Crosswalk: CHIP Annual Report Template System (CARTS)

Attachment B - CARTS Template Crosswalk.docx

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

Crosswalk: CHIP Annual Report Template System (CARTS)

OMB: 0938-1148

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1148 can be found here:

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Section

2011 (old Version)

2020 (New Version)

Type of change

Reason for Change

Burden of change

(Yes or No)

Section I

1) To provide a summary at-a-glance of your CHIP program characteristics, please provide the following information. You are encouraged to complete this table for the different CHIP programs within your state, e.g., if you have two types of separate child health programs within your state with different eligibility rules. If you would like to make any comments on your responses, please explain in narrative below this table. Please note that the numbers in brackets, e.g., [500] are character limits in the Children’s Health Insurance Program (CHIP) Annual Report Template System (CARTS). You will not be able to enter responses with characters greater than the limit indicated in the brackets.

1) To provide a summary at-a-glance of your CHIP program, please provide the following information. If you would like to make any comments on your responses, please explain in the narrative section below this table.

Provide an assurance that your state’s CHIP program eligibility criteria as set forth in the CHIP state plan in section 4, inclusive of PDF pages related to Modified Adjusted Gross Income eligibility, is accurate as of the date of this report.

Please note that the numbers in brackets, e.g., [500] are character limits in the Children’s Health Insurance Program (CHIP) Annual Report Template System (CARTS). You will not be able to enter responses with characters greater than the limit indicated in the brackets.

Revision

Revised to collect information that is needed and clarify instructions

Is income calculated as gross or net income?

N/A

Deletion

Question no longer needed

Yes, reduced burden

Eligibility

N/A

Deletion

Question no longer needed

Yes, reduced burden

Is presumptive eligibility provided for children?

1. Do you have authority in your CHIP State Plan to provide for presumptive eligibility in your Separate CHIP program, and have you implemented this?

Revision

Question revised for clarity and moved to Section IIIC, Subpart A

Is retroactive eligibility available?

N/A

Deletion

Question no longer needed

Yes, burden reduced

Does your State Plan contain authority to implement a waiting list?

Do you have a waiting list for your program?

Revision

Moved to Section IIIE

Please check all the methods of application utilized by your state.

N/A

Deletion

Question no longer needed

Does your program require a face-to-face interview during initial application

N/A

Deletion

Question no longer needed

Does your program require a child to be uninsured for a minimum amount of time prior to enrollment (waiting period)?

1. Does your Separate CHIP program require a child to be uninsured for a minimum amount of time before enrollment (the waiting period)?

Revision

Modified for clarity and moved to Section IIIB

Does your program match prospective enrollees to a database that details private insurance status?

2. Does your program match prospective enrollees to a database that also details their private insurance status?

Revision

Moved to Section IIIB

Does your program provide period of continuous coverage regardless of income changes?

N/A

Deletion

Question no longer needed

Does your program require premiums or an enrollment fee?

Does your program require premiums or an enrollment fee? (see page 6 of PRA CARTS 2019 Template)

Revision

Question and tables reformatted to be 508 compliant

Yes, reduced burden

Does your program impose copayments or coinsurance?

N/A

Deletion

Question no longer needed

Yes, reduced burden

Does your program impose deductibles?

N/A

Deletion

Question no longer needed

Yes, reduced burden

Does your program require an assets test?

N/A

Deletion

Question no longer needed

Yes, reduced burden

Does your program require income disregards?

N/A

Deletion

Question no longer needed

Yes, reduced burden

Which delivery system(s) does your program use?

Managed Care

Primary Care Case Management

Fee for Service

Please describe which groups receive which delivery system: [500]

Revision

Question reformatted to be 508 compliant

Is a preprinted renewal form sent prior to eligibility expiring?

N/A

Deletion

Question no longer needed

Yes, reduced burden

2. Is there an assets test for children in your Medicaid program?

N/A

Deletion

Question no longer needed

Yes, reduced burden

3. Is it different from the assets test in your separate child health program?

N/A

Deletion

Question no longer needed

Yes, reduced burden

4. Are there income disregards for your Medicaid program?

N/A

Deletion

Question no longer needed

Yes, reduced burden

5. Are they different from the income disregards in your separate child health program?

N/A

Deletion

Question no longer needed

Yes, reduced burden

6. Is a joint application (i.e., the same, single application) used for your Medicaid and separate child health program?

N/A

Deletion

Question no longer needed

Yes, reduced burden

7. If you have a joint application, is the application sufficient to determine eligibility for both Medicaid and CHIP?

N/A

Deletion

Question no longer needed

Yes, reduced burden

8. Indicate what documentation is required at initial application for

N/A

Deletion

Question no longer needed

Yes, reduced burden

9. Have you made changes to any of the following policy or program areas during the reporting period? Please indicate “yes” or “no change” by marking appropriate column.

2) Have you made changes to any of the following policy or program areas during the reporting period? Please indicate “yes” or “no change” by marking the appropriate column.

Revision

Question 9 in previous version is now question 2 in new version. Response Table reformatted to be more 508 compliant.

9. c) Application documentation requirements

N/A

Deletion

Question no longer needed

Yes, reduced burden

9. k) Asset tests

N/A

Deletion

Question no longer needed

Yes, reduced burden

9. l) Income disregards

N/A

Deletion

Question no longer needed

Yes, reduced burden

9. o) family coverage

N/A

Deletion

Question no longer needed

Yes, reduced burden

9. v) Waiver populations (funded under title XXI)

N/A

Deletion

Question no longer needed

Yes, reduced burden

8. For each topic you responded yes to above, please explain the change and why the change was made, below:

3) For each topic you responded “yes” to above, please explain the change and why the change was made, below:

Revision

Response table reformatted to be more 508 compliant

8. c) Application documentation requirements

N/A

Deletion

Question no longer needed

Yes, reduced burden

8. k) Assets test in Medicaid and/or CHIP

N/A

Deletion

Question no longer needed

Yes, reduced burden

8. l) Income disregards in Medicaid and/or CHIP

N/A

Deletion

Question no longer needed

Yes, reduced burden

8. o) Family coverage

N/A

Deletion

Question no longer needed

Yes, reduced burden

8. v) Waiver populations (funded under title XXI)

N/A

Deletion

Question no longer needed

Yes, reduced burden

Section IIA (2011 version)

This section consists of three subsections that gather information on the initial core set of children’s health care quality measures for the CHIP and/or Medicaid program as well as your State’s progress toward meeting its general program strategic objectives and performance goals. Section IIA captures data on the initial core set of measures to the extent data are available. Section IIB captures your enrollment progress as well as changes in the number and/or rate of uninsured children in your State. Section IIC captures progress towards meeting your State’s general strategic objectives and performance goals.

SECTION IIA: REPORTING OF THE INITIAL CORE SET OF CHILDREN’S HEALTH CARE QUALITYMEASURES

N/A

Deletion

Core Set Quality Measure questions in Section IIA of the older template (pages 14-76) removed because they were moved to MACPRO.

Yes, reduced burden

Section IIB (Section IIA in 2019 version)

1. The information in the table below is the Unduplicated Number of Children Ever Enrolled in CHIP in your State for the two most recent reporting periods. The enrollment numbers reported below should correspond to line 7 (Unduplicated # Ever Enrolled Year) in your State’s 4th quarter data report (submitted in October) in the CHIP Statistical Enrollment Data System (SEDS). The percent change column reflects the percent change in enrollment over the two-year period. If the percent change exceeds 10 percent (increase or decrease), please explain in letter A below any factors that may account for these changes (such as decreases due to elimination of outreach or increases due to program expansions). This information will be filled in automatically by CARTS through a link to SEDS. Please wait until you have an enrollment number from SEDS before you complete this response.

Table 1: Children enrolled in CHIP

This table is pre-filled with the state’s your SEDS data for the two most recent federal fiscal years. If the information is inaccurate, adjust the data in your the SEDS report (See line 7: Unduplicated Number Ever Enrolled in your fourth quarter SEDS report) and refresh this page. (Note: Iit may take some time to see updated data.)

Revision

Question revised for clarity and conciseness

1.A. Please explain any factors that may account for enrollment increases or decreases exceeding 10 percent.

1. If the percent change exceeds a 10% increase or decrease, what are some possible reasons for this change? (For example: Changes in outreach strategies or an expansion of programs.)

Revision

Question revised for plain language and clarity

2. The table below shows trends in the three-year averages for the number and rate of uninsured children in your State based on the Current Population Survey (CPS), along with the percent change between 1996-1998 and 2009-2010. Significant changes are denoted with an asterisk (*). If your state uses an alternate data source and/or methodology for measuring change in the number and/or rate of uninsured children, please explain in Question #3. CARTS will fill in this information automatically, but in the meantime, please refer to the CPS data attachment that was sent with the FFY 2011 Annual Report Template.

Table 2: Uninsured children (under age 19) below 200% FPL

Current Population Survey

This table is pre-filled with rates of uninsured children below 200% of the Federal Poverty Line (FPL) based on three-year averages from the Current Population Survey. Significant changes are denoted with an asterisk (*).

Revision

Question revised for clarity and conciseness

N/A

Table 3: Uninsured children (under age 19) below 200% FPL

American Community Survey

This table is pre-filled with numbers of uninsured children below 200% of the Federal Poverty Line (FPL) based on single year estimates from the American Community Survey. Significant changes are denoted with an asterisk (*).

Addition

Change in data source

2.A. Please explain any activities or factors that may account for increases or decreases in your number and/or rate of uninsured children.

2. What are some possible reasons for increases or decreases in the number of uninsured children in your state?

Revision

Plain language revision

2.B. Please note any comments here concerning CPS data limitations that may affect the reliability or precision of these estimates.

3. Were there any limitations on the American Community Survey data that could affect the reliability or precision of this data?

Revision

Revised to add plain language and change data source

3. Please indicate by checking the box below whether your State has an alternate data source and/or methodology for measuring the change in the number and/or rate of uninsured children.

Yes (please report your data in the table below)

No (skip to Question #4)

Please report your alternate data in the table below. Data are required for two or more points in time to demonstrate change (or lack of change). Please be as specific and detailed as possible about the method used to measure progress toward covering the uninsured.

4. Do you have any alternate data source(s) or methodology for measuring the number and/or rate of uninsured children in your state?

Yes

If yes, please report your alternate data in the table below. Data are required for two or more points in time to demonstrate change (or lack of change). Please be as specific and detailed as possible about the method used to measure progress toward covering the uninsured

Revision

Plain language revision

4. How many children do you estimate have been enrolled in Medicaid as a result of CHIP outreach activities and enrollment simplification? Describe the data source and method used to derive this information.

N/A

Deletion

Question no longer needed

Yes, reduced burden

N/A

5. Anything else you’d like to share about your data on enrollment and uninsured children?

Addition

Space for state to provide additional information if needed

Section IIC (Section IIB in 2019 version)

Instructions on page 79: Note that the term performance measure is used differently in Section IIA versus IIC. In Section IIA, the term refers to the 24 core child health measures. In this section, the term is used more broadly, to refer to any data your State provides as evidence towards a particular goal within a strategic objective. For the purpose of this section, “objectives” refer to the five broad categories listed above, while “goals” are State-specific, and should be listed in the appropriate subsections within the space provided for each objective.

Instructions on page 16: In this section, the term performance measure is used to refer to any data your state provides as evidence towards a particular goal within a strategic objective. For the purpose of this section, “objectives” refer to the five broad categories listed above, while “goals” are state-specific, and should be listed in the appropriate subsections within the space provided for each objective.

Revision

Instructions revised to remove reference to an older version of Section IIA has been removed from the report.

Instructions on page 79: In addition, please do not report the same data that were reported in Sections IIA or IIB. The intent of this section is to capture goals and measures that your State did not report elsewhere in Section II.

Instructions on page 16: In addition, please do not report the same data that were reported for Child Core Set reporting. The intent of this section is to capture goals and measures that your state did not report elsewhere. As a reminder, Child Core Set reporting migrated to MACPRO in December 2015. Historical data are still available for viewing in CARTS.

Revision

Instructions revised to clarify information that should not be included in this section.

Instructions on page 82: Note: CARTS will calculate the rate when you enter the numerator and denominator.

For CARTS versions prior to 2011 States were able to enter a rate without entering a numerator and denominator (If you typically calculate separate rates for each health plan, report the aggregate state-level rate for each measure [or component]. The preferred method is to calculate a “weighted rate” by summing the numerators and denominators across plans, and then deriving a single state-level rate based on the ratio of the numerator to the denominator.) Beginning in 2011, CARTS will be requiring States to report numerators and denominators rather than providing them the option of only reporting the rate. If States reported a rate in years prior to 2011, that data will be able to be edited if the need arises.

Instructions on pages 19-20: The preferred method is to calculate a “weighted rate” by summing the numerators and denominators across plans, and then deriving a single state-level rate based on the ratio of the numerator to the denominator). The reporting unit for each measure is the state as a whole. If states calculate rates for multiple reporting units (e.g., individual health plans, different health care delivery systems), states must aggregate data from all these sources into one state rate before reporting the data to CMS. In the situation where a state combines data across multiple reporting units, all or some of which use the hybrid method to calculate the rates, the state should enter zeroes in the “Numerator” and “Denominator” fields. In these cases, it should report the state-level rate in the “Rate” field and, when possible, include individual reporting unit numerators, denominators, and rates in the field labeled “Additional Notes on Measure,” along with a description of the method used to derive the state-level rate.

Revision

Updated to further clarify instructions and remove outdated information.

Year row in all goals tables in objective section

Year of Data: 

Date range row in all goals tables in objective section

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Revision

Revised to clarify the information needed

Explanation of progress and other comments and measures rows in all goals tables in objectives section (see table on page 84 as example)

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your ability to report on this measure, improve your results for this measure, or make progress toward your goal?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012: 

Annual Performance Objective for FFY 2013: 

Annual Performance Objective for FFY 2014: 

Explain how these objectives were set: 

Other Comments on Measure:

Explanation of progress and other comments and measures rows in all goals tables in objectives section (see table on page 19 as example)

Revision

Goal tables revised to be more 508 compliant

N/A

Deviations from Measure Specific row in all goal tables for objectives related to access to care and use of preventative care

Deviations from Measure Specifications:

Year of Data, Explain.

Data Source, Explain.

Numerator, Explain.

Denominator, Explain.

Other, Explain.

Addition

Revised to include information that was asked for in the instructions of previous reports but not previously included in the goal tables for this section.

Yes, burden added

Page 114: Please list attachments here and summarize findings or list main findings

N/A

Deletion

Question no longer needed

Yes, reduced burden

Section IIIA (both versions)

Section III A: Outreach

Section III A: Program Outreach

Revision

More accurate title

1. How have you redirected/changed your outreach strategies during the reporting period?

1. Have you changed your outreach methods over the past federal fiscal year? If so, what have you done differently?

Revision

Plain language revision

2. What methods have you found most effective in reaching low-income, uninsured children (e.g., T.V., school outreach, word-of-mouth)? How have you measured effectiveness?

3. What methods have been most effective in reaching low-income, uninsured children? (For example: TV, school outreach, or word of mouth)

Revision

Plain language revision

3. Which of the methods described in Question 2 would you consider a best practice(s)?

N/A

Deletion

Question removed because it is duplicative.

Yes, reduced burden.

4. Is your state targeting outreach to specific populations (e.g., minorities, immigrants, and children living in rural areas)?

es No

Have these efforts been successful, and how have you measured effectiveness?

2. Are you targeting specific populations in your outreach? (For example: minorities, immigrants, or children living in rural areas.)

If you answered YES:

Have these efforts been successful?

How have you measured the effectiveness?

Revision

Plain language revision

5. What percentage of children below 200 percent of the Federal poverty level (FPL) who are eligible for Medicaid or CHIP have been enrolled in those programs? (Identify the data source used).

4. What percent of children below 200% of the Federal Poverty Level (FPL) who are eligible for Medicaid or CHIP have been enrolled in those programs? [For example: “23.78%”]

a. Where did you source this data from?

Revision

Plain language revision

N/A

5. Anything else you’d like to add about your state’s outreach efforts?

Addition

Addition of question to capture any additional information states would like to share

Section III B (Both versions)

N/A

Substitution of coverage (also known as crowd-out) occurs when someone with private insurance decides to drop their private coverage and substitute it with publicly funded insurance coverage such as CHIP.

Addition

Addition of description of the section.

Do you have substitution prevention policies in place?

es No

If yes, indicate if you have the following policies:

Imposing waiting periods between terminating private coverage and enrolling in CHIP

Imposing cost sharing in approximation to the cost of private coverage

Monitoring health insurance status at the time of application

[7500][7500]

1. Does your separate CHIP program require a child to be uninsured for a minimum amount of time before enrollment (the waiting period)?

Yes

If you answered YES:

a. How long does your program require a child to be uninsured before enrollment?
b. Which population groups does the period of uninsurance apply to? (Include Federal Poverty Levels for each group.)
c. What exemptions apply to the period of uninsurance?

Revision

Revised this question to better reflect current policies.

2. Describe how substitution of coverage is monitored and measured and how the State evaluates the effectiveness of its policies. [7500]

N/A

Deletion

Deleted this question.

Yes, reduced burden.

3. Identify the trigger mechanism or point at which your substitution prevention policy is instituted or modified if you currently have a substitution policy. [7500]

N/A

Deletion

Deleted this question.

Yes, reduced burden.

4. At the time of application, what percent of CHIP applicants are found to have Medicaid [(# applicants found to have Medicaid/total # applicants) * 100] [5] and what percent of applicants are found to have other group health insurance [(# applicants found to have other insurance/total # applicants) * 100] [5]? Provide a combined percent if you cannot calculate separate percentages. [5]

3. What percent of individuals screened for CHIP eligibility can’t be enrolled because they have group health plan coverage? [For example “23.17%”]

Revision

Revised this question to better reflect current policies.

No.

5. What percent of CHIP applicants cannot be enrolled because they have group health plan coverage? [5]

a. Of those found to have had other, private insurance and have been uninsured for only a portion of the state’s waiting period, what percent meet your state’s exemptions to the waiting period (if your state has a waiting period and exemptions) [(# applicants who are exempt/total # of new applicants who were enrolled)*100]? [5]

5. Do you track the number of individuals who have access to private insurance?

No

Yes
If you answered YES:

a. How many individuals who enrolled in CHIP over the last FFY (federal fiscal year) had access to private insurance when they applied?

b. How many individuals were enrolled in CHIP during the last FFY?

c. What percent of individuals that enrolled in CHIP had access to private health insurance when they applied? [Divide 5a by 5b]

Revision

Revised the question to more accurately reflect the information we need to collect.

No.

N/A

2. Does your program match prospective enrollees to a database that also details their private insurance status?

Yes

N/A

If you answered YES:

Which database do you use?

Addition

Additional question to capture necessary information

N/A

4. What percent of individuals with group health insurance who are subject to the waiting period meet state and federal exemptions?

To calculate this number: Divide the number of individuals subject to the waiting period who meet an exemption by the total number of individuals subject to the waiting period, then multiply this number by 100.

Addition

Additional question to capture necessary information

N/A

6. Anything else to add about this section that wasn’t already covered? Did you run into any limitations when collecting data? [Max 7500 characters]

Addition

Addition of narrative question to capture any additional information states would like to share.

No.

6. Does your State have an affordability exception to its waiting period?

es No

If yes, please respond to the following questions. If no, skip to question 7.

a. Has the State established a specific threshold for defining affordability (e.g., when the cost of the child’s portion of the family’s employer-based health insurance premium is more than X percent of family income)?

es No

If the State has established a specific threshold, please provide this figure and whether this applies to net or gross income. If no, how does the State determine who meets the affordability exception? [7500]

b. What expenses are counted for purposes of determining when the family exceeds the affordability threshold? (e.g., Does the State consider only premiums, or premiums and other cost-sharing charges? Does the State base the calculation on the total premium for family coverage under the employer plan or on the difference between the amount of the premium for employee-only coverage and the amount of the premium for family coverage? Other approach?) [7500]

c. What percentage of enrollees at initial application qualified for this exception in the last Federal Fiscal Year? (e.g., Number of applicants who were exempted because of affordability exception/total number of applicants who were enrolled). [5]

d. Does the State conduct surveys or focus groups that examine whether affordability is a concern?

es No

If yes, please provide relevant findings. [7500]

N/A

Deletion

Question no longer required

Yes, reduced burden

7. If your State does not have an affordability exception, does your State collect data on the cost of health insurance for an individual or family? [7500]

N/A

Deletion

Question no longer required

Yes, reduced burden

8. Does the State’s CHIP application ask whether applicants have access to private health insurance?

es No

If yes, do you track the number of individuals who have access to private insurance?

es No

If yes, what percent of individuals that enrolled in CHIP had access to private health insurance at the time of application during the last Federal Fiscal Year [(# of individuals that had access to private health insurance/total # of individuals enrolled in CHIP)*100]? [5]

N/A

Deletion

Question no longer required

Yes, reduced burden

Section III C, Subpart A (2020 version)

Section IIIC: Subpart A: Overall CHIP and Medicaid Eligibility Coordination

Subpart A: Eligibility Renewal and Retention

Revision

Revised language to better reflect content of the section

1. Does the State use a joint application for establishing eligibility for Medicaid or CHIP?

Yes No

If no, please describe the screen and enroll process. [7500]

N/A

Deletion

Deleted question, no longer needed

Yes, reduced burden

2. Please explain the process that occurs when a child’s eligibility status changes from Medicaid to CHIP and from CHIP to Medicaid. Have you identified any challenges? If so, please explain. [7500]

N/A

Deletion

Deleted question, no longer needed

Yes, reduced burden

3. Are the same delivery systems (such as managed care or fee for service,) or provider networks used in Medicaid and CHIP?

Yes No

If no, please explain. [7500]

N/A

Deletion

Deleted question, no longer needed

Yes, reduced burden

4. Do you have authority in your CHIP State plan to provide for presumptive eligibility, and have you implemented this?

Yes No

If yes

What percent of children are presumptively enrolled in CHIP pending a full eligibility determination? [5]
Of those children who are presumptively enrolled, what percent of those children are determined eligible and enrolled upon completion of the full eligibility determination those children are determined eligible and enrolled? [5]

Do your state have authority in the CHIP State Plan to provide for presumptive eligibility in your Separate CHIP program, and has your state implemented this?

Yes

N/A, Medicaid Expansion CHIP only

If YES:

What percent of children are presumptively enrolled in CHIP pending a full eligibility determination?
Of those children who are presumptively enrolled, what percent are determined fully eligible and enrolled in the program?

Revision

Revised language to provide clarity

What additional measures, besides those described in Tables B1 or C1, does your State employ to simplify an eligibility renewal and retain eligible children in CHIP?

	Conducts follow-up with clients through caseworkers/outreach workers
	Sends renewal reminder notices to all families
	How many notices are sent to the family prior to disenrolling the child from the program? [500]
	At what intervals are reminder notices sent to families (e.g., how many weeks before the end of the current eligibility period is a follow-up letter sent if the renewal has not been received by the State?) [500]
	Other, please explain: [500]

2. In an effort to retain more children in CHIP, does your state conduct follow-up communication with families through caseworkers and outreach workers?
No

Yes

3. Does your state send renewal reminder notices to families?

Yes

If YES:

a. How many notices does your state send to families before disenrolling a child from the program?

b. When does your state send your reminder notices to families? (How many days before the end of the eligibility period?)

4. What other strategies does your state do to simplify the eligibility renewal process for families in order to increase retention?

Revision

Revised language to provide clarity

How does your state measure the effectiveness? What data sources and methodology does your state use to track retention?

5. Which of the above strategies appear to be the most effective? Have you evaluated the effectiveness of any strategies? If so, please describe the evaluation, including data sources and methodology. [7500]

6. Which retention strategies are the most effective?

Revision

Revised language to provide clarity

Section IIIC: Subpart B: Initial Eligibility, Enrollment, and Renewal for CHIP (Title XXI) and Medicaid (Title XIX) Programs

Table B1

N/A – This entire subsection has been removed.

Deletion

Questions no longer needed

Yes, burden reduced

Section III C, Subpart B (2020 version)

States are required to report on questions 1 and 2 in FFY 2011. Reporting on questions 2.a., 2.b., and 2.c. is voluntary in FFY 2011, FFY 2011, and FFY 2012. Reporting on questions 2.a., 2.b., and 2.c. is required in 2013. Please enter the data requested in the table below and the template will tabulate the requested percentages.

States are required to report on all questions (1, 1.a., 1.b., and 1.c) in FFY 2020. Please enter the data requested in the table below and the template will tabulate the requested percentages.

If your state is unable to provide data in this section due to the single streamlined application, please note this in the response to question 2.

Revision

Revised language to provide clarity

Definitions:

The “total number of title XXI applicants,” including those that applied using a joint application form, is defined as the total number of applicants that had an eligibility decision made for title XXI in FFY 2011. This measure is for applicants that have not been previously enrolled in title XXI or they were previously enrolled in title XXI but had a break in coverage, thus requiring a new application. Please include only those applicants that have had a Title XXI eligibility determination made in FFY 2011 (e.g., an application that was determined eligible in September 2011, but coverage was effective October 1, 2011 is counted in FFY 2011).
The “the total number of denials” is defined as the total number of applicants that have had an eligibility decision made for title XXI and denied enrollment for title XXI in FFY 2011. This definition only includes denials for title XXI at the time of initial application (not redetermination).

The “total number of procedural denials” is defined as the total number of applicants denied for title XXI procedural reasons in FFY 2011 (i.e., incomplete application, missing documentation, missing enrollment fee, etc.).
The “total number of eligibility denials” is defined as the total number of applicants denied for title XXI eligibility reasons in FFY 2011 (i.e., income too high, income too low for title XXI /referred for Medicaid eligibility determination/determined Medicaid eligible , obtained private coverage or if applicable, had access to private coverage during your State’s specified waiting period, etc.)

The total number of applicants that are denied eligibility for title XXI and determined eligible for title XIX

The “total number of applicants denied for other reasons” is defined as any other type of denial that does not fall into 2a or 2b. Please check the box provided if there are no additional categories.

Definitions:

1. The “the total number of denials of title XXI coverage” is defined as the total number of applicants that have had an eligibility decision made for title XXI and denied enrollment for title XXI in FFY 2020. This definition only includes denials for title XXI at the time of initial application (not redetermination).

a. The “total number of procedural denials” is defined as the total number of applicants denied for title XXI procedural reasons in FFY 2020 (i.e., incomplete application, missing documentation, missing enrollment fee, etc.).

b. The “total number of eligibility denials” is defined as the total number of applicants denied for title XXI eligibility reasons in FFY 2020 (i.e., income too high, income too low for title XXI /referred for Medicaid eligibility determination/determined Medicaid eligible , obtained private coverage or if applicable, had access to private coverage during your state’s specified waiting period, etc.)

i. The total number of applicants that are denied eligibility for title XXI and determined eligible for title XIX.

c. The “total number of applicants denied for other reasons” is defined as any other type of denial that does not fall into 2a or 2b. Please check the box provided if there are no additional categories.

Revision

Revised language to provide clarity

Table 2. Redetermination Status of Children Enrolled in Title XXI

For this table, States may voluntarily report in 2011 and 2012. Reporting is required for 2013.

Is the State reporting this data in the 2011 CARTS?

Yes (complete) State is reporting all measures in the redetermination table.

Yes (but incomplete) Please describe which measures the State did not report on, and why the State did not report on these measures.

Explain: [7500]

No If the State is not reporting any data, please explain why. Explain: [7500]

Table 2. Redetermination Status of Children

For tables 2a and 2b, reporting is required for FFY 2019FFY 2020.

Revision

Reporting is no longer optional

Yes, burden increased

Definitions:

The “total number of children who are eligible to be redetermined” is defined as the total number of children due to renew their eligibility in Federal Fiscal Year (FFY) 2011, and did not age out (did not exceed the program’s maximum age requirement) of the program by or before redetermination. This total number may include those children who are eligible to renew prior to their 12 month eligibility redetermination anniversary date. This total number may include children whose eligibility can be renewed through administrative redeterminations, whereby the State sends the family a renewal form that is pre-populated with eligibility information already available through program records and requires the family to report any changes. This total may also include ex parte redeterminations, the process when a State uses information available to it through other databases, such as wage and labor records, to verify ongoing eligibility.
The “total number of children screened for redetermination” is defined as the total number of children that were screened by the State for redetermination in FFY 2011 (i.e., those children whose families have returned redetermination forms to the State, as well as administrative redeterminations and ex parte redeterminations).
The “total number of children retained after the redetermination process” is defined as the total number of children who were found eligible and remained in the program after the redetermination process in FFY 2011.
The “total number of children disenrolled from title XXI after the redetermination process” is defined as the total number of children who are disenrolled from title XXI following the redetermination process in FFY 2011. This includes those children that States may define as “transferred” to Medicaid for title XIX eligibility screening.

The “total number of children disenrolled for failure to comply with procedures” is defined as the total number of children disenrolled from title XXI for failure to successfully complete the redetermination process in FFY 2011 (i.e., families that failed to submit a complete application, failed to provide complete documentation, failed to pay premium or enrollment fee, etc.).
The “total number of children disenrolled for failure to meet eligibility criteria” is defined as the total number of children disenrolled from title XXI for no longer meeting one or more of their State’s CHIP eligibility criteria (i.e., income too low, income too high, obtained private coverage or if applicable, had access to private coverage during your State’s specified waiting period, etc.). If possible, please break out the reasons for failure to meet eligibility criteria in i.-iv.
The “total number of children disenrolled for other reason(s)” is defined as the total number of children disenrolled from title XXI for a reason other than failure to comply with procedures or failure to meet eligibility criteria, and are not already captured in 4.a. or 4.b.

The data entered in 4.a., 4.b., and 4.c. should sum to the total number of children disenrolled from title XXI (line 4).

Definitions:

1. The “total number of children who are eligible to be redetermined” is defined as the total number of children due to renew their eligibility in federal fiscal year (FFY) 2020, and did not age out (did not exceed the program’s maximum age requirement) of the program by or before redetermination. This total number may include those children who are eligible to renew prior to their 12 month eligibility redetermination anniversary date. This total must include ex parte redeterminations, the process when a state uses information available to it through other databases, such as wage and labor records, to verify ongoing eligibility. This total number must also include children whose eligibility can be renewed through administrative redeterminations, whereby the state sends the family a renewal form that is pre-populated with eligibility information already available through program records and requires the family to report any changes.

2. The “total number of children screened for redetermination” is defined as the total number of children that were screened by the state for redetermination in FFY 2020 (i.e., ex parte redeterminations and administrative redeterminations, as well as those children whose families have returned redetermination forms to the state ).

3. The “total number of children retained after the redetermination process” is defined as the total number of children who were found eligible and remained in the program after the redetermination process in FFY 2020.

4. The “total number of children disenrolled from title XXI after the redetermination process” is defined as the total number of children who are disenrolled from title XXI following the redetermination process in FFY 2020. This includes those children that states may define as “transferred” to Medicaid for title XIX eligibility screening.

a. The “total number of children disenrolled for failure to comply with procedures” is defined as the total number of children disenrolled from title XXI for failure to successfully complete the redetermination process in FFY 2020 (i.e., families that failed to submit a complete application, failed to provide complete documentation, failed to pay premium or enrollment fee, etc.).

b. The “total number of children disenrolled for failure to meet eligibility criteria” is defined as the total number of children disenrolled from title XXI for no longer meeting one or more of their state’s CHIP eligibility criteria (i.e., income too low, income too high, obtained private coverage or if applicable, had access to private coverage during your state’s specified waiting period, etc.). If possible, please break out the reasons for failure to meet eligibility criteria in i.-iv.

c. The “total number of children disenrolled for other reason(s)” is defined as the total number of children disenrolled from title XXI for a reason other than failure to comply with procedures or failure to meet eligibility criteria, and are not already captured in 4.a. or 4.b.
The data entered in 4.a., 4.b., and 4.c. should sum to the total number of children disenrolled from title XXI (line 4).

Revision

Revised language to provide clarity

Duration Measure of Selected Children, Ages 0-16, Enrolled in Title XXI, Second Quarter FFY 2012

The purpose of this table is to measure title XXI enrollees’ duration, or continuity, of public coverage (title XIX and title XXI). This information is required by CHIPRA, Section 402(a). Reporting is not required until 2013, but States will need to identify newly enrolled children in the second quarter of FFY 2012 (January, February, and March of 2011). If your eligibility system already has the capability to track a cohort of enrollees over time, an additional “flag” or unique identifier may not be necessary.

Instructions: For this prospective duration measure, please identify newly enrolled children in title XXI in the second quarter of FFY 2012, ages 0 months to 16 years at time of enrollment. Children enrolled in January 2012 must have birthdates after July 1995 (e.g., children must be younger than 16 years and 5 months) to ensure that they will not age out of the program at the 18^th month of coverage. Similarly, children enrolled in February 2012 must have birthdates after August 1995, and children enrolled in March 2012 must have birthdates after September 1995. Each child newly enrolled during this time frame needs a unique identifier or “flag” so that the cohort can be tracked over time. If your eligibility system already has the capability to track a cohort of enrollees over time, an additional “flag” or unique identifier may not be necessary. Please follow the child based on the child’s age category at the time of enrollment (e.g., the child’s age at enrollment creates an age cohort that does not change over the 18 month time span). Please enter the data requested in the table below and the template will tabulate the percentages.

Specify how your “newly enrolled” population is defined:

Not Previously Enrolled in CHIP or Medicaid—“Newly enrolled” is defined as not enrolled in either title XXI or title XIX in the month before enrollment (i.e., for a child enrolled in January 2012, he/she would not be enrolled in either title XXI or title XIX in December 2011, etc.)

Not Previously Enrolled in CHIP—“Newly enrolled” is defined as not enrolled in title XXI in the month before enrollment (i.e., for a child enrolled in January 2012, he/she would not be enrolled in title XXI in December 2011, etc.)

Table 3. Duration Measure of Selected Children, Ages 0-16, Enrolled in Title XIX and Title XXI, Second Quarter FFY 2020

The purpose of tables 3a and 3b is to measure the duration, or continuity, of Medicaid and CHIP enrollees’ coverage. This information is required by Section 402(a) of CHIPRA. Reporting on this table is required.

The measure is designed to capture continuity of coverage for a cohort of children in title XIX and title XXI for 18 months of enrollment. This means that reporting spans two CARTS reports over two years, with enrollment status at 6 months being reported in the first reporting year, and 12 and 18 month enrollment status reported in the second reporting year. States identify a new cohort of children every two years. States identify newly enrolled children in the second quarter of FFY 2020 (January, February, and March of 2020) for the FFY 2020 CARTS report. This same cohort of children will be reported on in the FFY 2021 CARTS report for the 12 and 18 month status of children newly identified in quarter 2 of FFY 2020. If your state’s eligibility system already has the capability to track a cohort of enrollees over time, an additional “flag” or unique identifier may not be necessary.

The FFY 2020 CARTS report is the second year of reporting in the cycle of two CARTS reports on the cohort of children identified in the second quarter of FFY 2018. For the FFY 2018 report, States only reported on lines 1-4a of the tables. In the FFY 2020 report, no updates will be made to lines 1-4a. For the FFY 2020 report, data will be added to lines 5-10a.The next cohort of children will be identified in the second quarter of the FFY 2020 (January, February and March of 2020).

Instructions: For this measure, please identify newly enrolled children in both title XIX (for Table 3a) and title XXI (for Table 3b) in the second quarter of FFY 2020, ages 0 months to 16 years at time of enrollment. Children enrolled in January 2018 must have birthdates after July 2001 (e.g., children must be younger than 16 years and 5 months) to ensure that they will not age out of the program at the 18th month of coverage. Similarly, children enrolled in February 2020 must have birthdates after August 2001, and children enrolled in March 2020 must have birthdates after September 2001. Each child newly enrolled during this time frame needs a unique identifier or “flag” so that the cohort can be tracked over time. If your state’s eligibility system already has the capability to track a cohort of enrollees over time, an additional “flag” or unique identifier may not be necessary. Please follow the child based on the child’s age category at the time of enrollment (e.g., the child’s age at enrollment creates an age cohort that does not change over the 18 month time span)

Please enter the data requested in the tables below, and the template will tabulate the percentages. In the FFY 2020 report your state will enter data on lines 5-7a related to the 12-month enrollment status of children identified on line 1. Your state will also enter data on lines 8-10a related to the 18-month enrollment status of children identified on line 1. Only enter a “0” (zero) if the data are known to be zero. If data are unknown or unavailable, leave the field blank.

Note that all data must sum correctly in order to save and move to the next page. The data in each individual row must add across to sum to the total in the “All Children Ages 0-16” column for that row. And in each column, the data within each time period (6, 12 and 18 months) must each sum up to the data in row 1, which is the number of children in the cohort. This means that in each column, rows 2, 3 and 4 must sum to the total in row 1; rows 5, 6 and 7 must sum to row 1; and rows 8, 9 and 10 must sum to row 1. These tables track a child’s enrollment status over time, so when data are added or modified at each milestone (6, 12, and 18 months), there should always be the same total number of children accounted for in line 1 “All Children Ages 0-16” over the entire 18 month period. Rows numbered with an “a” (e.g., rows 3a and 4a) are excluded from the totals because they are subsets of their respective rows. The system will not move to the next section of the report until all applicable sections of the table for the reporting year are complete and sum correctly to line 1.

Table 3 a. Duration Measure of Children Enrolled in Title XIX

Not Previously Enrolled in CHIP or Medicaid—“Newly enrolled” is defined as not enrolled in either title XXI or title XIX in the month before enrollment (i.e., for a child enrolled in January 2020, he/she would not be enrolled in either title XXI or title XIX in December 2019, etc.)

Not Previously Enrolled in Medicaid—“Newly enrolled” is defined as not enrolled in title XIX in the month before enrollment (i.e., for a child enrolled in January 2020, he/she would not be enrolled in title XIX in December 2019, etc.)

Revision

Revised language to provide clarity

Definitions:

The “total number of children newly enrolled in title XXI in the second quarter of FFY 2012” is defined as those children either new to public coverage or new to title XXI, in the month before enrollment. Please define your population of “newly enrolled” in the Instructions section.

Definitions:

The “total number of children newly enrolled in title XIX in the second quarter of FFY 2020” is defined as those children either new to public coverage or new to title XIX, in the month before enrollment. Please define your state’s population of “newly enrolled” in the Instructions section.

Revision

Revised language to provide clarity

N/A

Enter any Narrative text related to Section IIIC below. [7500]

Addition

Addition of Narrative question for any other information the state would like to share

Section III D

Describe how the State tracks cost sharing to ensure enrollees do not pay more than 5 percent aggregate maximum in the year?

a. Cost sharing is tracked by:

Enrollees (shoebox method)

Health Plan(s)

State

Third Party Administrator

N/A (No cost sharing required)

Other, please explain. [7500]

If the State uses the shoebox method, please describe informational tools provided to enrollees to track cost sharing. [7500]

Describe how the state tracks cost sharing to ensure enrollees do not pay more than 5 percent aggregate maximum in the year? If the state checks N/A for this question because no cost sharing is required, please skip to Section IIIE.

a. Cost sharing is tracked by:

Enrollees (shoebox method)

If the state uses the shoebox method, please describe informational tools provided to enrollees to track cost sharing. [7500]

Health Plan(s)
State
Third Party Administrator
N/A (No cost sharing required)
Other, please explain. [7500]

Revision

Revised language to provide clarity

5. Has your State undertaken any assessment of the effects of premiums/enrollment fees on participation in CHIP?

Yes No If so, what have you found? [7500]

5. Has your state undertaken any assessment of the effects of premiums/enrollment fees on participation in CHIP?

Yes
No

If so, what are the findings? [7500]

Revision

Revised language for clarity

6. Has your State undertaken any assessment of the effects of cost sharing on utilization of health services in CHIP?

Yes No If so, what have you found? [7500]

6. Has your state undertaken any assessment of the effects of cost sharing on utilization of health services in CHIP?

Yes
No

If so, what are the findings? [7500]

Revision

Revised language for clarity

7. If your State has increased or decreased cost sharing in the past Federal Fiscal year, how is the State monitoring the impact of these changes on application, enrollment, disenrollment, and utilization of children’s health services in CHIP. If so, what have you found? [7500]

7. If your state has increased or decreased cost sharing in the past federal fiscal year, how is the state monitoring the impact of these changes on application, enrollment, disenrollment, and utilization of children’s health services in CHIP. If so, what are the findings? [7500]

Revision

Revised language for clarity

N/A

Enter any Narrative text related to Section IIID below. [7500]

Addition

Addition of narrative question to capture any additional information states would like to share.

Section III E

E. EMPLOYER SPONSORED INSURANCE PROGRAM (INCLUDING PREMIUM ASSISTANCE PROGRAM(S)) UNDER THE CHIP STATE PLAN OR A SECTION 1115 TITLE XXI DEMONSTRATION

Section IIIE: Employer sponsored insurance Program (including Premium Assistance)

Revision

Revised language for clarity

1. Does your State offer an employer sponsored insurance program (including a premium assistance program) for children and/or adults using Title XXI funds?

Yes, please answer questions below.

No, skip to Program Integrity subsection.

Children

		Yes, Check all that apply and complete each question for each authority.

			Purchase of Family Coverage under the CHIP State Plan (2105(c)(3))
			Additional Premium Assistance Option under CHIP State Plan (2105(c)(10))
			Section 1115 Demonstration (Title XXI)
			Premium Assistance Option (applicable to Medicaid expansion) children (1906)
			Premium Assistance Option (applicable to Medicaid expansion) children (1906A)

Adults

		Yes, Check all that apply and complete each question for each authority.

			Purchase of Family Coverage under the CHIP State Plan (2105(c)(10)
			Additional Premium Assistance Option under the CHIP State Plan (2105(c)(3)
			Section 1115 Demonstration (Title XXI)
			Premium Assistance option under the Medicaid State Plan (1906)
			Premium Assistance option under the Medicaid State Plan (1906A)

1. Does your state offer an employer sponsored insurance program (including a premium assistance program under the CHIP State Plan or a Section 1115 Title XXI Demonstration) for children and/or adults using Title XXI funds?

Yes, please answer questions below.

No, skip to Program Integrity subsection.

Check all that apply and complete each question for each authority

Purchase of Family Coverage under the CHIP state plan (2105(c)(3))

Additional Premium Assistance Option under CHIP state plan (2105(c)(10))

Section 1115 Demonstration (Title XXI)

Revision

Revised language to capture the necessary information only

2. Please indicate which adults your State covers with premium assistance. (Check all that apply.)

	Parents and Caretaker Relatives
	Childless Adults
	Pregnant Women

2. Please indicate which adults your state covers with premium assistance. (Check all that apply.)

Parents and Caretaker Relatives

Pregnant Women

Revision

Removed a response that is no longer an option

7. Are there limits on cost sharing for children in your ESI program?

Yes No

7. Are there limits on cost sharing for children in your state’s ESI program?

Yes

Revision

Editorial revision

8. Are there any limits on cost sharing for adults in your ESI program?

Yes No

8. Are there any limits on cost sharing for adults in your state’s ESI program?

Yes

Revision

Editorial revision

9. Are there protections on cost sharing for children (e.g., the 5 percent out-of-pocket maximum) in your premium assistance program?

Yes No If yes, how is the cost sharing tracked to ensure it remains within the 5 percent yearly aggregate maximum [7500]?

9. Are there protections on cost sharing for children (e.g., the 5 percent out-of-pocket maximum) in your state’s premium assistance program?

Yes

If yes, how is the cost sharing tracked to ensure it remains within the 5 percent yearly aggregate maximum [7500]?

Revision

Editorial revision

10. Identify the total number of children and adults enrolled in the ESI program for whom Title XXI funds are used during the reporting period (provide the number of adults enrolled in this program even if they were covered incidentally, i.e., not explicitly covered through a demonstration).

		Number of childless adults ever-enrolled during the reporting period
		Number of adults ever-enrolled during the reporting period
		Number of children ever-enrolled during the reporting period

Number of adults ever-enrolled during the reporting period

Number of children ever-enrolled during the reporting period

Revision

Removed an outdated question

12. During the reporting period, what has been the greatest challenge your ESI program has experienced? [7500]

12. During the reporting period, what has been the greatest challenge your state’s ESI program has experienced? [7500]

Revision

Editorial revision

13. During the reporting period, what accomplishments have been achieved in your ESI program? [7500]

13. During the reporting period, what accomplishments have been achieved in your state’s ESI program? [7500]

Revision

Editorial revision

14. What changes have you made or are planning to make in your ESI program during the next fiscal year? Please comment on why the changes are planned. [7500]

14. What changes has your state made or planning to make to the ESI program during the next fiscal year? Please comment on why the changes are planned. [7500]

Revision

Editorial revision

15. What do you estimate is the impact of your ESI program (including premium assistance) on enrollment and retention of children? How was this measured? [7500]

15. What do you estimate is the impact of your state’s ESI program (including premium assistance) on enrollment and retention of children? How was this measured? [7500]

Revision

Editorial revision

16. Identify the total state expenditures for providing coverage under your ESI program during the reporting period. [7500]

N/A

Deletion

Question removed

Yes, reduced burden

17. Provide the average amount each entity pays towards coverage of the dependent child/parent under your ESI program:

16. Provide the average amount each entity pays towards coverage of the dependent child/parent under your state’s ESI program:

Revision

Editorial revision

18. Indicate the range in the average monthly dollar amount of premium assistance provided by the state on behalf of a child or parent.

17. Indicate the range in the average monthly dollar amount of premium assistance provided by the state on behalf of a child or parent.

Revision

Editorial revision

19. If you offer a premium assistance program, what, if any, is the minimum employer contribution? [500]

18. If your state offers a premium assistance program, what, if any, is the minimum employer contribution? [500]

Revision

Editorial revision

20. Do you have a cost effectiveness test that you apply in determining whether an applicant can receive coverage (e.g., the state’s share of a premium assistance payment must be less than or equal to the cost of covering the applicant under SCHIP or Medicaid)?

Yes No

N/A

Deletion

Question removed, no longer needed

Yes, reduced burden

23. Do you have a waiting list for your program? Yes No

21. Does your state have a waiting list for its program?

Yes

Revision

Editorial revision

24. Can you cap enrollment for your program? Yes No

22. Does your state cap enrollment for its program?

Yes

Revision

Editorial revision

Section III F

1. Do managed health care plans with which your program contracts have written plans?

1. Do managed health care plans with which your state’s program contracts have written plans?

Revision

Editorial revision

6. Do you contract with managed care health plans and/or a third party contractor to provide this oversight?

Yes

Please Explain: [500]

6. Does your state contract with managed care health plans and/or a third party contractor to provide this oversight?

Yes

Please Explain: [500]

Revision

Editorial revision

N/A

Enter any Narrative text related to Section IIIF below. [7500]

Addition

Addition of narrative question to capture any additional information the state wants to share

Section III G

Is the State reporting this data in the 2011 CARTS?

Yes If yes, then please complete G1 and G2.

No If the State is not reporting data, please explain why.

Explain: [7500]

N/A

Deletion

Question no longer needed

Yes, burden reduced

N/A

Please ONLY report data in this section for children in Separate CHIP programs. Reporting is required for all states with Separate CHIP programs. If your state has a Separate CHIP program but data are not reported in this section, please explain why. Explain: [7500]

Addition

Instructions added to section for clarity

1. Information on Dental Care for CHIP Children (Include all delivery types, i.e. MCO, PCCM, FFS).

Data for this table are based from the definitions provided on the Early and Periodic Screening,

Diagnostic, and Treatment (EPSDT) Report (Form CMS-416)

1. Information on dental care for children in Separate CHIP programs. Include all delivery system types, e.g. MCO, PCCM, FFS.

Data for this table are based on the definitions provided on the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Report (Form CMS-416)

Revision

Question revised to clarify the information being requested

1.a. Annual Dental Participation Table for CHIP Enrolled Children (Include children receiving full CHIP benefits and supplemental benefits) .

Please check which populations of CHIP children are included in the following table:

Medicaid Expansion

Separate CHIP

Both Medicaid Expansion and Separate CHIP

1. a. Annual dental participation table for children enrolled in Separate CHIP programs (please include ONLY children receiving full CHIP benefits and supplemental benefits).

Revision

Instructions revised to clarify the information being requested

Table 1a on page 133

Table 1a on pages 68-69

Revision

Table reformatted to be more 508 compliant, also new row added to table in 2020 template to collect the Total Individuals Enrolled for at Least 90 Continuous Days. Table footnotes revised for clarity.

Yes, burden added

N/A

Enter any Narrative text related to Section IIIG below. [7500]

Addition

Optional Space added for states to expand on any of the responses provided in Section III G

Section III H (2020 Version)

N/A

Section IIIH: CHIPRA CAHPS Requirement:

CHIPRA section 402(a)(2), which amends reporting requirements in section 2108 of the Social Security Act, requires Title XXI Programs (i.e., CHIP Medicaid Expansion programs, Separate Child Health Programs, or a combination of the two) to report CAHPS results to CMS starting December 2013. While Title XXI Programs may select any CAHPS survey to fulfill this requirement, CMS encourages these programs to align with the CAHPS measure in the Children’s Core Set of Health Care Quality Measures for Medicaid and CHIP (Child Core Set). Starting in 2013, Title XXI Programs should submit summary level information from the CAHPS survey to CMS via the CARTS attachment facility. We also encourage states to submit raw data to the Agency for Healthcare Research and Quality’s CAHPS Database. More information is available in the Technical Assistance fact sheet, Collecting and Reporting the CAHPS Survey as Required Under the CHIPRA: https://www.medicaid.gov/medicaid/quality-of-care/downloads/cahpsfactsheet.pdf

Addition

Section III H was added to meet CHIPRA Quality Measure Requirements

Yes, burden added

Section III I (2020 version)

N/A

Section III I: Health Services Initiatives Under the CHIP State Plan

Addition

Section III I was added in order to collect information related to states’ CHIP HSIs. This information is not collected through any other source.

Yes, burden increased

Section IV

	2011		2012		2013
	# of eligibles	$ PMPM	# of eligibles	$ PMPM	# of eligibles	$ PMPM
Managed Care		$		$		$
Fee for Service		$		$		$

Year	Number of Eligibles	PMPM ($)
2019		$
2020		$
2021		$

Revision

Instead of everything in one table. There are two tables, one for managed care and the other for Fee for service.

Section V

(Section 6 in 2011)

For the reporting period, please provide an overview of your state’s political and fiscal environment as it relates to health care for low income, uninsured children and families, and how this environment impacted CHIP. [7500]

Tell us about your state’s political and fiscal environment. How has the environment impacted your ability to provide healthcare to low-income, uninsured children?

Revision

Revised language for clarity

During the reporting period, what has been the greatest challenge your program has experienced? [7500]

What’s the greatest challenge your program has experienced in the past FFY (federal fiscal year)?

Revision

Revised language for clarity

During the reporting period, what accomplishments have been achieved in your program? [7500]

What are some of the greatest accomplishments your program has experienced in the past FFY?

Revision

Revised language for clarity

What changes have you made or are planning to make in your CHIP program during the next fiscal year? Please comment on why the changes are planned. [7500]

Anything else you’d like to add about your state’s challenges and accomplishments that wasn’t already covered? [Max 7500 characters]

Revision

Plain language revision

Section V in 2011 Removed

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