
D - This is the number of enrollment months for children in Column B divided by the unduplicated number adults in Column A,
representing the average number of enrollment months for the reporting period
E - This is the total unduplicated number of children enrolled in TMA at any time during the reporting period who received Medicaid
F - This is the number of enrolled children who received services in Column E divided by the total number of adults in Column A,
representing the average monthly participation rate for children

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
State:

XX

Report Period:
From (mm/dd/yyyy): mm/dd/20yy
To (mm/dd/yyyy): mm/dd//20yy

IV. ARRA Section 5004(d) Data Collection (Cont'd)
Table 3. Transitional Medical Assistance - Children Continued Eligibility Under Title XIX or Title XXI

Number of Children Previously
Enrolled in TMA (Fill-in)

A

Percentage of Children
Number of Children Continued Percentage of Children Continued
Number of Children Continued
Continued in Title XIX (Col B/Col
in Title XXI (Fill-in)
in Title XIX (Fill-in)
in Title XXI (Col D/Col A)
A)

B

C

D

E

A –This is the total unduplicated number of children who were enrolled in TMA during the month immediately preceding
the reporting period, or during either or both of the first two months of the reporting period
B - This is the total unduplicated number of those children reported in A who were enrolled in a title XIX eligibility group
other than TMA, including expansions under title XXI, at any time during the reporting period.
C- This is the percentage of children enrolled in a title XIX eligibility group other than TMA at any time during the reporting
period who were enrolled in TMA in the month immediately preceding other title XIX eligibility (Col. B/Col. A)
D- This is the total unduplicated number of those children reported in A who were enrolled in title XXI at any time during
the reporting period.
E- This the percentage of children enrolled in title XXI at any time during the reporting period who were enrolled in TMA in
the month immediately preceding title XXI eligibility (Col. D/Col. A)

State Report on the Transitional Medical Assistance
Section 5004 of ARRA
State:

XX

Report Period:
From (mm/dd/yyyy): mm/dd/20yy
To (mm/dd/yyyy): mm/dd//20yy

V. Comments

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 0938-1073. The time required to complete this information collection is estimated to
average 2 hours 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.