Crosswalk

Appendix B: Reporting Requirements Crosswalk
Data Collection Template as posted in 81 FR 29268; May 11, 2016
Weekly Progress Report
Number of consumers who have sought enrollment assistance from an
Assister in:
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
 Medicare
Number of consumers who have sought assistance from an Assister with:
o Coverage to Care activities:
 Assisting with health insurance literacy
 Locating providers
 Assisting with billing questions
o Marketplace tax forms (1095-A)
o Filing Marketplace exemptions
o Appeals
o Data matching issues
o Referrals to:
 Other consumer assistance/health insurance programs
 Issuers
 State department of insurances
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
List of outreach, education, and marketing events (including date, type of
event {outreach, education, or marketing}, event name, sponsor/partner,
event/ or social media description, location, number of consumers

NEWLY REVISED CHANGES
to the performance measures below
During one-on-one interactions with consumers, indicate the number of
consumers Navigators have directly assisted with:
o Addressing general inquiries about health insurance options
o Understanding and using health insurance:
 Health insurance literacy
 Locating providers
 Billing and payment questions
o Enrolling in a QHP
o Medicaid/CHIP applications or referrals
o Enrolling into SHOP
o Answering questions about and/or making referrals to:
 Agents/brokers
 Medicare
 Other consumer assistance/health insurance programs
 Issuers
 State departments of insurance
o Marketplace tax forms (1095-A)
o Filing Marketplace exemptions
o Submitting Marketplace or insurance coverage appeals
o Complex cases and other Marketplace issues, such as:
 Data matching issues/Periodic data matching issues
 SEP eligibility
 Employer-sponsored coverage issues
 APTC/CSR
 Other (text field)
Events and Marketing/Promotion Activities
Provide a list of events and/or marketing/promotion activities.
For each event, include the date, time, name of event, sponsor/partner, event
description, location, point of contact information, and type of populationbased event {faith based, women, youth, African American, American
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targeted, type of population-based event {faith based, women, youth,
African American, American Indian/Alaskan Native, Latino/Hispanic, Asian
American/Pacific Islander, Lesbian/Gay/Bisexual/Transgender}, point of
contact information)
Monthly Progress Report
Indicate the amount of grant funds spent during the previous month for:
Current Grant Year ______
Indicate the amount of grant funds remaining as of the last day of the
previous month for:
Current Grant Year ______
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

Indian/Alaskan Native, Latino/Hispanic, Asian American/Pacific Islander,
Lesbian/Gay/Bisexual/Transgender}, if applicable).
For marketing/promotion activities, provide a description of the activity and
the number of consumers expected to be reached through social media
impressions, viewership, listenership, etc.
Indicate the total amount of grant funds spent to date as of the last day of the
previous month
Indicate the total amount of grant funds remaining as of the last day of the
previous month
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, if applicable.

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

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

Describe how you have collaborated with the 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.
• work with CACs (if applicable)

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.
• work with CACs (if applicable)

Provide a complete list of the sub-grantee organizations you are currently
supporting with your Navigator grant funds to perform Navigator duties. If
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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.

there are any changes to the organizations who have served as sub-grantees
(additions/deletions) during the current budget period, please indicate those
changes along with a brief description.
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 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 up to 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.

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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