Form CMS-10371 Weekly Report

Center for Consumer Information & Insurance Oversight
Centers for Medicare & Medicaid Services
Department of Health & Human Services

SBM Weekly Indicators: Layout for State's Data Submission
This document is the submission format for states with state based marketplaces to submit data to the federal government. This format does not require the submission of individual-level, granular data. The data will be used to assess the Marketplace progress in operational performance, QHP plan
premiums and subsidies, and enrollment/eligibility activity for initial years of operations.
QHP Data in this layout are specific to medical QHPs ands stand-alone dental plans (not vision) and coverage offered through the marketplaces (not Medicaid or CHIP coverage).
If no data match the restrictions of a particular data element, enter "-777". 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.
Reporting Schedule: Weekly during Open Enrollment; aggregated to 4 weeks of data during other parts of the year. For each report, states should report cumulative data from the start of Open Enrollment (November 15, 2014). The first scheduled reporting due date is November 25, 2014. Questions
should be directed to Nick Sukachevin at [email protected] or Carly Rhyne at [email protected]

Indicator
Number

1

State (select cell to reveal drop down box)

Select One:

Reference Period (DD/MM/YY) - (DD/MM/YY)

Select One:

Date of Report (DD/MM/YY)

Select One:

Category

7
8
9
10

Determined Eligible QHP / Assessed Eligible
Medicaid/CHIP
For QHPs: An individual is QHP Eligible if they
Number of Individuals Determined Eligible for Enrollment
submitted a completed application (or had a complete into a QHP (whether or not applying for financial assistance,
application submitted on their behalf) and the SBM
and whether or not enrolled with financial assistance) by
has deemed the individual eligible for QHP enrollment
Financial Assistance [FA] (APTC Only, APTC + CSRs)
(either provisional or final eligibility) during the
reference period. These individuals may or may not
have enrolled in coverage (meaning picked a QHP or
paid the first premium) by the end of the reference
period.
Number of Individuals Determined Eligible for Enrollment
into a QHP (Individual Level) by Language Preference

11
Number of Individuals Determined Eligible for Enrollment
into a QHP by Gender

13
14

22
23
24
25
26
27
28

Number of Individuals with QHP Plan Selection: TOTAL
Calculate Covered Lives

31

Eligible with FA: APTC + CSRs
Eligible by Language Preference: No Language Preference
Eligible by Language Preference: Spanish

Eligible by Gender: Male
Eligible by Gender: Female

Individuals Enrolled: Total

Number of Individuals with QHP Plan Selection by Language Plan Selection by Language Preference: No Language Preference
Preference
Plan Selection by Language Preference: Language Spanish
Indiviudal Level
Plan Selection by Language Preference: Other Language

Number of Individuals Selecting a 2015 QHP Who Were Not Plan Selection for New Enrollees: Total
Enrolled in a 2014 Marketplace Plan (New Enrollment).
Enter Stand Alone Dental Plan new enrollments separately in Plan Selection for New Enrollees by FA: Enrollment New without FA
SADP column.
Plan Selection for New Enrollees by FA: Enrollment New with FA
Calculate Covered Lives
Number of Individuals Selecting a 2015 QHP Who Were
Plan Selection for Re-enrollees: Total
Enrolled in a 2014 Marketplace Plan (Re-Enrollment). Enter
Stand Alone Dental Plan Re-enrollments separately in SADP Plan Selection for Re- enrollees by FA: Re-enrollment without FA
column.
Plan Selection for Re-enrollees by FA: Re-enrollment with FA
Calculate Covered Lives
Number of Individuals Selecting a QHP by FA (No FA, APTC
Only, and APTC+CSRs)
Calculate Covered Lives

29
30

Eligible with FA: APTC Only

Eligib assessment: Medicaid + CHIP

Plan Selection: Effective (not effectuated) Enrollment
During the Reference Period. Individuals Who were
deemed QHP eligible, selected a QHP and a financial
assistance [FA] amount (if eligible), and the SBM
approved the QHP selection during the reference
period

20
21

Eligible: Without FA

Eligib assessment: Medicaid (if breakout possible)

16

19

Eligible: Total

Distribution of Assessed Eligible Individuals by Medicaid and
CHIP
Eligib assessment: CHIP (if breakout possible)

15

18

Individuals Appl: Total

Eligible by Language Preference: Other Language

12

17

Compl Appl: Paper
Compl Appl: Total

Number of Individuals Applying for Coverage through the
Marketplace (Individual Level)

4

6

Indicator for Cell

Compl Appl: Electronic

Number of Applications Completed, by Electronic and Paper

3

5

Date of Report (if not listed in dropdown):

Measure

Initial Applications - Application Level (see Glossary)

2

NOTE: First Reference Period is 11/15/14-11/22/14. ***If applicable, report any early 2015 QHP re-enrollments (performed before 11/15/14) during this reporting
period.***

Plan Selection without FA: Total
Plan Selection by FA: APTC Only
Plan Selection by FA: APTC + CSRs

Number of Individuals Selecting a QHP by Gender
Calculate Covered Lives

Plan Selection by Gender: Male
Plan Selection by Gender: Female

32

Plan Selection by Age: AGE1<18

33

Plan Selection by Age: AGE2 18-25

34
35

Plan Selection by Age: AGE3 26-34

Number of Individuals Selecting a QHP by Age Group
Calculate Covered Lives

Plan Selection by Age: AGE4 35-44

36

Plan Selection by Age: AGE5 45-54

37

Plan Selection by Age: AGE6 55-64

38

Plan Selection by Age: AGE7 >=65

39

Plan Selection by Gender: Male: AGE1<18

40

Plan Selection by Gender and Age: Male: AGE2 18-25

41

Plan Selection by Gender and Age: Male: AGE3 26-34

42

Plan Selection by Gender and Age: Male: AGE4 35-44

43

Plan Selection by Gender and Age: Male: AGE5 45-54

44
45
46

Plan Selection by Gender and Age: Male: AGE6 55-64

Number of Individuals Selecting a QHP by Gender and Age
Group
Calculate Covered Lives

Plan Selection by Gender and Age: Male: AGE7 >=65
Plan Selection by Gender and Age: Female: AGE1<18

47

Plan Selection by Gender and Age: Female: AGE2 18-25

48

Plan Selection by Gender and Age: Female: AGE3 26-34

49

Plan Selection by Gender and Age: Female: AGE4 35-44

50

Plan Selection by Gender and Age: Female: AGE5 45-54

51

Plan Selection by Gender and Age: Female: AGE6 55-64

52

Plan Selection by Gender and Age: Female: AGE7 ≥65

53

Plan Selection by Metal Level: Catastrophic

54
55

Plan Selection by Metal Level: Bronze

Number of Individuals Selecting a QHP by Metal Level
Calculate Covered Lives

Plan Selection by Metal Level: Silver

56

Plan Selection by Metal Level: Gold

57

Plan Selection by Metal Level: Platinum

58

Plan Selection by Age and Metal Level: AGE1<18: Catastrophic

59

Plan Selection by Age and Metal Level: AGE1<18: Bronze

60

Plan Selection by Age and Metal Level: AGE1<18: Silver

61

Plan Selection by Age and Metal Level: AGE1<18: Gold

62

Plan Selection by Age and Metal Level: AGE1<18: Platinum

63

Plan Selection by Age and Metal Level: AGE2 18-25: Catastrophic

64

Plan Selection by Age and Metal Level: AGE2 18-25: Bronze

65

Plan Selection by Age and Metal Level: AGE2 18-25: Silver

66

Plan Selection by Age and Metal Level: AGE2 18-25: Gold

67

Plan Selection by Age and Metal Level: AGE2 18-25: Platinum

68

Plan Selection by Age and Metal Level: AGE3 26-34: Catastrophic

69

Plan Selection by Age and Metal Level: AGE3 26-34: Bronze

70

Plan Selection by Age and Metal Level: AGE3 26-34: Silver

71

Plan Selection by Age and Metal Level: AGE3 26-34: Gold

Number of Individuals Selecting a QHP by Age and Metal
Level
Calculate Covered Lives

Special Enrollment Period (SEP):
2014 Coverage
(Applies only to 11/15/201412/31/2014, NOT Including
Stand-alone Dental Plans)

Open Enrollment: 2015
Coverage (Not Including
Stand-alone Dental Plans)

Stand-alone Dental Plans:
2015 Coverage

Indicator
Number

72
73
74
75

Category

Measure

Initial Applications - Application Level (see Glossary)

Indicator for Cell

Number of Individuals Selecting a QHP by Age and Metal
Level
Calculate Covered Lives

Plan Selection by Age and Metal Level: AGE4 35-44: Bronze
Plan Selection by Age and Metal Level: AGE4 35-44: Silver
Plan Selection by Age and Metal Level: AGE4 35-44: Gold
Plan Selection by Age and Metal Level: AGE4 35-44: Platinum

78

Plan Selection by Age and Metal Level: AGE5 45-54: Catastrophic

79

Plan Selection by Age and Metal Level: AGE5 45-54: Bronze

80

Plan Selection by Age and Metal Level: AGE5 45-54: Silver

81

Plan Selection by Age and Metal Level: AGE5 45-54: Gold

82

Plan Selection by Age and Metal Level: AGE5 45-54: Platinum

83

Plan Selection by Age and Metal Level: AGE6 55-64: Catastrophic

84

Plan Selection by Age and Metal Level: AGE6 55-64: Bronze

85

Plan Selection by Age and Metal Level: AGE6 55-64: Silver

86

Plan Selection by Age and Metal Level: AGE6 55-64: Gold

87

Plan Selection by Age and Metal Level: AGE6 55-64: Platinum

88

Plan Selection by Age and Metal Level: AGE7 >=65: Catastrophic

89

Plan Selection by Age and Metal Level: AGE7 >=65: Bronze

90

Plan Selection by Age and Metal Level: AGE7 >=65: Silver

91

Plan Selection by Age and Metal Level: AGE7 >=65: Gold

92

Plan Selection by Age and Metal Level: AGE7 >=65: Platinum

93

Plan Selection by FA and Metal Level: Enrolled Without FA: Catastrophic

94

Plan Selection by FA and Metal Level: Enrolled without FA: Bronze

95

Plan Selection by FA and Metal Level: Enrolled without FA: Silver

96

Plan Selection by FA and Metal Level: Enrolled without FA: Gold

Number of Individuals Selecting a QHP by FA (without FA,
with FA) and Metal Level
Calculate Covered Lives

Plan Selection by FA and Metal Level: Enrolled without FA: Platinum
Plan Selection by FA and Metal Level: Enrolled with FA: Catastrophic

99

Plan Selection by FA and Metal Level: Enrolled with FA: Bronze

100

Plan Selection by FA and Metal Level: Enrolled with FA: Silver

101

Plan Selection by FA and Metal Level: Enrolled with FA: Gold

102

Plan Selection by FA and Metal Level: Enrolled with FA: Platinum

103

Plan Selection with FA by FPL: FA and FPL1

104

Plan Selection with FA by FPL: FA and FPL2

105

Plan Selection with FA by FPL: FA and FPL3

106
107

Number of Individuals with FA Selecting a QHP by FPL
(Among Indiviudals Receiving FA)
Calculate Covered Lives

Plan Selection with FA by FPL: FA and FPL4
Plan Selection with FA by FPL: FA and FPL5

108

Plan Selection with FA by FPL: FA and FPL6

109

Plan Selection with FA by FPL: FA and FPL7

110

Plan Selection with FA by FPL: FA and FPL8

111

Plan Selection with FA by FPL: FA and FPL9 (unknown)

112

Plan Selection by Issuer: Issuer 1

113

Plan Selection by Issuer: Issuer 2

114

Plan Selection by Issuer: Issuer 3

115

Plan Selection by Issuer: Issuer 4

116

Plan Selection by Issuer: Issuer 5

117

Plan Selection by Issuer: Issuer 6

118

Plan Selection by Issuer: Issuer 7

119

Plan Selection by Issuer: Issuer 8

120

Plan Selection by Issuer: Issuer 9

121

Plan Selection by Issuer: Issuer 10

122

Plan Selection by Issuer: Issuer 11

123

Plan Selection by Issuer: Issuer 12

124

Plan Selection by Issuer: Issuer 13

125
126
127

Stand-alone Dental Plans:
2015 Coverage

Plan Selection by Age and Metal Level: AGE3 26-34: Platinum

77

98

Open Enrollment: 2015
Coverage (Not Including
Stand-alone Dental Plans)

Number of Applications Completed, by Electronic and Paper Plan Selection by Age and Metal Level: AGE4 35-44: Catastrophic

76

97

Special Enrollment Period (SEP):
2014 Coverage
(Applies only to 11/15/201412/31/2014, NOT Including
Stand-alone Dental Plans)

Plan Selection by Issuer: Issuer 14

Number of Individuals Selecting a QHP by Issuer
Calculate Covered Lives

Plan Selection by Issuer: Issuer 15
Name Issuer 1

Enter Text Here

Enter Text Here

Enter Text Here

128

Name Issuer 2

Enter Text Here

Enter Text Here

Enter Text Here

129

Name Issuer 3

Enter Text Here

Enter Text Here

Enter Text Here

130

Name Issuer 4

Enter Text Here

Enter Text Here

Enter Text Here

131

Name Issuer 5

Enter Text Here

Enter Text Here

Enter Text Here

132

Name Issuer 6

Enter Text Here

Enter Text Here

Enter Text Here

133

Name Issuer 7

Enter Text Here

Enter Text Here

Enter Text Here

134

Name Issuer 8

Enter Text Here

Enter Text Here

Enter Text Here

135

Name Issuer 9

Enter Text Here

Enter Text Here

Enter Text Here

136

Name Issuer 10

Enter Text Here

Enter Text Here

Enter Text Here

137

Name Issuer 11

Enter Text Here

Enter Text Here

Enter Text Here

138

Name Issuer 12

Enter Text Here

Enter Text Here

Enter Text Here

139

Name Issuer 13

Enter Text Here

Enter Text Here

Enter Text Here

140

Name Issuer 14

Enter Text Here

Enter Text Here

Enter Text Here

141

Name Issuer 15

Enter Text Here

Enter Text Here

Enter Text Here

142

Median Individ Age Level: AGE1<18

143

Median Individ Age Level: AGE2 18-25

144
145

Median Individ Age Level: AGE3 26-34

Median Individual-Policy QHP Premium by Age GroupCalculate cumulative since November 15, 2014

Median Individ Age Level: AGE4 35-44

146

Median Individ Age Level: AGE5 45-54

147

Median Individ Age Level: AGE6 55-64

148

Median Individ Age Level: AGE7 >=65

149

Median Individual-Policy QHP Premium Before APTC ($):
(Only individuals who enroll with APTC) Calculate cumulative Median Indiv Premium: Before APTC
since November 15, 2014

150

Median Individual-Policy QHP Premium After APTC Deducted
Median individ Premium: After APTC
($) (Only individuals who enroll with APTC) Calculate
cumulative since November 15, 2014

151

152

153

154

Average Per Person Full Premium for Plans with APTC
Individuals Before APTC Applied. [Average Individual
Premium Before APTC Deducted ($)] All QHPs

Average Per Person Full premium for Plans With APTC
Individuals, After APTC Applied. Average Individual Premium Ave indiv premium all QHPs:After APTC
After APTC Deducted ($) All QHPs
Average Per Person Full Premium for Plans With APTC
Individuals, Before APTC Applied. [Average Individual
Premium Before APTC Deducted ($)]

Ave Indiv Premium: Before APTC

Average Per Person Premium for Plans With APTC Individuals,
After APTC Applied. Average Individual Premium After APTC Ave Indiv premium: After APTC
Deducted ($)

155
156

Ave indiv premium all QHPs:Before APTC

Ave Individ Premium: APTC: Catastrophic

Average Per Person Full Premium Before APTC Deducted by
Metal Level ($) Calculate cumulative since November 15,
2014.

Ave Individ Premium:APTC: Bronze

Indicator
Number

157
158

Category

Initial Applications - Application Level (see Glossary)

Measure

Indicator for Cell

Average Per Person Full Premium Before APTC Deducted by
Metal Level ($) Calculate cumulative since November 15, Ave Individ Premium: APTC: Silver
2014.
Number of Applications Completed, by Electronic and Paper Ave Individ Premium: APTC: Gold

159

Ave Individ Premium: APTC: Platinum

160

Ave Individ Premium: No APTC:Catastrophic

161

Ave Individ Premium: No APTC:Bronze

162

Average Per Person Premium Without APTC by Metal Level
Ave Individ Premium: No APTC:Silver
($) Calculate cumulative since November 15, 2014.

163

Ave Individ Premium: No APTC:Gold

164

165

166
167

168

169
170
171
172
173
174

175

176
177
178
179
180
181
182
183
184
185

Ave Individ Premium: No APTC:Platinum

Average APTC Payment Selected, by tax household ($) See
glossary. Calculate cumulative since November 15, 2014.

Number of Enrollments Using Assistance (at Application
Level)

Ave APTC Selected

Enrollment Using Assistance: Yes
Enrollment Using Assistance: No

Effectuated Enrollment Individuals who have
Number of Individuals with Effectuated Enrollment in QHP:
submitted an application (or had application
Individ Effect:Total
TOTAL
submitted on their behalf), were deemed QHP Eligible
Calculate Covered Lives
and selected a QHP, the SBM has approved the QHP
selection, and the first premium payment was
Effect by Language Preference: No Language Preference
received (either directly by the SBM or by the issuer). Number of Individuals with Effectuated Enrollment in QHP by
Language Preference
Effect by Language Preference: Spanish
Individual Level
Effect by Language Preference: Other Language
Effectuated Enrollment New Enrollee: Total
Effectuated Enrollment by New Enrollees: Number of
Individuals with Effectuated Enrollment in a 2015 QHP who
Effectuated Enrollment New Enrollee by FA: Effect New without FA
Were NOT Enrolled in a 2014 Marketplace Plan (New
Enrollment)
Effectuated Enrollment New Enrollee by FA: Effect New with FA
Calculate Covered Lives

Effectuated Enrollment for Re-enrollees: Total

Effectuated Enrollmenbt by Re-enrollees: Number of
individuals with Effectuated Enrollment in a 2015 QHP who
were Enrolleed in a 2014 Marketplace Plan (Re-enrollments) Effectuated Enrollment for Re-enrollees by FA: Effect new without FA
Calculate Covered Lives
Effectuated Enrollment for Re-enrollees by FA: Effect new with FA
Effect without FA: Total

Number of Individuals with Effectuated Enrollment in QHP by
FA (no FA, APTC Only, and APTC + CSRs)
Effect with FA: APTC Only
Calculate Covered Lives
Effect with FA: APTCs+CSRs

Number of Individuals with Effectuated Enrollment in QHP by Effect by Gender: Male
Gender
Effect by Gender: Female
Calculate Covered Lives
Effect by Age: AGE1<18
Effect by Age: AGE2 18-25
Effect by Age: AGE3 26-34

186

Number of Individuals with Effectuated Enrollment in QHP by
Age Group
Effect by Age: AGE4 35-44
Calculate Covered Lives

187

Effect by Age: AGE5 45-54

188

Effect by Age: AGE6 55-64

189

Effect by Age: AGE7 >=65

190

Effect by Gender: Male: AGE1<18

191

Effect by Gender and Age: Male: AGE2 18-25

192

Effect by Gender and Age: Male: AGE3 26-34

193

Effect by Gender and Age: Male: AGE4 35-44

194

Effect by Gender and Age: Male: AGE5 45-54

195

Effect by Gender and Age: Male: AGE6 55-64

196

Number of Individuals with Effectuated Enrollment in QHP by Effect by Gender and Age: Male: AGE7 >=65
Gender and Age Group
Effect by Gender and Age: Female: AGE1<18
Calculate Covered Lives

197
198

Effect by Gender and Age: Female: AGE2 18-25

199

Effect by Gender and Age: Female: AGE3 26-34

200

Effect by Gender and Age: Female: AGE4 35-44

201

Effect by Gender and Age: Female: AGE5 45-54

202

Effect by Gender and Age: Female: AGE6 55-64

203

Effect by Gender and Age: Female: AGE7 ≥65

204
205

Effect by Level: Catastrophic
Effect by Level: Bronze

206

Number of Individuals with Effectuated Enrollment in QHP by
Metal Level
Effect by Level: Silver
Calculate Covered Lives

207

Effect by Level: Gold

208

Effect by Level: Platinum

209

Effect by Age and Metal Level: AGE1<18: Catastrophic

210

Effect by Age and Metal Level: AGE1<18: Bronze

211

Effect by Age and Metal Level: AGE1<18: Silver

212

Effect by Age and Metal Level: AGE1<18: Gold

213

Effect by Age and Metal Level: AGE1<18: Platinum

214

Effect by Age and Metal Level: AGE2 18-25: Catastrophic

215

Effect by Age and Metal Level: AGE2 18-25: Bronze

216

Effect by Age and Metal Level: AGE2 18-25: Silver

217

Effect by Age and Metal Level: AGE2 18-25: Gold

218

Effect by Age and Metal Level: AGE2 18-25: Platinum

219

Effect by Age and Metal Level: AGE3 26-34: Catastrophic

220

Effect by Age and Metal Level: AGE3 26-34: Bronze

221

Effect by Age and Metal Level: AGE3 26-34: Silver

222

Effect by Age and Metal Level: AGE3 26-34: Gold

223

Effect by Age and Metal Level: AGE3 26-34: Platinum

224
225

Effect by Age and Metal Level: AGE4 35-44: Catastrophic
Effect by Age and Metal Level: AGE4 35-44: Bronze

226

Number of Individuals with Effectuated Enrollment in a QHP
by Age and Metal Level
Effect by Age and Metal Level: AGE4 35-44: Silver
Calculate Covered Lives

227

Effect by Age and Metal Level: AGE4 35-44: Gold

228

Effect by Age and Metal Level: AGE4 35-44: Platinum

229

Effect by Age and Metal Level: AGE5 45-54: Catastrophic

230

Effect by Age and Metal Level: AGE5 45-54: Bronze

231

Effect by Age and Metal Level: AGE5 45-54: Silver

232

Effect by Age and Metal Level: AGE5 45-54: Gold

233

Effect by Age and Metal Level: AGE5 45-54: Platinum

234

Effect by Age and Metal Level: AGE6 55-64: Catastrophic

235

Effect by Age and Metal Level: AGE6 55-64: Bronze

236

Effect by Age and Metal Level: AGE6 55-64: Silver

237

Effect by Age and Metal Level: AGE6 55-64: Gold

238

Effect by Age and Metal Level: AGE6 55-64: Platinum

239

Effect by Age and Metal Level: AGE7 >=65: Catastrophic

240

Effect by Age and Metal Level: AGE7 >=65: Bronze

241

Effect by Age and Metal Level: AGE7 >=65: Silver

242

Effect by Age and Metal Level: AGE7 >=65: Gold

243

Effect by Age and Metal Level: AGE7 >=65: Platinum

Special Enrollment Period (SEP):
2014 Coverage
(Applies only to 11/15/201412/31/2014, NOT Including
Stand-alone Dental Plans)

Open Enrollment: 2015
Coverage (Not Including
Stand-alone Dental Plans)

Stand-alone Dental Plans:
2015 Coverage

Indicator
Number

244

Category

Measure

Initial Applications - Application Level (see Glossary)

245

Indicator for Cell

Effect by FA and Metal Level: Enrolled without FA: Catastrophic

Number of Applications Completed, by Electronic and Paper Effect by FA and Metal Level: Enrolled without FA: Bronze

246

Effect by FA and Metal Level: Enrolled without FA: Silver

247

Effect by FA and Metal Level: Enrolled without FA: Gold

Number of Individuals with Effectuated Enrollment in QHP by Effect by FA and Metal Level: Enrolled without FA: Platinum
FA (Without FA, With FA) by Metal Level
Effect by FA and Metal Level: Enrolled with FA: Catastrophic
Calculate Covered Lives

248
249
250

Effect by FA and Metal Level: Enrolled with FA: Bronze

251

Efffect by FA and Metal Level: Enrolled with FA: Silver

252

Effect by FA and Metal Level: Enrolled with FA: Gold

253

Effect by FA and Metal Level: Enrolled with FA: Platinum

254

Effect with FA by FPL: FA and FPL1

255

Effect with FA by FPL: FA and FPL2

256

Effect with FA and FPL: FA and FPL3

257

Number of Individuals with FA Effect Enrolled in a QHP by
FPL (Among Individuals Receiving FA)
Calculate Covered Lives

258

Effect with FA by FPL: FA and FPL4
Effect with FA by FPL: FA and FPL5

259

Effect with FA by FPL: FA and FPL6

260

Effect with FA by FPL: FA and FPL7

261

Effect with FA by FPL: FA and FPL8

262
263

Effect with FA and FPL: FA and FPL9 (unknown)

SHOP

264
265
266
267
268

Operations

Number of Employers who completed an application through
SHOP
Number of SHOP Participating Employers (Effectuated
Enrollment) Calculate cumulative since January 1, 2015.
Average Number of SHOP Employees per Participating
Employer (Effectuated Enrollment) Calculate cumulative
Average Employer Premium Contribution Percent
(Effectuated Enrollment) Calculate cumulative since January
Number of Employees (covered lives, including dependents)
Enrolled through SHOP (Effectuated Enrollment) Calculate
Call Center Volume

269

Call Center Wait Time (in seconds)

270

Call Center Abandonment Rate

271

Average Call Handle Time (in seconds)

272
273
274

Number of Mail/Written Correspondence Received
Number of Website Visits
Number of Website Unique Visitors

275
276
277

Number of Website Page Views

SHOP: Employers Appl: Total
SHOP: Employers Effect: Total
SHOP: Ave Enrolled Employees in Empl Gr
SHOP: Ave Percent Empl Contrib
SHOP: Enrolled Employees: Total
Call Ctr: Total Calls
Call Ctr: Ave Wait Time
Call Ctr: Aband Rate

Call Ctr: Ave Handle Time
Written+Fax: Total
Website: Visits: Total
Website: Visitors: Total
Website: Views:Total

Number of Trained/Certified Assistors Calculate cumulative
Train+Cert Assist: Total
since November, 2014.
Website Time Offline (in seconds)

Website Offline: Total Time

Special Enrollment Period (SEP):
2014 Coverage
(Applies only to 11/15/201412/31/2014, NOT Including
Stand-alone Dental Plans)

Open Enrollment: 2015
Coverage (Not Including
Stand-alone Dental Plans)

Stand-alone Dental Plans:
2015 Coverage

Glossary of Data Elements for Weekly and Other Marketplace Metrics Reported by States
Category

Data Coding

Initial Applications-Application level
Individual Market Only

Measure/Indicator

Definition / Clarification

Applies to any numeric indicator

If no data match the restrictions of a particular data element, enter "-777". 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.

Initiated Electronic Applications

An initiated application submitted via electronic channels includes applications where data is provided through the web portal by
the applicant or inputted into the system electronically by call center staff or other assisters. The applicant must have a registered
account, started the application, and provided enough information to hit "save."

Number of Applications Completed, by
Electronic and Paper

A completed application is defined as an application that was submitted during the reference period with sufficient information to
begin processing eligibility for any type of coverage (QHP or Medicaid/CHIP). For electronic applications, these applications where
the applicant has ‘hit submit’ and the application is accepted for further processing.

Eligible for enrollment into a QHP

An individual is QHP Eligible if s/he submitted a completed application (or had a complete application submitted on their behalf)
and the SBM has deemed the individual eligible for QHP enrollment (either provisional or final eligibility) during the reference
period. These individuals may or may not have enrolled in coverage (meaning picked a QHP or paid the first premium) by the end
of the reference period.
• Individuals deemed eligible for Medicaid or CHIP are not considered QHP Eligible.

Determined Eligible QHP
/ Assessed Eligible
Medicaid/CHIP
Individual Market Only

Eligible without Financial Assistance (FA)

Eligible with FA: APTC Only: Total
Eligible with APTCs + CSRs: Total
Eligib assessment: Medicaid
Eligib assessment: CHIP
Eligib assessment: Medicaid + CHIP
Number of Individuals enrolled in QHP

Number of individuals Selecting a 2015
QHP Who Were Not Enrolled in a 2014
Marketplace Plan (New Enrollment)

Unit/population of interest includes all of the following:
• Individuals deemed ineligible for QHP coverage with financial assistance (APTC and/or CSR)
• Individuals that requested their application not be considered for financial assistance
• Individuals deemed 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"
Number of individuals determined eligible for enrollment to a QHP with only an APTC
Number of individuals determined eligible for enrollment to a QHP with both an APTC and CSR
For SBMs with integrated eligibility systems: report the number of individuals assessed for Medicaid or CHIP eligibility based on
Medicaid MAGI during the reference period. This data element includes all Medicaid MAGI assessments, whether the individuals
are found to be eligible or ineligible.
If a state does not break out Medicaid or CHIP, please provide the number of individuals determined eligible for Medicaid or CHIP
in this cell.
Number of individuals that received effective enrollment during the reference period. These individuals were deemed QHP
eligible, selected a QHP and a financial assistance amount (if eligible), and the SBM approved the QHP selection during the
reference period.

Units/population of interest: Individuals enrolled in any 2015 Marketplace QHP who were not enrolled in ANY Marketplace QHP at
any time during the 2014 coverage year. For Stand Alone Dental Plans (SADP): Individuals enrolled in any 2015 Marketplace SADP
who were not enrolled in any Marketplace SADP at any time in 2014. Calculate SADP new enrollments and report separately in
SADP column.

Number of individuals Selecting a 2015
QHP Who Were Enrolled in a 2014
Marketplace Plan (Re-Enrollments)

Units/population of interest: Individuals enrolled in any 2015 Marketplace QHP who were enrolled in a Marketplace QHP at some
point during the 2014 coverage year (regardless of current status of the 2014 policy). For Stand Alone Dental Plans (SADP):
Individuals enrolled in any 2015 Marketplace SADP who were enrolled in a Marketplace SADP at some point in 2014 (regardless of
current status of 2014 policy). Calculate SADP re-enrollments and report separately in SADP column.

Total Number of Individuals enrolled in a QHP without Financial Assistance (FA)
Individuals that do not fall into "Total Enrolled with FA: APTC only" or "Total Enrolled with FA: APTCs+CSRs" should be counted in
"Enrolled without FA"
Enrolled with FA
Total Number of Individuals Submitting Enrollment in a QHP with APTC only OR with both APTC and CSRs
Total Enrolled with FA: APTC only
Total Number of Individuals Submitting Enrollment in a QHP with APTC only
Total Enrolled with FA: APTCs+CSRs
Total Number of Individuals Submitting Enrollment in a QHP with both APTC and CSR
Unit/population of interest: Individuals enrolled in Individual-only QHPs (excludes individuals enrolled in multi-member/family
Median Individual-Policy QHP Premium - By
policies). Full Premium Before Any Financial Assistance Applied. (All Individual-only QHPs; Include those with and Financial
Age Group
Assistance.)
Enrolled without FA

Median Individual Premium Before APTC Unit/population of interest: Individuals enrolled in Individual-only QHPs (excludes individuals enrolled in multi-member/family
deducted ($)
policies) and who enroll with APTC. Calculate based on full premium amount, before the APTC is deducted.
Median Individual Premium After APTC
Deducted ($)

Enrollment Activity
Individual Market Only

Unit/population of interest: Individuals enrolled in Individual-only QHPs (excludes individuals enrolled in multi-member/family
policies) and who enroll with APTC. Calculate based on the balance of the premium owed, after the APTC is deducted. (Full
premium minus APTC.)

Average Per Person Full Premium for Plans
with APTC Individuals Before APTC Applied. Unit/population of interest: All enrolled individuals (= # in Indicator 17). Sum the full premiums of all QHPs before the APTC is
[Average Individual Premium Before APTC deducted. Then divide by the number of individuals covered by all QHPs (Indicator 17).
Deducted ($)] All QHPs
Average Per Person Full premium for Plans
With APTC Individuals, After APTC Applied. Unit/population of interest: All enrolled individuals (= # in Indicator 17). Sum the premiums for all QHP enrollees; after the APTC
Average Individual Premium After APTC is deducted. Then divide by the number of individuals covered by all QHPs (Indicator 17).
Deducted ($) All QHPs
Average Per Person Full Premium for Plans
Unit/population of interest: Individuals who enroll with an APTC (includes enrollees in multi-enrollee policies). Sum the premiums
With APTC Individuals, Before APTC
of QHPs which are associated with an APTC before the APTC is deducted. Then divide by the number of individuals covered by
Applied. [Average Individual Premium
those plans associated with an APTC (sum of indicators 28 and 29).
Before APTC Deducted ($)]
Average Per Person Premium for Plans
Unit/population of interest: Individuals who enroll with an APTC (includes enrollees multi-enrollee policies). Sum the premiums of
With APTC Individuals, After APTC Applied.
QHPs which are associated with an APTC after the APTC is deducted. Then divide by the number of individuals covered by those
Average Individual Premium After APTC
plans associated with an APTC (sum of indicators 28 and 29).
Deducted ($)
Average APTC payment selected, by tax
household.

Reflects the average monthly APTC that the tax household selects. The population included are tax households with individuals
that received effective enrollment during the reference period, and qualified for APTC, including those who qualify for an APTC but
select $0 .

Please provide data at the application level; if the State can capture only at the individual level, please indicate this. This metric is
intended to capture all recorded types of assistance either with submission of application for QHP enrollment or with selection of a
QHP. Describes whether individuals received assistance with either submission of application for QHP enrollment or with selection
of a QHP. **This does not include insurance agents and brokers.**
1) Any (i.e. at least one type of the assistors list below)
2) None (i.e., no recorded assistance)
Enrollment Using Assistance (Yes/no)

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 assistance. 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)
- Authorized Representative
- Other (includes Community Health Center and other types of assistance not categorized above)Describes whether individuals
received assistance with either submission of application for QHP enrollment or with selection of a QHP.

Special Enrollment Period: 2014 Coverage

Units/population of interest: Total number of Individuals who enrolled in 2014 QHP after Nov. 15, 2014 for coverage ending on
December 31, 2014. Do not include enrollments in stand-alone dental plans. Record Using Special Enrollment Period Column.

Stand-alone Dental Plans: 2015 Coverage

Units/population of interest: Total number of Individuals who enrolled in a 2015 Stand-Alone Dental Plan. Record Using StandAlone Dental Plan column.

New Columns

Number of Individuals with Effectuated
Enrollment in QHP
Effectuated Enrollment
Individual Market Only

Effectuated enrollment occurs when an individual has submitted an application (or had application submitted on their behalf), was
deemed QHP Eligible and selected a QHP, the SBM has approved the QHP selection, and the first premium payment was received
(either directly by the SBM or by the issuer).

Number of Individuals with Effectuated
Please exclude individuals eligible for APTC but where no APTC is not applied to the premium. Also, please exclude individuals
Enrollment with APTCs only, and APTCs and
eligible for CSR, but is not in a plan with CSR.
CSRs:

Number of Employers who completed an Unit of interest: Report the number of employers who completed an application for a SHOP QHP for coverage beginning in the
application through SHOP
2015 coverage year (January 1, 2015 and thereafter).
Number of SHOP Participating Employers
Unit of interest: Report the number of employers with at least one employee who has effectuated enrollment in a SHOP QHP
(Effectuated Enrollment) Calculate
beginning on January 1, 2015.
cumulative since January 1, 2015.
Average Number of SHOP Employees per
Calculate the average number of employees who have effectuated coverage in a SHOP QHP for 2015 coverage out of the total
Participating Employer (Effectuated
Enrollment) Calculate cumulative since employees on the employee rosters submitted by employers.
January 1, 2015.
Average Employer Premium Contribution
Percent (Effectuated Enrollment) Calculate Calculate the average percent that all employers participating in SHOP in 2015 are contributing to their employees' premiums.
cumulative since January 1, 2015.
Number of Employees (covered lives,
including dependents) Enrolled through
SHOP (Effectuated Enrollment) Calculate Unit of interest: Total number of covered lives (including employees and their dependents) across all SHOP QHPs who have
cumulative number of employees that effectuated coverage for the 2015 coverage year.
effectuate coverage beginning on January
1, 2015.
# Enrollment Assisters completing
Marketplace training
# Enrollment Assisters registered and
certified
Total call volume
Average call wait time
(Average speed of answer- ASA)
Average call handle time (AHT)
Operations
Abandonment Rate
Total website page views
Total website visits
Total website unique visitors
# of registered users
Number of Mail/Written Correspondence
Received
Website Time Offline

FPL

Data Breakouts

Number of enrollment assisters who completed Marketplace training during the reference period.
Number of enrollment assisters who were registered and certified during the reference period. Please exclude agents and brokers.
Number of calls that entered the integrated voice response system during the reference period.
Average length of time for which a call is connected to automated call distribution system before answered (average time a caller
waits in queue before being connected to an agent) during the reference period. Average is for the reporting time period.
Reported in timestamp format (hh:mm:ss).
Average amount of time an agent spends on call. Average is for the reporting time period. Quarterly reporting is a Quarterly
average. Reported in timestamp format (mm:ss).
Count of total number of calls abandoned (numerator)in the queue (Calls that terminate or drop before reaching an agent or being
answered) divided by total call volume (denominator). Carry answer to 2 decimal points.
Count of page views across the whole Marketplace site during the reference period.
Count of unique visits to the marketplace website during the reference period.
Count of unique visitors to the marketplace website during the reference period.
Count of secure accounts established (registered users) during the reference period.
Number of letters or written inquiries received via mail or fax; please exclude correspondence not related to Marketplace
functions, health insurance, or coverage for any insurance affordability program.
Please include only unplanned time offline.
FPL (Federal Poverty Level) is calculated based on the projected, total, annual modified adjusted gross income (MAGI) for the
- MAGI includes the sum of the income of the taxpayer and the lawfully present individuals for whom the taxpayer properly claims
- 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
- For individuals that do not request an eligibility determination for financial assistance, MAGI may not be available. If MAGI is
The breakouts of FPL based on annual household income are:
1) <100%
2) ≥100 - ≤138%

FPL

Data Breakouts

Age

3) >138 - ≤150%
4) >150 - ≤200%
5) >200 - ≤250%
6) >250 - ≤300%
7) >300- ≤400%
8) > 400%
9) Unkown
Age of the individual as of the most recent effective enrollment date.
1. < 18 years
2) 18-25
3) 26-34
4) 35-44
5) 45-54
6) 55-64
7) ≥65
8) Unknown