Form CMS-10371 Quarterly Template

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for
internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in
prosecution to the fullest extent of the law.

State Based Marketplace (SBM) Quarterly Data Submission: Data Collection Template for Reporting Outcomes
This document describes all data elements included in the quarterly SBM Data Submission. Additional information about the data elements and
submission process can be found in the Submission Guide
Generally, data elements in the SBM Data Submission are specific to the individual marketplace (not SHOP) and to medical qualified health plans
(QHPs), not stand-alone dental (SADP) or vision plans. Exceptions to this rule are clearly labeled.
All fields in the SBM Data Submission should be populated (i.e. no null values).
Questions about the data elements should be directed to Carly Rhyne ([email protected]), Nick.Sukachevin
([email protected]) or Dena Pushkin ([email protected]) within CCIIO’s Division of State Policy and Market Analysis.

Metric No.

Tab Name

Description of Tab Contents

Reporting Frequency

# Data
Elements in
each Report

n/a

Glossary of Breakouts

Glossary with detail about data breakouts

n/a

n/a

1

Current health covg

Current health insurance coverage at time of
application (individuals found eligible for
financial assistance only)

Quarterly

50

2

MCAID CHIP Elig

Medicaid and CHIP eligibility assessments and
determinations by the SBM

Quarterly

6

3
4
5

QHP App Elig
QHP Enrollment
SADP

Quarterly
Quarterly
Quarterly

162
264
83

6

QHP eligible-assist

Quarterly

91

7
8

SHOP
Appeals

QHP Applications and Eligibility
QHP Enrollment
Stand-alone Dental Plans
QHP eligible application submissions by type
of assistance
SHOP
Efficiency of eligibility appeals

Quarterly
Quarterly

95
72

9

Complaints

Type and number of complaints submitted

Quarterly

9

10

Exemptions

Exemption applications and granted

Quarterly

2

Total Data Elements in Draft
Last revised: January 20, 2015

834

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.
Unauthorized disclosure may result in prosecution to the fullest extent of the law.

Glossary of Data Breakout Terms for SBM Data Submission

Glossary of Data Elements for Quarterly and Other Marketplace Metrics Reported by States
Measure/Indicator

Definition / Clarification
Individual Marketplace Metrics

New Enrollment/Re-enrollment

QHP Eligibility by Financial Assistance (FA)

Effectuated Enrollment

Metal Tier

Age

New Enrollment. Individuals enrolled in any 2015 Marketplace QHP who were not enrolled in ANY Marketplace QHP at any time during the 2014 coverage year.
Re-enrollment. Individuals enrolled in any 2015 Marketplace QHP who were enrolled in a Marketplace QHP at some point during the 2014 coverage year.
No Financial Assistance
Unit/population of interest includes all of the following:
• Individuals determined eligible for QHP coverage, but ineligible for financial assistance (APTC/CSR)
• Individuals that were determined eligible for QHP coverage but did not request financial assistance..
• Individuals determined eligible for QHP coverage with financial assistance (APTC and/or CSR) but did not select financial assistance.
Individuals that do not fall into "Total Eligible with FA: APTC only" or "Total Eligible with FA: APTCs+CSRs" should be counted in "Eligible without FA"
APTC Only. Number of individuals determined eligible for enrollment into a QHP with only APTC.
APTC+CSRs. Number of individuals determined eligible for enrollment into a QHP with both APTC and CSR
Effectuated enrollment occurs when an individual has submitted an application (or had application submitted on their behalf), was determined QHP Eligible, selected a QHP, and the first
premium payment was received (either directly by the SBM or by the issuer).
Metal tier associated with a health plan:
- Catastrophic
- Bronze
- Silver
- Gold
- Platinum
Age of the individual as of the most recent effective enrollment date:
<18 years
18-25
26-34
35-44
45-54
55-64
≥65

The definitions for classifying persons according to race/ethnicity based on OMB (http://www.whitehouse.gov/omb/fedreg_1997standards):

Race/Ethnicity

American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or
community attachment.
Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea,
Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American. A person having origins in any of the black racial groups of Africa.
Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.
Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Multi-racial. A person reporting more than one of the following racial categories: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific
Islander, or White.
Please use the following steps to report SBM data on race/ethnicity (this follows the classification process employed by ASPE to report FFM data:
http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf):
1) Classify as Latino anyone who reported any Latino/Hispanic ethnicity
2) Non-Latinos are classified as multiracial if they reported two or more major race categories
3) Remaining non-Latinos are classified as American Indian/Alaska Native alone, African-American alone, Asian alone, Native Hawaiian/Pacific Islander alone, White alone, or Multi-racial.
Describes whether individuals received assistance with either submission of an 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)

Application 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 assistors. 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 Counselor (CAC)
- Broker (includes Agents and Web Brokers)
- Authorized Representative
- Other (includes Community Health Center and other types of assistance not categorized above)
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-2012-0523/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.

FPL
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

Language Preference:

No language preference. Person did not indicate a language preference and/or English was chosen as the preferred language.
Spanish. Person indicated that Spanish was preferred language.
Other. Person indicated that their preference was a language other than English or Spanish.

Apply the zip codes designated as Rural by the Office of Rural Health Policy (ORHP). A file with the designated zip codes is included below. Additional information about ORHPs process can
be found in the attached MS Word document.
Rural/Non-Rural

RURAL ZIPs.xlsx

Policy Structure

Describes the number of 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 + 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.

Stand-alone Dental Plan (SADP)

A dental plan that is separate from a QHP (does not include dental plans that are integrated with a QHP).

SHOP Marketplace Metrics

SHOP Employer Group Size

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. The
"Group Size - Covered Employees" is the number of employees covered by a SHOP QHP.
1 <=Employees<=9
10<=Employees<=24
25<=Employees<=50
51<=Employees<100
101<=Employees

Numeric indicators based on the number of employers who have paid For metrics based on the number of employers who have paid a premium for 2015 SHOP coverage, please report data based on QHPs that begin coverage anytime in the 2015 coverage year
a premium for 2015 SHOP coverage
(anytime from January 1, 2015 through December 31, 2015).

Number of Employers who completed an application through SHOP

Report the number of employers who completed an application for a SHOP QHP for coverage beginning anytime during the 2015 coverage year.

New Employers: Number of Employers selecting a 2015 QHP/Metal
Level through SHOP who were NOT enrolled in a 2014 SHOP QHP
(NEW Enrollment)

Depending on the SHOP employee choice model in your state, report the number of employers selecting either a 2015 QHP, Metal Level, OR Issuer through SHOP (Plan Selection). NEW
employers to SHOP are employers who were not enrolled in ANY a SHOP QHP at any time during the 2014 coverage year.

Re-Enrolled Employers: Number of Employers selecting a 2015
QHP/Metal Level through SHOP who were enrolled in a 2014 SHOP
QHP (RE-Enrollment)

Depending on the SHOP employee choice model in your state, report the number of employers selecting either a 2015 QHP, Metal Level, OR Issuer through SHOP (Plan Selection). REenrolling employers to SHOP are employers who were enrolled in a SHOP QHP at any time during the 2014 coverage year.

New Employers: Number of NEW SHOP Enrolled Employers.
Calculated the cumulative number of employers who selected a 2015 Report the number of employers who have selected a 2015 QHP/Metal level through SHOP and have paid a premium for 2015 coverage. For NEW SHOP enrolled employers, report the
QHP/Metal Level through SHOP and paid a premium and who did NOT number of employers who did NOT enroll in a SHOP QHP at any time during the 2014 coverage year.
enroll in a 2014 SHOP QHP (NEW Enrollment).

Re-Enrolled Employers: Number of RE-Enrolled SHOP Employers.
Calculate the cumulative number of employers who selected a 2015 Report the number of employers who have selected a 2015 QHP/Metal level through SHOP and have paid a premium for 2015 coverage.. For RE-Enrolled SHOP employers, report the
QHP/Metal Level through SHOP, who paid a premium and who were number of employers who also enrolled in SHOP at any time during the 2014 coverage year.
also enrolled in a 2014 SHOP QHP [Re-enrollment].

Number of employers offering dependent coverage

Number of employers offering employee choice

Average Employer Premium Contribution Percent. Calculate the
average percent that employers enrolled in 2015 SHOP coverage
contributed towards their employees' premiums.

Number of employers enrolled in a 2015 SHOP QHP who offer coverage for employees' dependents in their 2015 QHPs.
Number of employers enrolled in a 2015 SHOP WHP who offer employees a choice of QHPs. If employers in your state do not offer employee choice, please enter "-999" to indicate that this
metric is not applicable.

Calculate the average percent that employers participating in SHOP in 2015 coverage year are contributing to their employees' premiums. Calculate separate amounts for employees
enrolled in individual coverage and employees enrolled in family coverage.

Numeric indicators based on the number of employees who have paid For metrics based on the number of employees who have paid a premium for 2015 SHOP coverage, please report data based on employees enrolled in a SHOP QHPs that begin coverage
a premium for 2015 SHOP coverage
anytime in the 2015 coverage year (anytime from January 1, 2015 through December 31, 2015).

Number of Employees Enrolled through SHOP. Calculate the
cumulative number of employees who selected a SHOP QHP for
coverage during the 2015 coverage year and paid a premium.

Number of Total Employees on Employee Roster submitted by
Employers

Total number of employees who have selected a SHOP QHP for coverage during the 2015 coverage year and paid a premium.

Total number of employees on employee rosters submitted by employers who are enrolled in a 2015 SHOP QHP.

Number of Employees (covered lives, including dependents) Enrolled
through SHOP. Calculate cumulative number of employees and their
Total number of employees and their dependents (covered lives) who selected a QHP through SHOP for coverage during the 2015 coverage year and paid a premium.
dependents who selected a QHP through SHOP for coverage during
the 2015 coverage year and paid a premium.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to
persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the fullest extent of the law.

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 during the reference period. Include individuals that have been determined eligible but may not have selected a QHP or paid an initial premium.
Include individuals that were given a positive eligibility determination but discrepancies must be resolved (i.e., in an inconsistency period) or individuals that received final eligibility determination. Metric excludes
individuals that were not determined eligible for financial assistance (e.g., determined ineligible or no determination took place)
Source for Data Breakouts: Most recent eligibility determination.
First Reference Period: 11/15/2014 - 3/31/2015
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 in 'Current Coverage' tab

Reference Period

Please select in 'Current Coverage' tab.

#

Data Element

Data Element Description

Individual Marketplace (SBM)- Does not include SHOP
1
2
3
Among individuals determined eligible for
4
Individuals Not Enrolled financial assistance with coverage through the
5
in Any Coverage When SBM, number of individuals that did not have
6
Application Submitted any of the types of coverage listed (i.e., likely
7
uninsured).
8
9
Total
10
11
12
Among individuals determined eligible for
13
Individuals Enrolled in financial assistance with coverage through the
14
15 Employer-Based Coverage SBM, number of individuals enrolled in
When Application
employer-based coverage (aka employer16
Submitted
sponsored insurance or ESI) at the time the
17
application was submitted.
18
19
Total
20

Data Breakouts
(for more info, see Glossary tab)

FPL

FPL

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown

Data Element Name

Data Type

CURRENTCOV_UNINS_FPL1
CURRENTCOV_UNINS_FPL2
CURRENTCOV_UNINS_FPL3
CURRENTCOV_UNINS_FPL4
CURRENTCOV_UNINS_FPL5
CURRENTCOV_UNINS_FPL6
CURRENTCOV_UNINS_FPL7

Number
Number
Number
Number
Number
Number
Number

CURRENTCOV_UNINS_FPL9
CURRENTCOV_UNINS_TOTAL
CURRENTCOV_EMP_FPL1
CURRENTCOV_EMP_FPL2
CURRENTCOV_EMP_FPL3
CURRENTCOV_EMP_FPL4
CURRENTCOV_EMP_FPL5
CURRENTCOV_EMP_FPL6
CURRENTCOV_EMP_FPL7

Number
Number
Number
Number
Number
Number
Number
Number
Number

CURRENTCOV_EMP_FPL9
CURRENTCOV_EMP_TOTAL

Number
Number

Data from
State

21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
50

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%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown

Total

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 nongroup coverage at the time the application was
submitted.

FPL

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown

Total

Individuals that Don't
Provide Information
About Coverage When
Application Submitted

Among individuals determined eligible for
financial assistance with coverage through the
SBM, number of individuals that did not
provide information about prior coverage at
time the application was submitted.

FPL

Total

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown

CURRENTCOV_MCAID_FPL1
CURRENTCOV_MCAID_FPL2
CURRENTCOV_MCAID_FPL3
CURRENTCOV_MCAID_FPL4
CURRENTCOV_MCAID_FPL5
CURRENTCOV_MCAID_FPL6
CURRENTCOV_MCAID_FPL7

Number
Number
Number
Number
Number
Number
Number

CURRENTCOV_MCAID_FPL9
CURRENTCOV_MCAID_TOTAL
CURRENTCOV_NONGRP_FPL1
CURRENTCOV_NONGRP_FPL2
CURRENTCOV_NONGRP_FPL3
CURRENTCOV_NONGRP_FPL4
CURRENTCOV_NONGRP_FPL5
CURRENTCOV_NONGRP_FPL6
CURRENTCOV_NONGRP_FPL7

Number
Number
Number
Number
Number
Number
Number
Number
Number

CURRENTCOV_NONGRP_FPL9
CURRENTCOV_NONGRP_TOTAL
CURRENTCOV_NOTPROVIDED_FPL1
CURRENTCOV_NOTPROVIDED_FPL2
CURRENTCOV_NOTPROVIDED_FPL3
CURRENTCOV_NOTPROVIDED_FPL4
CURRENTCOV_NOTPROVIDED_FPL5
CURRENTCOV_NOTPROVIDED_FPL6
CURRENTCOV_NOTPROVIDED_FPL7

Number
Number
Number
Number
Number
Number
Number
Number
Number

CURRENTCOV_NOTPROVIDED_FPL9
CURRENTCOV_NOTPROVIDED_TOTAL

Number
Number
0

0

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated,

Transfers Between Marketplace and Medicaid/CHIP
Description: Data used to understand the assessments/determinations for Medicaid/CHIP and the transfers between SBM and Medicaid/CHIP. Transfer means moving accounts between the SBM and the
Medicaid/CHIP agencies for the purposes of eligibility determination. Transfers do not include movement of accounts after determination for the purposes of enrollment.
Unit : Number of Individuals
Population Included: Individuals with a completed, submitted application
Source for Data Breakouts: N/A
First Reference Period: 11/15/2014 - 3/31/2015
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. If the SBM cannot distinguish between eligibility and/or assessments for Medicaid and CHIP, provide your total numbers (Medicaid/CHIP) under
Medicaid, and enter -888 for CHIP.

State
Reference Period
#

Please select in 'Current Coverage' tab
Please select in 'Current Coverage' tab.
Data Element

Data Element Description

Data Element Name

Data Type

Individual Marketplace (SBM) - Does not include SHOP

1

2

3

Individuals that received eligibility assessment for Medicaid.

Whether SBM is integrated or not, report the number of individuals assessed
for Medicaid eligibility during the reference period. This data element includes
all Medicaid assessments, whether the individuals are found likely to be
eligible or ineligible.

Individuals that received eligibility assessment for CHIP.

Whether SBM is integrated or not, report the number of individuals assessed
for Medicaid eligibility during the reference period. This data element includes
all CHIP assessments, whether the individuals are found likely to be eligible or
ineligible.

Individuals determined eligible for Medicaid - SBMs with
integrated Medicaid eligibility systems.

For SBMs 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

4

Individuals transferred to Medicaid agencies for eligibility
determination - SBMs that do not have integrated Medicaid
eligibility systems.

For SBMs with eligibility systems that are referred to Medicaid agency for final
determination, report the number of individuals referred to Medicaid during
the reference period.
For SBMs with eligibility systems that are integrated with Medicaid eligibility
systems, enter -999.

DET_MCAID_ELG

Number

Data from
State

5

6

6

For SBMs with eligibility systems that are integrated with CHIP eligibility
systems, report the number of individuals determined eligible for CHIP by the
Individual determined eligible for CHIP - SBMs with integrated SBM during the reference period.
CHIP eligibility systems.
For SBMs with eligibility systems that are not integrated with CHIP eligibility
systems, enter -999
For SBMs with eligibility systems that are referred to CHIP agency for final
determination, report the number of individuals referred to CHIP during the
Individuals transferred to CHIP agencies for eligibility
reference period.
determination - SBMs that do not have integrated CHIP
eligibility systems.
For SBMs with eligibility systems that are integrated with Medicaid eligibility
systems, enter -999.

DET_CHIP_ELG

Number

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not

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 (APTC/CSR). Do not include information for SADPs.

Unit : Number of Individuals
Population Included: Individuals with a completed, submitted application
Source for Data Breakouts: Most recent eligibility determination.
First Reference Period: 11/15/2014 - 3/31/2015
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
Reference Period
#

Data Element

Please select in 'Current Coverage' tab
Please select in 'Current Coverage' tab.
Data Breakouts
(for more info, see Glossary tab)

Data Element Description

Individual Marketplace (SBM)- Does not include SHOP
1
2
3
4
5
Number of individuals that submitted a complete application for
6
coverage to the SBM during the reference period.

Age

7
A completed application is defined as an application with sufficient
information to begin processing eligibility for any type of coverage
(QHP or Medicaid/CHIP).

8
9

12

15
16
17
18
19
20
21
22
23
24
25

<18
18-25
26-34
35-44
45-54
55-64

QHP_APP_AGE1
QHP_APP_AGE2
QHP_APP_AGE3
QHP_APP_AGE4
QHP_APP_AGE5
QHP_APP_AGE6

Number
Number
Number
Number
Number
Number

≥65

QHP_APP_AGE7

Number

QHP_APP_ANY
QHP_APP_NONE
QHP_APP_TRIBE
QHP_APP_TOTAL

Number
Number
Number
Number

Black or African American
Asian

11

14

Data Type

American Indian/Alaska Native

10

13

Data Element Name

Applied for coverage
through SBM

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.

Race/Ethnicity

Hispanic or Latino
Native Hawaiian/Pacific Islander
White
Multi-racial
Unknown/Other

No Language Preference
Tribe Members should be included in each of the categorical breakouts Language Preference Spanish
and total metric as well as being reported in the “Members of a
Other
federally recognized tribe” category.
Rural
Rural/Non-Rural
Non-Rural
Unknown
Any
None
Members of a federally recognized tribe
Total
Application Assistance

Data from
State

26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78

QHP Eligible

Ineligible for QHP

<18
18-25
Age
26-34
35-44
45-54
55-64
≥65
American Indian/Alaska Native
Number of individuals determined QHP eligible during the reference
Black or African American
period.
Asian
Hispanic or Latino
Include all individuals who requested financial assistance (APTC/CSR) or
Race/Ethnicity
Native Hawaiian/Pacific Islander
did not request financial assistance. Include all individuals who were
White
determined eligible or ineligible for financial assistance.
Multi-racial
Unknown/Other
Tribe Members should be included in each of the categorical breakouts
No Language Preference
and total metric as well as being reported in the “Members of a
Language Preference Spanish
federally recognized tribe” category.
Other
Rural
Rural/Non-Rural
Non-Rural
Unknown
Without FA
Financial Assistance APTC Only
APTC+CSRs
Any
Application Assistance
None
Members of a federally recognized tribe
Total
<18
18-25
26-34
Age
35-44
45-54
55-64
≥65
American Indian/Alaska Native
Black or African American
Asian
Hispanic or Latino
Race/Ethnicity
Native Hawaiian/Pacific Islander
Number of individuals determined ineligible for QHP coverage during
White
the reference period. Includes both individuals that requested financial
Multi-racial
assistance (APTC/CSR) and did not request financial assistance.
Unknown/Other
No Language Preference
Language Preference Spanish
Other
Rural
Rural/Non-Rural
Non-Rural
Unknown
Any
Application Assistance
None
Members of a federally recognized tribe
Total

QHP_ELG_AGE1
QHP_ELG_AGE2
QHP_ELG_AGE3
QHP_ELG_AGE4
QHP_ELG_AGE5
QHP_ELG_AGE6
QHP_ELG_AGE7

Number
Number
Number
Number
Number
Number
Number

QHP_ELG_ANY
QHP_ELG_NONE
QHP_ELG_TRIBE
QHP_ELG_TOTAL
QHP_INELG_AGE1
QHP_INELG_AGE2
QHP_INELG_AGE3
QHP_INELG_AGE4
QHP_INELG_AGE5
QHP_INELG_AGE6
QHP_INELG_AGE7

Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number

QHP_INELG_ANY
QHP_INELG_NONE

Number
Number

QHP_INELG_TOTAL

Number

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
129
130
131
132
133
134
135
136
137

Assessed/determined
ineligible for
Medicaid/CHIP and
determined to be QHP
eligible with financial
assistance

Number of individuals that were:
1. determined/assessed to be ineligible for Medicaid/CHIP
2. determined QHP eligible
3. determined eligible for financial assistance (APTC/CSR) during the
reference period.

Number of individuals that:
Eligible for QHP but did not 1. were determined QHP eligible during the reference period and
request financial assistance 2. did not request financial assistance (APTC/CSR).

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
<18
18-25
26-34
Age
35-44
45-54
55-64
≥65
American Indian/Alaska Native
Black or African American
Asian
Hispanic or Latino
Race/Ethnicity
Native Hawaiian/Pacific Islander
White
Multi-racial
Unknown/Other
No Language Preference
Language Preference Spanish
Other
Rural
Rural/Non-Rural
Non-Rural
Unknown
Any
Application Assistance
None
Members of a federally recognized tribe
Total
<18
18-25
26-34
Age
35-44
45-54
55-64
≥65
American Indian/Alaska Native
Black or African American
Asian
Hispanic or Latino
Race/Ethnicity
Native Hawaiian/Pacific Islander
White
Multi-racial
Unknown/Other
No Language Preference
Language Preference Spanish
Other
Rural
Rural/Non-Rural
Non-Rural
Unknown
Any
Application Assistance
None
Members of a federally recognized tribe
Total

QHP_INELGMCAID_APTC_FPL1
QHP_INELGMCAID_APTC_FPL2
QHP_INELGMCAID_APTC_FPL3
QHP_INELGMCAID_APTC_FPL4
QHP_INELGMCAID_APTC_FPL5
QHP_INELGMCAID_APTC_FPL6
QHP_INELGMCAID_APTC_FPL7

Number
Number
Number
Number
Number
Number
Number

QHP_INELGMCAID_APTC_FPL9
QHP_INELGMCAID_APTC_AGE1
QHP_INELGMCAID_APTC_AGE2
QHP_INELGMCAID_APTC_AGE3
QHP_INELGMCAID_APTC_AGE4
QHP_INELGMCAID_APTC_AGE5
QHP_INELGMCAID_APTC_AGE6
QHP_INELGMCAID_APTC_AGE7

Number
Number
Number
Number
Number
Number
Number
Number

QHP_INELGMCAID_APTC_ANY
QHP_INELGMCAID_APTC_NONE

Number
Number

QHP_INELGMCAID_APTC_TOTAL
QHP_NOREQ_AGE1
QHP_NOREQ_AGE2
QHP_NOREQ_AGE3
QHP_NOREQ_AGE4
QHP_NOREQ_AGE5
QHP_NOREQ_AGE6
QHP_NOREQ_AGE7

Number
Number
Number
Number
Number
Number
Number
Number

QHP_NOREQ_ANY
QHP_NOREQ_NONE

Number
Number

QHP_NOREQ_TOTAL

Number

138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158

Eligible for QHP and
requested financial
assistance

Number of individuals that:
1. were determined QHP eligible during the reference period and
2. requested financial assistance (APTC/CSR).

<18
18-25
26-34
Age
35-44
45-54
55-64
≥65
American Indian/Alaska Native
Black or African American
Asian
Hispanic or Latino
Race/Ethnicity
Native Hawaiian/Pacific Islander
White
Multi-racial
Unknown/Other
No Language Preference
Language Preference Spanish
Other
Rural
Rural/Non-Rural
Non-Rural
Unknown

159
160
161

Application Assistance Any
None
Members of a federally recognized tribe

162
162

Total

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or

QHP Enrollment
Description: Data used to measure the number of individuals were enrolled or cancelled coverage in a QHP during the reference period. Do not include information for SADPs.
Unit : Number of Individuals
Population Included: Individuals determined eligible for QHP coverage
Source for Data Breakouts: Most recent eligibility determination.
First Reference Period: 11/15/2014 - 3/31/2015
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,

State
Reference Period
#

Data Element

Please select in 'Current Coverage' tab
Please select in 'Current Coverage' tab.

Individual Marketplace (SBM)- Does not include SHOP
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

Number of individuals that selected and were
determined eligible for a QHP with financial assistance
(APTC/CSR) during the reference period.

Plan Selection -

Data Breakouts
(for more info, see Glossary tab)

Data Element Description

Include both individuals that were given a positive
eligibility determination but discrepancies must be
resolved (i.e., in an inconsistency period) and

New/Re-enrollment

FPL

Age

Race/Ethnicity

Language Preference

Newly Enrolled
Re-enrolled
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
<18
18-25
26-34
35-44
45-54
55-64
≥65
American Indian/Alaska Native
Black or African American
Asian
Hispanic or Latino
Native Hawaiian/Pacific Islander
White
Multi-racial
Unknown/Other
No Language Preference
Spanish
Other

Data Element Name

Data Type

QHP_EFFECTIVE_APTC_FPL1
QHP_EFFECTIVE_APTC_FPL2
QHP_EFFECTIVE_APTC_FPL3
QHP_EFFECTIVE_APTC_FPL4
QHP_EFFECTIVE_APTC_FPL5
QHP_EFFECTIVE_APTC_FPL6
QHP_EFFECTIVE_APTC_FPL7
QHP_EFFECTIVE_APTC_FPL8

Number
Number
Number
Number
Number
Number
Number
Number

QHP_EFFECTIVE_APTC_AGE1
QHP_EFFECTIVE_APTC_AGE2
QHP_EFFECTIVE_APTC_AGE3
QHP_EFFECTIVE_APTC_AGE4
QHP_EFFECTIVE_APTC_AGE5
QHP_EFFECTIVE_APTC_AGE6
QHP_EFFECTIVE_APTC_AGE7

Number
Number
Number
Number
Number
Number
Number

Data from
State

Bronze

30
Metal Tier
Number of individuals that selected and were
determined eligible for a QHP with financial assistance
(APTC/CSR) during the reference period.

31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78

Plan Selection Financial Assistance

Include both individuals that were given a positive
eligibility determination but discrepancies must be
resolved (i.e., in an inconsistency period) and
individuals that received final eligibility determination.
Tribe Members should be included in each of the
categorical breakouts and total metric as well as being
reported in the “Members of a federally recognized
tribe” category.

Silver
Gold
Platinum
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL by Metal: Bronze
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL by Metal: Silver
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL by Metal: Gold
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL by Metal: Platinum
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
APTC Only
Financial Assistance
APTC+CSRs
Any
Application Assistance
None
Rural
Rural/Non-Rural
Non-Rural
unknown
Members of a federally recognized tribe
Total

QHP_EFFECTIVE_APTC_ANY
QHP_EFFECTIVE_APTC_NONE

Number
Number

QHP_EFFECTIVE_APTC_TRIBE
QHP_EFFECTIVE_APTC_TOTAL

Number
Number

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

New/Re-enrollment

Age

Number of individuals that selected a QHP without
financial assistance (APTC/CSR) during the reference
period. These individuals were determined QHP eligible
without financial assistance, and selected a QHP during
the reference period.

Plan Selection- NO
Financial Assistance

Race/Ethnicity

Include both individuals that were given a positive
eligibility determination but discrepancies must be
resolved (i.e., in an inconsistency period) and
individuals that received final eligibility determination.
Language Preference
Includes all of the following: (1) individuals determined
eligible for QHP coverage but ineligible for financial
assistance; (2) individuals determined eligible for QHP
coverage but did not request financial assistance; and
(3) individuals determined eligible for QHP coverage
with financial assistance and did not select financial
assistance.

Metal Tier

Channel

Application Assistance
Rural/Non-Rural

Newly Enrolled
Re-enrolled
<18
18-25
26-34
35-44
45-54
55-64
≥65
American Indian/Alaska Native
Black or African American
Asian
Hispanic or Latino
Native Hawaiian/Pacific Islander
White
Multi-racial
Unknown/Other
No Language Preference
Spanish
Other
Catastrophic
Bronze
Silver
Gold
Platinum
web
phone
paper
other/unknown
Any
None
Rural
Non-Rural
Unknown
Total

QHP_EFFECTIVE_NOAPTC_AGE1
QHP_EFFECTIVE_NOAPTC_AGE2
QHP_EFFECTIVE_NOAPTC_AGE3
QHP_EFFECTIVE_NOAPTC_AGE4
QHP_EFFECTIVE_NOAPTC_AGE5
QHP_EFFECTIVE_NOAPTC_AGE6
QHP_EFFECTIVE_NOAPTC_AGE7

Number
Number
Number
Number
Number
Number
Number

QHP_EFFECTIVE_NOAPTC_WEB
QHP_EFFECTIVE_NOAPTC_PHONE
QHP_EFFECTIVE_NOAPTC_PAPER
QHP_EFFECTIVE_NOAPTC_OTHER
QHP_EFFECTIVE_NOAPTC_ANY
QHP_EFFECTIVE_NOAPTC_NONE

Number
Number
Number
Number
Number
Number

QHP_EFFECTIVE_NOAPTC_TOTAL

Number

114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164

New/Re-enrollment

FPL

Age

Race/Ethnicity

Language Preference

Metal Tier
Number of individuals that received effectuated
enrollment with financial assistance (APTC/CSR) during
the reference period. These individuals were
determined QHP eligible with financial assistance,
selected a QHP and a financial assistance amount, and
the individual made the first premium payment during
the reference period.

FPL by Metal: Bronze

Effectuated Enrollment- Include both individuals that were given a positive
Financial Assistance eligibility determination but discrepancies must be
resolved (i.e., in an inconsistency period) and
individuals that received final eligibility determination.
Tribe Members should be included in each of the
categorical breakouts and total metric as well as being
reported in the “Members of a federally recognized
tribe” category.

FPL by Metal: Silver

Newly Enrolled
Re-enrolled
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
<18
18-25
26-34
35-44
45-54
55-64
≥65
American Indian/Alaska Native
Black or African American
Asian
Hispanic or Latino
Native Hawaiian/Pacific Islander
White
Multi-racial
Unknown/Other
No Language Preference
Spanish
Other
Bronze
Silver
Gold
Platinum
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown

QHP_EFFECTUATED_FIN_FPL1
QHP_EFFECTUATED_FIN_FPL2
QHP_EFFECTUATED_FIN_FPL3
QHP_EFFECTUATED_FIN_FPL4
QHP_EFFECTUATED_FIN_FPL5
QHP_EFFECTUATED_FIN_FPL6
QHP_EFFECTUATED_FIN_FPL7

Number
Number
Number
Number
Number
Number
Number

QHP_EFFECTUATED_FIN_FPL9
QHP_EFFECTUATED_FIN_AGE1
QHP_EFFECTUATED_FIN_AGE2
QHP_EFFECTUATED_FIN_AGE3
QHP_EFFECTUATED_FIN_AGE4
QHP_EFFECTUATED_FIN_AGE5
QHP_EFFECTUATED_FIN_AGE6
QHP_EFFECTUATED_FIN_AGE7

Number
Number
Number
Number
Number
Number
Number
Number

Tribe Members should be included in each of the
categorical breakouts and total metric as well as being
reported in the “Members of a federally recognized
tribe” category.
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL by Metal: Gold
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL by Metal: Platinum
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
APTC Only
Financial Assistance
APTC+CSRs
Any
Application Assistance
None
Single
Single + 1 spouse/partner
Policy Structure
Single + 1 child
Single + 2 or more dependents
Child-only
Rural
Rural/Non-Rural
Non-Rural
Unknown
Members of a federally recognized tribe
Total

QHP_EFFECTUATED_FIN_ANY
QHP_EFFECTUATED_FIN_NONE
QHP_EFFECTUATED_FIN_PS1
QHP_EFFECTUATED_FIN_PS2
QHP_EFFECTUATED_FIN_PS3
QHP_EFFECTUATED_FIN_PS4
QHP_EFFECTUATED_FIN_PS5

Number
Number
Number
Number
Number
Number
Number

QHP_EFFECTUATED_FIN_TRIBE
QHP_EFFECTUATED_FIN_TOTAL

Number
Number

197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232

New/Re-enrollment

Age

Number of individuals that received effectuated
enrollment without financial assistance (APTC/CSR)
during the reference period. These individuals were
determined QHP eligible without financial assistance,
selected a QHP, and the individual made the first
premium payment during the reference period.
Include both individuals that were given a positive
Effectuated Enrollmenteligibility determination but discrepancies must be
NO Financial Assistance
resolved (i.e., in an inconsistency period) and
individuals that received final eligibility determination.
Includes all of the following: (1) individuals determined
eligible for QHP coverage but ineligible for financial
assistance (APTC/CSR); (2) individuals that were
determined eligible for QHP coverage but did not
request financial assistance; and (3) individuals
determined eligible for QHP coverage with financial
assistance and did not select financial assistance.

Race/Ethnicity

Language Preference

Metal Tier

Application Assistance

Policy Structure

Rural/Non-Rural

Newly Enrolled
Re-enrolled
<18
18-25
26-34
35-44
45-54
55-64
≥65
American Indian/Alaska Native
Black or African American
Asian
Hispanic or Latino
Native Hawaiian/Pacific Islander
White
Multi-racial
Unknown/Other
No Language Preference
Spanish
Other
Catastrophic
Bronze
Silver
Gold
Platinum
Any
None
Single
Single + 1 spouse/partner
Single + 1 child
Single + 2 or more dependents
Child-only
Rural
Non-Rural
Unknown
Total

QHP_EFFECTUATED_NOFIN_AGE1
QHP_EFFECTUATED_NOFIN_AGE2
QHP_EFFECTUATED_NOFIN_AGE3
QHP_EFFECTUATED_NOFIN_AGE4
QHP_EFFECTUATED_NOFIN_AGE5
QHP_EFFECTUATED_NOFIN_AGE6
QHP_EFFECTUATED_NOFIN_AGE7

Number
Number
Number
Number
Number
Number
Number

QHP_EFFECTUATED_NOFIN_ANY
QHP_EFFECTUATED_NOFIN_NONE
QHP_EFFECTUATED_NOFIN_PS1
QHP_EFFECTUATED_NOFIN_PS2
QHP_EFFECTUATED_NOFIN_PS3
QHP_EFFECTUATED_NOFIN_PS4
QHP_EFFECTUATED_NOFIN_PS5

Number
Number
Number
Number
Number
Number
Number

QHP_EFFECTUATED_NOFIN_TOTAL

Number

233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263

264

264

Cancelled for NonPayment

Number of individuals who had their enrollment
cancelled by a QHP for non-payment during the
reference period. These individuals would be
determined QHP eligible and selected a QHP but the
individual was disenrolled during the reference period
due to non-payment of the first premium and before
the effective enrollment date (i.e. coverage cancelled).
Tribe Members should be included in each of the
categorical breakouts and total metric as well as being
reported in the “Members of a federally recognized
tribe” category.

Cancelled for Other
Reason

Number of individuals that cancelled for reasons other
than non-payment during the reference period. These
individuals would be determined 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 cancelled) due for reasons other than nonpayment.

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
<18
18-25
26-34
Age
35-44
45-54
55-64
≥65
Without FA
Financial Assistance
APTC Only
APTC+CSRs
Rural
Rural/Non-Rural
Non-Rural
Unknown
Any
Application Assistance
None
Single
Single + 1 spouse/partner
Policy Structure
Single + 1 child
Single + 2 or more dependents
Child-only
Members of a federally recognized tribe
Total

Total

QHP_NONPYMT_FPL1
QHP_NONPYMT_FPL2
QHP_NONPYMT_FPL3
QHP_NONPYMT_FPL4
QHP_NONPYMT_FPL5
QHP_NONPYMT_FPL6
QHP_NONPYMT_FPL7
QHP_NONPYMT_FPL8
QHP_NONPYMT_FPL9
QHP_NONPYMT_AGE1
QHP_NONPYMT_AGE2
QHP_NONPYMT_AGE3
QHP_NONPYMT_AGE4
QHP_NONPYMT_AGE5
QHP_NONPYMT_AGE6
QHP_NONPYMT_AGE7

Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number

QHP_NONPYMT_ANY
QHP_NONPYMT_NONE
QHP_NONPYMT_PS1
QHP_NONPYMT_PS2
QHP_NONPYMT_PS3
QHP_NONPYMT_PS4
QHP_NONPYMT_PS5
QHP_NONPYMT_TRIBE
QHP_NONPYMT_TOTAL

Number
Number
Number
Number
Number
Number
Number
Number
Number

QHP_OTHCANCEL_TOTAL

Number

Stand Alone Dental Plans (SADPs)
Description: Data used to measure the number of applications for SADPs, plan selection for SADPs, and effectuated enrollment in SADPs.
Unit : Varies by data element
Population Included: Varies by data element
Source for Data Breakouts: Most recent eligibility determination
First Reference Period: 11/15/2014 - 3/31/2015
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
Reference Period

#

Data Element

Please select in 'Current
Coverage' tab
Please select in 'Current
Coverage' tab.

Data Element Description

Data Breakouts
(for more info, see Glossary tab)

Individual Marketplace (SBM)- Does not include SHOP
1
<18
2
18-25
3
26-34
Age
4
35-44
5
45-54
6
55-64
Number of individuals that
7
≥65
submitted a complete application for
8
American Indian/Alaska Native
coverage for a SADP during the
9
Black or African American
reference period.
10
Asian
11
Hispanic or Latino
Race/Ethnicity
Tribe members should be included in
12
Native Hawaiian/Pacific Islander
Applied for coverage
each of the categorical breakouts
13
White
through SBM
and total metric as well as being
14
Multi-racial
reported in the “Members of a
15
Unknown/Other
federally recognized tribe” category.
16
No Language Preference
Language Preference
17
Spanish
18
Other
19
Rural
Rural/Non-Rural
20
Non-Rural
21
unknown
22
Any
Application Assistance
23
None
Members of a federally recognized tribe
24

Data Element
Name

Data Type

Data from State

25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54

Total
New Enrollment:
Re-enrollment
High
Coverage Level
Low
<18
18-25
26-34
Age
35-44
45-54
55-64
≥65
American Indian/Alaska Native
Black or African American
Asian
Hispanic or Latino
Race/Ethnicity
Native Hawaiian/Pacific Islander
White
Multi-racial
Unknown/Other
No Language Preference
Language Preference
Spanish
Other
Rural
Rural/Non-Rural
Non-Rural
unknown
Any
Application Assistance
None
Members of a federally recognized tribe
Total
New vs. Re-enrollment

Number of individuals that selected
a SADP during the reference period.
Plan Selection

Tribe members should be included in
each of the categorical breakouts
and total metric as well as being
reported in the “Members of a
federally recognized tribe” category.

55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
83

New Enrollment:
Re-enrollment
High
Coverage Level
Low
<18
18-25
26-34
Age
35-44
45-54
55-64
Number of individuals with
≥65
effectuated enrollment in a SADP
American Indian/Alaska Native
during the reference period.
Black or African American
Asian
Tribe members should be included in
Hispanic or Latino
Race/Ethnicity
each of the categorical breakouts
Native Hawaiian/Pacific Islander
and total metric as well as being
White
reported in the “Members of a
Multi-racial
federally recognized tribe” category.
Unknown/Other
No Language Preference
Language Preference
Spanish
Other
Rural
Rural/Non-Rural
Non-Rural
unknown
Any
Application Assistance
None
Members of a federally recognized tribe
Total
New vs. Re-enrollment

Effectuated
Enrollment

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and
must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the fullest extent of the law.

QHP Eligible Application Submission- By Type of Assistance
Description: Data used to report on QHP eligible (both subsidized and unsubsidized) in the SBM (not SHOP) by type of assistance. Do not include information for SADPs. This metric is intended to
capture all recorded types of assistance. Assistance may be provided 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 assistors. CCIIO does 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. 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
Population Included: Both individuals that were given a positive eligibility determination during the reference period but discrepancies must be resolved (i.e., in an inconsistency
period) and individuals that received final eligibility determination.
Source for Data Breakouts: Most recent eligibility determination.
First Reference Period: 11/15/2014 - 3/31/2015
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
Reference Period
#

Data Element

Please select in 'Current Coverage' tab
Please select in 'Current Coverage' tab.

Individual Marketplace (SBM)- Does not include SHOP
1
2
3
4
5
6
QHP eligible -Any Number of QHP eligible individuals in the
7
assistance
reference period that received any assistance.
8
9
10
11
12
13

Data Breakouts
(for more info, see Glossary tab)

Data Element Description

FPL

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown

Rural
Rural/NonRural
Non-Rural
Unknown
Total

Data Element Name

Data Type

ASSIST_ANY_FPL1
ASSIST_ANY_FPL2
ASSIST_ANY_FPL3
ASSIST_ANY_FPL4
ASSIST_ANY_FPL5
ASSIST_ANY_FPL6
ASSIST_ANY_FPL7
ASSIST_ANY_FPL8
ASSIST_ANY_FPL9

Number
Number
Number
Number
Number
Number
Number
Number
Number

ASSIST_ANY_TOTAL

Number

Data from
State

14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52

Number of QHP eligible individuals in the
QHP eligible -No
reference period that did not receive any
assistance
assistance.

QHP eligible Navigator

Number of QHP eligible individuals in the
reference period with assistance from a
navigator.

Number of QHP eligible individuals in the
QHP eligible-IPA reference period with assistance from an InPerson Assister (IPA).

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
Rural
Rural/NonNon-Rural
Rural
Unknown
Total
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
Rural
Rural/NonNon-Rural
Rural
Unknown
Total
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
Rural
Rural/NonNon-Rural
Rural
Unknown
Total

ASSIST_NONE_FPL1
ASSIST_NONE_FPL2
ASSIST_NONE_FPL3
ASSIST_NONE_FPL4
ASSIST_NONE_FPL5
ASSIST_NONE_FPL6
ASSIST_NONE_FPL7
ASSIST_NONE_FPL8
ASSIST_NONE_FPL9

Number
Number
Number
Number
Number
Number
Number
Number
Number

ASSIST_NONE_TOTAL
ASSIST_NAV_FPL1
ASSIST_NAV_FPL2
ASSIST_NAV_FPL3
ASSIST_NAV_FPL4
ASSIST_NAV_FPL5
ASSIST_NAV_FPL6
ASSIST_NAV_FPL7
ASSIST_NAV_FPL8
ASSIST_NAV_FPL9

Number
Number
Number
Number
Number
Number
Number
Number
Number
Number

ASSIST_NAV_TOTAL
ASSIST_IPA_FPL1
ASSIST_IPA_FPL2
ASSIST_IPA_FPL3
ASSIST_IPA_FPL4
ASSIST_IPA_FPL5
ASSIST_IPA_FPL6
ASSIST_IPA_FPL7
ASSIST_IPA_FPL8
ASSIST_IPA_FPL9

Number
Number
Number
Number
Number
Number
Number
Number
Number
Number

ASSIST_IPA_TOTAL

Number

53
54
55
56
57
58
59
60
61
62
63
64
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
91

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL
>200 - ≤250%
Number of QHP eligible individuals in the
>250 - ≤300%
QHP eligible-CAC reference period with assistance from a
>300- ≤400%
Certified Application Counselor (CAC).
>400%
unknown
Rural
Rural/NonNon-Rural
Rural
Unknown
Total
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL
>200 - ≤250%
Number of QHP eligible individuals in the
>250 - ≤300%
QHP eligiblereference period with assistance from an Agent
>300- ≤400%
Broker
or a Broker (includes web broker).
>400%
unknown
Rural
Rural/NonNon-Rural
Rural
Unknown
Total
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
FPL
>200 - ≤250%
Number of QHP eligible individuals in the
>250 - ≤300%
QHP eligible- reference period with assistance from an entity
>300- ≤400%
other assistance or person not in the list (e.g., Community
>400%
Health Centers).
unknown
Rural
Rural/NonNon-Rural
Rural
Unknown
Total

ASSIST_CAC_FPL1
ASSIST_CAC_FPL2
ASSIST_CAC_FPL3
ASSIST_CAC_FPL4
ASSIST_CAC_FPL5
ASSIST_CAC_FPL6
ASSIST_CAC_FPL7
ASSIST_CAC_FPL8
ASSIST_CAC_FPL9

Number
Number
Number
Number
Number
Number
Number
Number
Number

ASSIST_CAC_TOTAL
ASSIST_BKR_FPL1
ASSIST_BKR_FPL2
ASSIST_BKR_FPL3
ASSIST_BKR_FPL4
ASSIST_BKR_FPL5
ASSIST_BKR_FPL6
ASSIST_BKR_FPL7
ASSIST_BKR_FPL8
ASSIST_BKR_FPL9

Number
Number
Number
Number
Number
Number
Number
Number
Number
Number

ASSIST_BKR_TOTAL
ASSIST_OTHER_FPL1
ASSIST_OTHER_FPL2
ASSIST_OTHER_FPL3
ASSIST_OTHER_FPL4
ASSIST_OTHER_FPL5
ASSIST_OTHER_FPL6
ASSIST_OTHER_FPL7
ASSIST_OTHER_FPL8
ASSIST_OTHER_FPL9

Number
Number
Number
Number
Number
Number
Number
Number
Number
Number

ASSIST_OTHER_TOTAL

Number

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to
receive the information. Unauthorized disclosure may result in prosecution to the fullest extent of the law.

SHOP
Description: Data used to report employer and employee SHOP QHP activity. Do not include information about SADPs except in the ONE cell where it is specifically requested. 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: Two g roup size data breakouts, referring to either the number of employees on census/roster submitted by the employer to the SHOP or the number of enrolled employees
First Reference Period: 1/1/2015 - 3/31/2015. For all metrics on SHOP marketplace, please report data based on QHPs that begin sometime in the 2015 coverage year (any time from January 1, 2015 through December 31, 2015).
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

State
Reference Period

Please select in 'Current Coverage' tab
(Please select from list)

# Data Element
SHOP

Data Element Description

Data Breakouts

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Data Element Name

Data Type

SHOP_EMP_APP

Number

1<=Employees<=9
Total number of employers who completed an application through
SHOP.

Group Size - All
Employees

10<=Employees<=24
25<=Employees<=50
51<=Employees<=100
Employees>100

Total
New Employers, Plan Selection: Number of employers selecting a
2015 QHP/metal level through SHOP who were not enrolled in a
2014 SHOP QHP

Group Size - All
Employers

1<=Employees<=9
10<=Employees<=24
25<=Employees<=50
51<=Employees<=100
Employees>100

Total

Employers

Returning Employers, Plan Selection: Number of employers
selecting a 2015 QHP/metal level through SHOP who were enrolled
in a 2014 SHOP QHP

Group Size - All
Employers

1<=Employees<=9
10<=Employees<=24
25<=Employees<=50
51<=Employees<=100
Employees>100

Total
New Employers: Number of enrolled employers during the 2015
coverage year. Calculate the cumulative number of employers
who selected a 2015 QHP/metal level through SHOP and paid a
premium - employers who were not enrolled in a 2014 SHOP QHP.

Group Size - All
Employers

1<=Employees<=9
10<=Employees<=24
25<=Employees<=50
51<=Employees<=100
Employees>100

Total
Returning Employers: Number of enrolled employers during the
2015 coverage year. Calculate the cumulative number of
employers who selected a 2015 QHP/metal level through SHOP
and paid a premium (employers who were enrolled in a 2014 SHOP
QHP).

Group Size - All
Employers

1<=Employees<=9
10<=Employees<=24
25<=Employees<=50
51<=Employees<=100
Employees>100

Total

Data from State

31

Total number of employers offering dependent coverage through a
Total
SHOP QHP.

SHOP_EMP_DEP

Number

32

Total number of employers offering Stand-alone Dental Plan
(SADP) coverage at some point during the reference period.

Total

SHOP_EMP_DENTAL

Number

Total

SHOP_EMP_CHOICE1

Number

Total

SHOP_EMP_CHOICE2

Number

Total

SHOP_EMP_CHOICE3

Number

36

Total number of employers offering all SHOP QHPs at all metal
levels of coverage (states where employers cannot offer more than Total
one QHP should enter -999 for not applicable).

SHOP_EMP_CHOICE4

Number

37

Total number of employers offering SHOP 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

38

Total number of employers offering SHOP QHPs from all insurance
carriers across two contiguous metal levels of coverage (states
Total
where employers cannot offer more than one QHP should enter 999 for not applicable).

SHOP_EMP_CHOICE6

Number

SHOP_EE_ROSTERTOT

Number

Total number of employers offering a single SHOP QHP to
employees
Total number of employers offering two or more SHOP QHPs to
employees.

33
34

35
Employee Choice

39
40
41
42
43
44
45
46
47
48
49
50

Total number of employers offering all SHOP QHPs at a single
metal level of coverage (states where employers cannot offer
more than one QHP should enter -999 for not applicable).

Total number of employees (excluding dependents) enrolled
through a SHOP QHP during reference period, by employer size.
Calculate the cumulative number of employees who selected a
SHOP QHP for coverage during the 2015 coverage year and paid a
premium.

Employees

Total number of employees plus dependents (covered lives)
enrolled through a SHOP QHP during reference period, by
employer size. Calculate the cumulative number of employees and
their dependents who selected a QHP through SHOP for coverage
during the 2015 coverage year and paid a premium.

51
52
53
54
55
56

Group Size- All
Employees

1<=Employees<=9
10<=Employees<=24
25<=Employees<=50
51<=Employees<=100
Employees>100

Total
Group Size- All
Employees

1<=Employees<=9
10<=Employees<=24
25<=Employees<=50
51<=Employees<=100
Employees>100

Total
1<=Employees<=9

Total number of employees on employee roster submitted by
employers.

Group Size10<=Employees<=24
Employees on Roster
25<=Employees<=50
51<=Employees<=100
Employees>100
Total

Total number of agents/brokers registered for SHOP (including
web brokers or related organizations such as third party assistors).
Total
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.

57

58
59
60
61
62
63
64
65

1 <=Employees<=9
10<=Employees<=25
Enrollment Assistance to Total number of employer applications submitted with
Group Size- Enrolled 26<=Employees<=50
agent/broker
assistance
(including
web
brokers
or
related
Employers
Employees
51<=Employees<=74
organizations such as third party assistors) as of the last day in the
75<=Employees<=100
reference period.
Employees>100
Total
Total number of employer applications submitted with Navigator
Total
assistance

SHOP_ASSIST_TOTBKR

Number

SHOP_ASSIST_BKR

Number

SHOP_ASSIST_NAV

Number

66

Total number of employer applications submitted with assistance
other than from agent/broker or navigator.

Total

SHOP_ASSIST_OTHER

Number

67

Total number of employer applications submitted without
assistance.

Total

SHOP_ASSIST_NONE

Number

SHOP_EMP_EMPLOYEE_PREM

Number

SHOP_EMP_FAMILY_PREM

Number

68

1<=Employees<=9
Average employer percent contribution to monthly premium for
employees with individual coverage through a SHOP QHP.

69
70
71
72
73

Include only employees with individual, not family, coverage.
Employer Premium
Contribution

Average across all employers

74
75
76
77

Average employer percent contribution to monthly premium for
employees with family coverage through a SHOP QHP.

78

Include only employees with family, not individual, coverage.

79

Group Size- Enrolled
10<=Employees<=24
Employees
25<=Employees<=50
51<=Employees<=100
101<=Employees

1<=Employees<=9
10<=Employees<=24
Group Size- Enrolled 25<=Employees<=50
Employees
51<=Employees<=100
Employees>100
Average across all employers

80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95

Rates

95

Bronze
Lowest individual (employee-only) rate offered in the state for any
Silver
certified SHOP QHP; the definition for “Individual” for this metric
Gold
is a 27 year-old.
Platinum
Bronze
Highest individual (employee-only) rate offered in the state for any
Silver
certified SHOP QHP; the definition for “Individual” for this metric
Gold
is a 27 year-old.
Platinum
Bronze
Lowest family rate offered in the state for any certified SHOP QHP;
Silver
the definition for “Family” in this metric is a 30 year old employee,
Gold
30 year old spouse/partner and 2 children.
Platinum
Bronze
Highest family rate offered in the state for any certified SHOP QHP;
Silver
the definition for “Family” in this metric is a 30 year old employee,
Gold
30 year old spouse/partner and 2 children.
Platinum

SHOP_LOW_IND_RATE_BRZ
SHOP_LOW_IND_RATE_SLV
SHOP_LOW_IND_RATE_GLD
SHOP_LOW_IND_RATE_PLT
SHOP_HIGH_IND_RATE_BRZ
SHOP_HIGH_IND_RATE_SLV
SHOP_HIGH_IND_RATE_GLD
SHOP_HIGH_IND_RATE_PLT
SHOP_LOW_FAM_RATE_BRZ
SHOP_LOW_FAM_RATE_SLV
SHOP_LOW_FAM_RATE_GLD
SHOP_LOW_FAM_RATE_PLT
SHOP_HIGH_FAM_RATE_BRZ
SHOP_HIGH_FAM_RATE_SLV
SHOP_HIGH_FAM_RATE_GLD
SHOP_HIGH_FAM_RATE_PLT

Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only
and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the fullest extent of the law.

Appeals
Description: Data used to understand status of appeals and report mean and 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.). Include appeals related to Standalone Dental Plans (SADPs). Data breakouts are specific to individual-level appeals. SHOP appeals may be included in the total but not in the data breakouts.
Some individuals may contest the marketplace's decision and their appeal would receive a second consideration (for example, by an administrative law judge). In that case, the SBM should
consider the contested appeal to be distinct and new submission of an appeal.
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.
Source for Data Breakouts: Most recent eligibility determination.
First Reference Period: 11/15/2014 - 3/31/2015
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
Reference Period
#

Data Element

Please select in 'Current Coverage' tab
Please select in 'Current Coverage' tab.
Data Element Description

Data Breakouts
(for more info, see Glossary tab)

Combined SBM and SHOP
1
2
3
4
FPL
5
Number of appeals that were submitted during
Appeals6
the reference period and upheld (unfavorable
Upheld
7
outcome for consumer).
8
9
Application
10
Assistance
11
Total
12

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
Any
None

Data Element Name

Data Type

APPEAL_UPHLD_FPL1
APPEAL_UPHLD_FPL2
APPEAL_UPHLD_FPL3
APPEAL_UPHLD_FPL4
APPEAL_UPHLD_FPL5
APPEAL_UPHLD_FPL6
APPEAL_UPHLD_FPL7
APPEAL_UPHLD_FPL8
APPEAL_UPHLD_FPL9
APPEAL_UPHLD_ANY
APPEAL_UPHLD_NONE
APPEAL_UPHLD_TOTAL

Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number

Data from
State

13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48

Number of appeals that were submitted during
Appeals- Reversed the reference period and reversed (favorable
outcome for consumer).

FPL

Application
Assistance
Total

AppealsWithdrawn,
Dismissed, or
Halted

Number of appeals that were submitted during
the reference period and withdrawn, dismissed,
or halted.

FPL

Application
Assistance
Total

AppealsUnresolved

Number of appeals that were submitted during
the reference period and remain unresolved
(meaning in progress or pending and not
halted).

FPL

Application
Assistance
Total

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
Any
None
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
Any
None
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
Any
None

APPEAL_RVSD_FPL1
APPEAL_RVSD_FPL2
APPEAL_RVSD_FPL3
APPEAL_RVSD_FPL4
APPEAL_RVSD_FPL5
APPEAL_RVSD_FPL6
APPEAL_RVSD_FPL7
APPEAL_RVSD_FPL8
APPEAL_RVSD_FPL9
APPEAL_RVSD_ANY
APPEAL_RVSD_NONE
APPEAL_RVSD_TOTAL
APPEAL_WDH_FPL1
APPEAL_WDH_FPL2
APPEAL_WDH_FPL3
APPEAL_WDH_FPL4
APPEAL_WDH_FPL5
APPEAL_WDH_FPL6
APPEAL_WDH_FPL7
APPEAL_WDH_FPL8
APPEAL_WDH_FPL9
APPEAL_WDH_ANY
APPEAL_WDH_NONE
APPEAL_WDH_TOTAL
APPEAL_UNRES_FPL1
APPEAL_UNRES_FPL2
APPEAL_UNRES_FPL3
APPEAL_UNRES_FPL4
APPEAL_UNRES_FPL5
APPEAL_UNRES_FPL6
APPEAL_UNRES_FPL7
APPEAL_UNRES_FPL8
APPEAL_UNRES_FPL9
APPEAL_UNRES_ANY
APPEAL_UNRES_NONE
APPEAL_UNRES_TOTAL

Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number

49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
72

AppealsMedian 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

Application
Assistance
Total

AppealsAverage Time

Average 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

Application
Assistance
Total

<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
Any
None
<100%
≥100 - ≤138%
>138 - ≤150%
>150 - ≤200%
>200 - ≤250%
>250 - ≤300%
>300- ≤400%
>400%
unknown
Any
None

APPEAL_MEDIAN_FPL1
APPEAL_MEDIAN_FPL2
APPEAL_MEDIAN_FPL3
APPEAL_MEDIAN_FPL4
APPEAL_MEDIAN_FPL5
APPEAL_MEDIAN_FPL6
APPEAL_MEDIAN_FPL7
APPEAL_MEDIAN_FPL8
APPEAL_MEDIAN_FPL9
APPEAL_MEDIAN_ANY
APPEAL_MEDIAN_NONE
APPEAL_MEDIAN_TOTAL

Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be

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
Unit : Varies by data element
Population Included: Includes all complaints associated with either the SBM and the SHOP that were submitted during the reference period and accepted by the SBM. Include complaints
related to Stand-alone Dental Plans (SADPs). Counts of complaints includes only complaints submitted during the reference period. Time to resolve complaints includes only complaints that
were resolved during the reference period, whether they were submitted during the reference period or in a previous reference period. Exclude complaints that were unresolved as of the last
day of the reference period.
Source for Data Breakouts: N/A
First Reference Period: 11/15/2014 - 3/31/2015
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

State
Reference Period

Please select in 'Current Coverage' tab
Please select in 'Current Coverage' tab.

#
Data Element
Data Element Description
Combined SBM and SHOP
1
2
3

Number of
Complaints

Data Breakouts
(for more info, see Glossary tab)

Resolved
Complaint Status
Number of complaints submitted during the reference
Unresolved
period that were resolved or unresolved as of the last day
in the reference period.
Total Number of Complaints

Data Element Name

Data from
Data Type State

COMPLAINTS_RESOLVED
COMPLAINTS_UNRESOLVED

Number
Number

COMPLAINTS_TOTAL

Number

COMPLAINTS_RESOLVEDTIME

Number

Average time between the day the complaint was received
to the date the complaint was resolved. Report average
calendar days (no decimals).
4

Time to Resolve
Average Number of Days
Include only complaints that were resolved during the
Complaints -Average
reference period, whether they were submitted during the
reference period or in a previous reference period.
Exclude complaints that were unresolved as of the last day
of the reference period.

Median time between the day the complaint was received
to the date the complaint was resolved. Report average
calendar days (no decimals).
5

6
7
8
9
9

Time to Resolve
Complaints Median

Complaints by Topic

Median Number of Days
Include only complaints that were resolved during the
reference period, whether they were submitted during the
reference period or in a previous reference period.
Exclude complaints that were unresolved as of the last day
of the reference period.

Number of complaints submitted during the reference
period and associated with the following topics.

Difficulties with website
Difficulties with phone contact
Problem with plan/benefit
Problem with eligibility and/or financial assistance
determination

COMPLAINTS_WEB
COMPLAINTS_PHONE
COMPLAINTS_PLAN

Number
Number
Number

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be

Exemptions
Description: Data used to understand the number of individuals that applied for an exemption and received an exemption during the reference period.
Unit : Number of individuals
Population Included: Includes all applications for exemptions from coverage that were submitted to the state during the reference period or granted during the reference period
Source for Data Breakouts: N/A
First Reference Period: 11/15/2014 - 3/31/2015
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

State
Reference Period

Please select in 'Current Coverage' tab
Please select in 'Current Coverage' tab.

#
Data Element
Data Element Description
Individual Marketplace (SBM)- Does not include SHOP
Applications for Number of individuals that submitted an application for exemption during
1
Exemptions
the reference period.
2
2

Exemptions
Granted

Data Breakouts
(for more info, see Glossary tab)
Total

Number of individuals that received an exemption during the reference
period. Includes applications submitted in the previous reference period that Total
were not granted until the current reference period

Data Element Name

Data from
Data Type State

EXEMPTIONS_APPLIED

Number

EXEMPTIONS_GRANTED

Number

States
Please select in 'Current Coverage' tab
California
CA
Colorado
CO
Connecticut
CT
District of Columbia
DC
Hawaii
HI
Idaho
ID
Kentucky
KY
Maryland
MD
Massachusetts
MA
Minnesota
MN
Mississippi
MS
New York
NY
New Mexico
NM
Rhode Island
RI
Utah
UT
Vermont
VT
Washington
WA

SBM
SBM
SBM
SBM

Reporting Dates
Quarter
Please select in 'Current Coverage' tab.
Nov 15, 2014 - March 31,2015
Q1
Nov 15, 2014 - June 30, 2015
Q2
Nov 15, 2014 - Sept 30, 2015
Q3
Nov 15, 2014 - Dec 30, 2015
Q4
(TBD, Time Period based on Calendar Year)

SBM
SBM
SBM
SBM
SBM
SBM
SHOP only (FFM individual)
SBM

(Please select from list)
Jan 1, 2015 - March 31,2015
Jan 1, 2015 - June 30, 2015
Jan 1, 2015 - Sept 30, 2015
Jan 1, 2015 - Dec 30, 2015
(TBD, Time Period based on Calendar Year)

State

2015 Operations

CA

SBM

CO

SBM

CT

SBM

DC

SBM

HI

SBM

ID

SBM

KY

SBM

MD

SBM

MA

SBM

MN

SBM

MS

SHOP only (FFM individual)

NV

FSSBM

NM

SHOP only (FSSBM individual)

SHOP only (FSSBM individual)

NY

SBM

SBM

OR

FSSBM

SHOP only (FFM individual)

RI

SBM

SBM

UT

SHOP only (FFM individual)

SBM

VT

SBM

WA

SBM