Track Changes: CHIP Annual Report Template System (CARTS)

FRAMEWORK FOR THE ANNUAL REPORT OF THE CHILDREN’S HEALTH INSURANCE PLANS UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

Preamble

Section 2108(a) and Section 2108(e) of the Social Security Act (the Act) provide that each state and territory* must assess the operation of its state child health plan in each federal fiscal year and report to the Secretary, by January 1 following the end of the federal fiscal year, on the results of the assessment. In addition, this section of the Act provides that the state must assess the progress made in reducing the number of uncovered, low-income children. The state is out of compliance with CHIP statute and regulations if the report is not submitted by January 1. The state is also out of compliance if any section of this report relevant to the state’s program is incomplete.

The framework is designed to:

• Recognize the diversity of state approaches to CHIP and allow states flexibility to highlight key accomplishments and progress of their CHIP programs, AND

• Provide consistency across states in the structure, content, and format of the report, AND

• Build on data already collected by CMS quarterly enrollment and expenditure reports, AND

• Enhance accessibility of information to stakeholders on the achievements under Title XXI

The CHIP Annual Report Template System (CARTS) is organized as follows:

• Section I: Snapshot of CHIP Programs and Changes

• Section II: Program’s Performance Measurement and Progress

• Section III: Assessment of State Plan and Program Operation

• Section IV: Program Financing for State Plan

• Section V:

• Program Challenges and Accomplishments

* - When “state” is referenced throughout this template it is defined as either a state or a territory.

*.Disclosure According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

REPORT UNTIL ALL SECTIONS ARE COMPLETE.THE DO NOT CERTIFY

State/Territory:  

Name of State/Territory

The following Annual Report is submitted in compliance with Title XXI of the Social Security Act (Section 2108(a) and Section 2108(e)).

Signature:  

CHIP Program Name(s):  

CHIP Program Type:

CHIP Medicaid Expansion Only

Separate Child Health Program Only

Combination of the above

Reporting Period: )2020 and ends 9/30/9 starts 10/1/2012020(Note: Federal Fiscal Year

Contact Person/Title:  

Address:  

 

City:   Zip:   State:

Phone:   Fax:

Email:  

Submission Date:  

(Due to CMS by January 1st of each year)

Section I. Snapshot of CHIP Program and Changes

1. To provide a summary at-a-glance of your state’s CHIP program, please provide the following information. Comments on the responses can be added to 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). Responses with characters greater than the limit indicated in the brackets cannot be entered.

Medicaid Expansion ProgramCHIP

Upper % of FPL (federal poverty level) fields are defined as Up to and Including

Does your program require premiums or an enrollment fee? state’s

NO

YES

N/A

Enrollment fee amount:

Premium fee amount:

If premiums are tiered by FPL, please breakout by FPL.

			Premium Amount From ($)		Premium Amount To ($)				From % of FPL				Up to % of FPL

Yearly Maximum Premium Amount per Family: $

If premiums are tiered by FPL, please breakout by FPL.

Premium Amount From ($)	Premium Amount To ($)	From % of FPL	Up to % of FPL

If yes, briefly explain fee structure: [500]

Which delivery system(s) does your program use? state’s

Managed Care

Primary Care Case Management

Fee for Service

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

Separate Child Health Program

Upper % of FPL (federal poverty level) fields are defined as Up to and Including

Does your program require premiums or an enrollment fee?state’s

NO

YES

N/A

Enrollment fee amount:

Premium fee amount:

If premiums are tiered by FPL, please breakout by FPL.

Premium Amount From ($)	Premium Amount To ($)	From % of FPL	Up to % of FPL

Yearly Maximum Premium Amount per Family: $

If premiums are tiered by FPL, please breakout by FPL.

Premium Amount From ($)	Premium Amount To ($)	From % of FPL	Up to % of FPL

If yes, briefly explain fee structure: [500]

Which delivery system(s) does your program use? state’s

Managed Care

Primary Care Case Management

Fee for Service

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

2. Has 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.r state

Medicaid expansion CHIP Program

Separate Child Health Program

Yes

No Change

N/A

Yes

No Change

N/A

Applicant and enrollee protections (e.g., changed from the Medicaid Fair Hearing Process to State Law)

Application

Benefits

Cost sharing (including amounts, populations, & collection process)

Crowd out policies

Delivery system

Eligibility determination process

Implementing an enrollment freeze and/or cap

Eligibility levels / target population

Eligibility redetermination process

Enrollment process for health plan selection

Outreach (e.g., decrease funds, target outreach)

Premium assistance

Prenatal care eligibility expansion (Sections 457.10, 457.350(b)(2), 457.622(c)(5), and 457.626(a)(3) as described in the October 2, 2002 Final Rule)

Expansion to “Lawfully Residing” children

Expansion to “Lawfully Residing” pregnant women

Pregnant Women state plan expansion

Methods and procedures for prevention, investigation, and referral of cases of fraud and abuse

Other – please specify

3. For each topic “yes” above, please explain the change and why the change was made, below: marked

Medicaid Expansion CHIP Program

Topic	List change and why the change was made
Applicant and enrollee protections Hearing Process to State Law) (e.g., changed from the Medicaid Fair
Application
Benefits
Cost sharing (including amounts, populations, & collection process)
Crowd out policies
Delivery system
Eligibility determination process
Implementing an enrollment freeze and/or cap
Eligibility levels / target population
Eligibility redetermination process
Enrollment process for health plan selection
Outreach (e.g., decrease funds, target outreach)
Premium assistance
Prenatal care eligibility expansion (Sections 2002 Final Rule)457.626(a)(3) as described in the October 2, 457.10, 457.350(b)(2), 457.622(c)(5), and
Expansion to “Lawfully Residing” children
Expansion to “Lawfully Residing” pregnant women
Pregnant Women state plan expansion
Methods and procedures for prevention, investigation, and referral of cases of fraud and abuse
Other – please specify

Separate Child Health Program

Topic					List change and why the change was made
Applicant and enrollee protections Hearing Process to State Law) (e.g., changed from the Medicaid Fair
Application
Benefits
			Cost sharing (including amounts, populations, & collection process)
Crowd out policies
Delivery system
Eligibility determination process
Implementing an enrollment freeze and/or cap
Eligibility levels / target population
Eligibility redetermination process
Enrollment process for health plan selection
Outreach (e.g. decrease funds, target outreach)
Premium assistance
Prenatal care eligibility expansion (Sections 2002 Final Rule)457.626(a)(3) as described in the October 2, 457.10, 457.350(b)(2), 457.622(c)(5), and
Expansion to “Lawfully Residing” children
Expansion to “Lawfully Residing” pregnant women
Pregnant Women state plan expansion
			Methods and procedures for prevention, investigation, and referral of cases of fraud and abuse
Other – please specify

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

Section II

Program’s Performance Measurement and Progress

Section IIA: Enrollment And Uninsured Data

t may take some time to see updated data.)Ifourth quarter SEDS report) and refresh this page. (Note: the SEDS report (See line 7: Unduplicated Number Ever Enrolled in the SEDS data for the two most recent federal fiscal years. If the information is inaccurate, adjust the data in state’sthe
This table is pre-filled with
Table 1: Children enrolled in CHIP

Program	FFY 201 9	FFY 2020	Percent change FFY 2012020-9
M-CHIP (Medicaid Expansion Program)
S-CHIP (Separate Child Health Program)

1. If
   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.) the

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 (*).

Time period

Uninsured children

Uninsured children as a percent of total children

Number

Standard error

Percent

Standard error

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 (*).

Time period

Uninsured children

Uninsured children as a percent of total children

Number

Margin of error

Percent

Margin of error

Percent change 2019 vs. 2018

%

N/A

%

N/A

Enter any Narrative text [7500]

Section II

Section

1. Status of Data Reported:

What are

• some possible reasons for increases or decreases in

2. Measurement Specification:

If “Other” measurement specification is selected, the explanation field must be completed.

HEDIS® Version:

“Other” measurement specification explanation:

If “Other”, measurement specification is selected, please complete the explanation of the “Other” measurement specification. The explanation field must be completed when “Other” measurement specification has been selected

the number of

• Data Source (e.g., use of different data sources among health plans or delivery systems),

Numerator (e.g., coding issues),

uninsured children in

The form fields have been set up to facilitate entering numerators and denominators for each measure.

2. your state?
   
   

3. Explanation of Progress:

Were there any

limitations on the

American Community Survey data that

[7500]

Section

[7500]

2. Significant changes are denoted with an asterisk (*).

[7500]

3. could affect the reliability or precision of this data?
   
   

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

Yes

• No

If yes, please report

the 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.

Topic	Description
Data source(s)
Reporting period (2 or more points in time)
Methodology
Population (Please include ages and income levels)
Sample sizes
Number and/or rate for two or more points in time
Statistical significance of results

1. Please explain why your state chose to adopt a different methodology to measure changes in the number and/or rate of uninsured children.

[7500]

1. What is your state’s assessment of the reliability of the estimate? Please provide standard errors, confidence intervals, and/or p-values if available.

[7500]

3. What are the limitations of the data or estimation methodology?

[7500]

4. How does your state use this alternate data source in CHIP program planning?

[7500]

5. Anything else to share about data on enrollment and uninsured children? the [7500]

[7500]

[7500]

Section IIB: State Strategic Objectives And Performance Goals

This subsection gathers information on your state’s general strategic objectives, performance goals, performance measures and progress towards meeting goals, as specified in the CHIP state plan. (If goals reported in the annual report now differ from Section 9 of the CHIP state plan, please indicate how they differ in “Other Comments on Measure.” Also, the state plan should be amended to reconcile these differences). The format of this section provides your state with an opportunity to track progress over time. This section contains templates for reporting performance measurement data for each of five categories of strategic objectives, related to:

• Reducing the number of uninsured children

• CHIP enrollment

• Medicaid enrollment

• Increasing access to care

• Use of preventative care (immunizations, well child care)

Please report performance measurement data for the three most recent years for which data are available (to the extent that data are available). In the first two columns, data from the previous two years’ annual reports (FFY 2018 and FFY 2019) will be populated with data from previously reported data in CARTS. If data are reported in the two previous years’ reports that need to be d/changedupdate, please enter those data. If data are not reported for either of those two years, but data are now available for them, please enter the data. In the third column, please report the most recent data available at the time of submission for the current annual report (FFY 2020).

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.

NOTES: Please do not reference attachments in this section. If details about a particular measure are located in an attachment, please summarize the relevant information from the attachment in the space provided for each measure.

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.

Additional instructions for completing each row of the table are provided below.

4. Goal:

For each objective, space has been provided to report up to three goals. Use this section to provide a brief description of each goal reported within a given strategic objective. All new goals should include a direction and a target. For clarification only, an example goal would be: “Increase (direction) by 5 percent (target) the number of CHIP beneficiaries who turned 13 years old during the measurement year who had a second dose of MMR, three hepatitis B vaccinations and one varicella vaccination by their 13th birthday.”

5. Type of Goal:

For each goal reported within a given strategic objective, please indicate the type of goal, as follows:

• New/revised: Check this box a goal has been revised or added. Please explain how and why the goal was revised.

• Continuing: Check this box if the goal that is being reported is the same goal reported in previous annual reports.

• Discontinued: Check this box if thehas been goal met and/or discontinued. Please explain why the goal was discontinued.

6. Status of Data Reported:

Please indicate the status of the data reported for each goal, as follows:

• Provisional: Check this box if the performance measure data for a goal is currently being modified, verified, or may change in any other way before they are finalized for FFY 2020.

Explanation of Provisional Data – When the value of the Status of Data Reported field is selected as “Provisional”, the state must specify why the data are provisional and when the state expects the data will be final.

• Final: Check this box if the data are considered final for FFY 2020.

• Same data as reported in a previous year’s annual report: Check this box if the data reported are the same data that your state reported for the goal in another annual report. Indicate in which year’s annual report your state previously reported the data.

7. Measurement Specification:

This section is included for only two of the objectives— objectives related to increasing access to care, and objectives related to use of preventative care—because these are the two objectives for which states may report using the HEDIS® measurement specification. In this section, for each goal, please indicate the measurement specification used to calculate the performance measure data (i.e., were the measures calculated using the HEDIS® specifications or some other method unrelated to HEDIS®).

Please indicate whether the measure is based on HEDIS® technical specifications or another source. If HEDIS® is selected, the HEDIS® Version field must be completed. If “Other” measurement specification is selected, the explanation field must be completed.

HEDIS® Version:

Please specify HEDIS® Version (example 2016). This field must be completed only when a user selects the HEDIS® measurement specification.

“Other” measurement specification explanation:

If “Other”, measurement specification is selected, please complete the explanation of the “Other” measurement specification. The explanation field must be completed when “Other” measurement specification has been selected

.

8. Data Source:

For each performance measure, please indicate the source of data. The categories provided in this section vary by objective. For the objectives related to reducing the number of uninsured children and CHIP or Medicaid enrollment, please indicate source of the data, such as eligibility/enrollment data, survey data (specify the survey used), or other source (specify the other source). Please also indicate the source of data used for the objectives related to access to care and use of preventative care, such as administrative data (claims) (specify the kind of administrative data used), hybrid data (claims and medical records) (specify how the two were used to create the data source), survey data (specify the survey used), or other source (specify the other source). In all cases, if another data source was used, please explain the source.

9. Definition of Population Included in Measure:

Numerator: Please indicate the definition of the population included in the numerator for each measure (such as the number of visits required for inclusion, e.g., one or more visits in the past year).

Denominator: Please indicate the definition of the population included in the denominator for each measure.

For measures related to increasing access to care and use of preventative care, please

• Check one box to indicate whether the data are for the CHIP population only, or include both CHIP and Medicaid (Title XIX) children combined.

• If the denominator reported is not fully representative of the population defined above (the CHIP population only, or the CHIP and Medicaid (Title XIX) populations combined), please further define the denominator. For example, denominator includes only children enrolled in managed care in certain counties, technological limitations preventing reporting on the full population defined, etc.). Please report information on exclusions in the definition of the denominator (including the proportion of children excluded), The provision of this information is important and will provide CMS with a context so that comparability of denominators across the states and over time can occur.

10. Deviations from Measure Specification

For the measures related to increasing access to care and use of preventative care.

If the data provided for a measure deviates from the measure specification, please select the type(s) of measure specification deviation. The types of deviation parallel the measure specification categories for each measure. Each type of deviation is accompanied by a comment field that states must use to explain in greater detail or further specify the deviation when a deviation(s) from a measure is selected.

The five types (and examples) of deviations are:

• Year of Data (e.g., partial year),

• Data Source (e.g., use of different data sources among health plans or delivery systems),

Numerator (e.g., coding issues),

Denominator (e.g., exclusion of MCOs, different age groups, definition of continuous

• enrollment),

• Other.

When one or more of the types are selected, states are required to provide an explanation.

Please report the year of data for each performance measure. The year (or months) should correspond to the period in which enrollment or utilization took place. Do not report the year in which data were collected for the measure, or the version of HEDIS® used to calculate the measure, both of which may be different from the period corresponding to enrollment or utilization of services.

11. Date Range: available for 2020 CARTS reporting period.

Please define the date range for the reporting period based on the “From” time period as the month and year which corresponds to the beginning period in which utilization took place and please report the “To” time period as the month and year which corresponds to the end period in which utilization took place. Do not report the year in which data were collected for the measure, or the version of HEDIS® used to calculate the measure, both of which may be different from the period corresponding to utilization of services.

12. Performance Measurement Data (HEDIS® or Other):

In this section, please report the numerators and denominators, rates for each measure (or component). The template provides two sections for entering the performance measurement data, depending on whether your state is reporting using HEDIS® or other methodologies. The form fields have been set up to facilitate entering numerators and denominators for each measure. If the form fields do not give enough space to fully report on the measure, please use the “additional notes” section.

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.

13. Explanation of Progress:

The intent of this section is to allow your state to highlight progress and describe any quality-improvement activities that may have contributed to your state’s progress. Any quality-improvement activity described should involve the CHIP program, benefit CHIP enrollees, and relate to the performance measure and your state’s progress. An example of a quality-improvement activity is a state-wide initiative to inform individual families directly of their children’s immunization status with the goal of increasing immunization rates. CHIP would either be the primary lead or substantially involved in the project. If improvement has not occurred over time, this section can be used to discuss potential reasons for why progress was not seen and to describe future quality-improvement plans. In this section, your state is also asked to set annual performance objectives for FFY 2021, 2022 and 2023. Based on recent performance on the measure (from FFY 2018 through 2020), use a combination of expert opinion and “best guesses” to set objectives for the next three years. Please explain the rationale for setting these objectives. For example, if the rate has been increasing by 3 or 4 percentage points per year, the state might project future increases at a similar rate. On the other hand, if the rate has been stable over time, the state might set a target that projects a small increase over time. If the rate has been fluctuating over time, the state might look more closely at the data to ensure that the fluctuations are not an artifact of the data or the methods used to construct a rate. The state might set an initial target that is an average of the recent rates, with slight increases in subsequent years. In future annual reports, your state will be asked to comment on how the actual performance compares to the objective set for the year, as well as any quality-improvement activities that have helped or could help your state meet future objectives.

14. Other Comments on Measure:

Please use this section to provide any other comments on the measure, such as data limitations, plans to report on a measure in the future, or differences between performance measures reported here and those discussed in Section 9 of the CHIP state plan.

Objectives Related to Reducing the Number of Uninsured Children (Do not report data that was reported in Section

Objectives Related to Reducing the Number of Uninsured Children (Do not report data that was reported in Section IIA, Questions 2 and 3)

FFY 2018	FFY 2019	FFY 2020
Goal #1 (Describe)	Goal #1 (Describe)	Goal #1 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Data Source: Eligibility/Enrollment data Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did Annual Report?7201the compare with the Annual Performance Objective documented in 8performance in 201	Explanation of Progress: How did Annual Report?8201the compare with the Annual Performance Objective documented in 9performance in 201	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improve state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improve state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s
Explanation of Progress: Please indicate how CMS might be of assistance in improving the completeness or accuracy of your state’s reporting of the data. Annual Performance Objective for FFY 201 :9 Annual Performance Objective for FFY 20 :20 Annual Performance Objective for FFY 202: 1Explain how these objectives were set:	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :20FFY 20 Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202: 3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Reducing the Number of Uninsured Children (Do not report data that was reported in Section IIA, Questions 2 and 3) (Continued)

FFY 2018	FFY 2019	FFY 2020
Goal #2 (Describe)	Goal #2 (Describe)	Goal #2 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Data Source: Eligibility/Enrollment data Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:
Date Range: From: (mm/yyyy)To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in 201 Annual Report?7201the compare with the Annual Performance Objective documented in 8	Explanation of Progress: How did performance in 201 Annual Report?8201the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improve state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improvestate’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s
Please indicate how CMS might be of assistance in improving the completeness or accuracy of your state’s reporting of the data. Annual Performance Objective for FFY 201 :9 Annual Performance Objective for FFY 20 :20 Annual Performance Objective for FFY 202 :1Explain how these objectives were set:	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :20FFY 20 Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202 :3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Reducing the Number of Uninsured Children (Do not report data that was reported in Section IIA, Questions 2 and 3) (Continued)

FFY 2018	FFY 2019	FFY 2020
Goal #3(Describe)	Goal #3(Describe)	Goal #3(Describe)
Type of Goal: Explain: New/revised. Continuing. Explain: Discontinued.	Type of Goal: Explain: New/revised. Continuing. Explain: Discontinued.	Type of Goal: Explain: New/revised. Continuing. Explain: Discontinued.
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Data Source: Eligibility/Enrollment data Specify: Survey data. Specify: Other.	Data Source: Eligibility/Enrollment data Specify: Survey data. Specify: Other.	Data Source: Eligibility/Enrollment data Specify: Survey data. Specify: Other.
Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in 201 Annual Report?7201the compare with the Annual Performance Objective documented in 8	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9 201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improvestate’s
Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data. state’s Annual Performance Objective for FFY 201 :9 Annual Performance Objective for : 2020FFY Annual Performance Objective for FFY 202: 1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data. state’s Annual Performance Objective for :2002FFY Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202 :3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to CHIP Enrollment

FFY 2018	FFY 2019	FFY 2020
Goal #1 (Describe)	Goal #1 (Describe)	Goal #1 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report?7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s
Explanation of Progress: Please indicate how CMS might be of assistance in improving the completeness or accuracy of your state’s reporting of the data. Annual Performance Objective for FFY 201 :9 Annual Performance Objective for FFY 20 :20 Annual Performance Objective for FFY 202:1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data. state’s Annual Performance Objective for : 20FFY 20 Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202: 3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to CHIP Enrollment (Continued)

FFY 2018	FFY 2019	FFY 2020
Goal #2 (Describe)	Goal #2 (Describe)	Goal #2 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report?7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?1920the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improvestate’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improvestate’s
Explanation of Progress: Please indicate how CMS might be of assistance in improving the completeness or accuracy of your state’s reporting of the data. Annual Performance Objective for FFY 201 :9 Annual Performance Objective for FFY 20 :20 Annual Performance Objective for FFY 202:1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :20FFY 20 Annual Performance Objective for FFY 202: 1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data. state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202 :3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to CHIP Enrollment (Continued)

FFY 2018	FFY 2019	FFY 2020
Goal #3 (Describe)	Goal #3 (Describe)	Goal #3 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report?7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?1920the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improvestate’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s
Please indicate how CMS might be of assistance in improving the completeness or accuracy of your state’s reporting of the data. Annual Performance Objective for FFY 201 :9 Annual Performance Objective for FFY 20 :20 Annual Performance Objective for FFY 202:1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :20FFY 20 Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202 :3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Medicaid Enrollment

FFY 2018	FFY 2019	FFY 2020
Goal #1 (Describe)	Goal #1 (Describe)	Goal #1 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report?7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improvestate’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal? the ability to report on this measure, improve results for this measure, or make progress toward state’s
Explanation of Progress: Please indicate how CMS might be of assistance in improving the completeness or accuracy of your state’s reporting of the data. Annual Performance Objective for FFY 201 :9 Annual Performance Objective for FFY 2020 : Annual Performance Objective for FFY 202:1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :FFY 2020 Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202 :3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Medicaid Enrollment (Continued)

FFY 2018	FFY 2019	FFY 2020
Goal #2 (Describe)	Goal #2 (Describe)	Goal #2 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report?7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improvestate’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s
Explanation of Progress: Please indicate how CMS might be of assistance in improving the completeness or accuracy of your state’s reporting of the data. Annual Performance Objective for FFY 201 :9 Annual Performance Objective for FFY 2020 : Annual Performance Objective for FFY 202:1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :FFY 2020 Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202 :3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Medicaid Enrollment (Continued)

FFY 2018	FFY 2019	FFY 2020
Goal #3 (Describe)	Goal #3 (Describe)	Goal #3 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:	Data Source: Eligibility/Enrollment data. Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:	Definition of Population Included in the Measure: Definition of denominator: Definition of numerator:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:	Performance Measurement Data: Described what is being measured: Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report?7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improve state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improve state’s
Please indicate how CMS might be of assistance in improving the completeness or accuracy of your state’s reporting of the data. Annual Performance Objective for FFY 201 :9 Annual Performance Objective for FFY 2020 : Annual Performance Objective for FFY 202:1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :FFY 2020 Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202: 2 Annual Performance Objective for FFY 202: 3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Increasing Access to Care (Usual Source of Care, Unmet Need)

FFY 2018	FFY 2019	FFY 2020
Goal #1 (Describe)	Goal #1 (Describe)	Goal #1 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:	Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:	Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:
Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:
Deviations from Measure Specifications: Explain. Year of Data, Explain. Data Source, Explain. Numerator, Explain.Denominator, Explain. Other,	Deviations from Measure Specifications: Explain. Year of Data, Explain. Data Source, Explain. Numerator, Explain.Denominator, Explain. Other,	Deviations from Measure Specifications: Explain. Year of Data, Explain. Data Source, Explain. Numerator, Explain.Denominator, Explain. Other,
Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report?7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improve state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improvestate’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improve state’s
Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 201 :9 Annual Performance Objective for :20FFY 20 Annual Performance Objective for FFY 202 :1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :20FFY 20 Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202 :3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Increasing Access to Care (Usual Source of Care, Unmet Need) (Continued)

FY 2018	FFY 2019	FFY 2020
Goal #2(Describe)	Goal #2(Describe)	Goal #2(Describe)
Type of Goal: Explain: New/revised. Continuing. Explain: Discontinued.	Type of Goal: Explain: New/revised. Continuing. Explain: Discontinued.	Type of Goal: Explain: New/revised. Continuing. Explain: Discontinued.
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Measurement Specification: Specify version of HEDIS used:HEDIS. Explain:Other.	Measurement Specification: Specify version of HEDIS used:HEDIS. Explain:Other.	Measurement Specification: Specify version of HEDIS used:HEDIS. Explain:Other.
Data Source: Administrative (claims data). Hybrid (claims and medical record data). Specify: Survey data. Specify: Other.	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Specify: Survey data. Specify: Other.	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Specify: Survey data. Specify: Other.
Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:
Deviations from Measure Specifications: Explain. Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,	Deviations from Measure Specifications: .Explain Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,	Deviations from Measure Specifications: Year of Data, Explain. Data Source, Explain. Numerator, Explain. Denominator, Explain. Other, Explain.
Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report?7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?theability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s
Explanation of Progress: Please indicate how CMS might be of assistance in improving the completeness or accuracy of your state’s reporting of the data. Annual Performance Objective for FFY 201: 9 Annual Performance Objective for FFY 2020: Annual Performance Objective for FFY 202:1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :FFY 2020 Annual Performance Objective for FFY 202: 1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202: 1 A: 2nnual Performance Objective for FFY 202 Annual Performance Objective for FFY 202: 3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Increasing Access to Care (Usual Source of Care, Unmet Need) (Continued)

FFY 2018	FFY 2019	FFY 2020
Goal #3 (Describe)	Goal #3 (Describe)	Goal #3 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:	Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:	Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:
Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:
Deviations from Measure Specifications: .Explain Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,	Deviations from Measure Specifications: .Explain Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,	Deviations from Measure Specifications: Year of Data, Explain. Data Source, Explain. Numerator, Explain. Denominator, Explain. Other, Explain.
Other Performance Measurement Data: Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report?7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s
Please indicate how CMS might be of assistance in improving the completeness or accuracy of your state’s reporting of the data. Annual Performance Objective for FFY 201 :9 Annual Performance Objective for FFY 20 :20 Annual Performance Objective for FFY 202:1Explain how these objectives were set:	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :20FFY 20 Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202 :3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Use of Preventative Care (Immunizations, Well Child Care)

FFY 2018	FFY 2019	FFY 2020
Goal #1 (Describe)	Goal #1 (Describe)	Goal #1 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:	Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:	Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:
Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:
Deviations from Measure Specifications: .Explain Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,	Deviations from Measure Specifications: .Explain Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,	Deviations from Measure Specifications: .Explain Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,
Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report?7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the results for this measure, or make progress toward ability to report on this measure, improve state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s
Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 201 :9 Annual Performance Objective for :20FFY 20 Annual Performance Objective for FFY 202 :1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :20FFY 20 Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202: 1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202 :3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Use of Preventative Care (Immunizations, Well Child Care) (Continued)

FFY 2018	FFY 2019	FFY 2020
Goal #2(Describe)	Goal #2(Describe)	Goal #2(Describe)
Type of Goal: Explain: New/revised. Continuing. Explain: Discontinued.	Type of Goal: Explain: New/revised. Continuing. Explain: Discontinued.	Type of Goal: Explain: New/revised. Continuing. Explain: Discontinued.
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data:Reported Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Measurement Specification: Specify version of HEDIS used:HEDIS. Explain:Other.	Measurement Specification: Specify version of HEDIS used:HEDIS. Explain:Other.	Measurement Specification: Specify version of HEDIS used:HEDIS. Explain:Other.
Data Source: Administrative (claims data). Hybrid (claims and medical record data). Specify: Survey data. Specify: Other.	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Specify: Survey data. Specify: Other.	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Specify: Survey data. Specify: Other.
Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:
Deviations from Measure Specifications: .Explain Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,	Deviations from Measure Specifications: .Explain Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,	Deviations from Measure Specifications: Year of Data, Explain. Data Source, Explain. Numerator, Explain. Denominator, Explain. Other, Explain.
Additional notes on measure:	Additional notes on measure:	Additional notes on measure:
Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report?7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s
Explanation of Progress: Please indicate how CMS might be of assistance in improving the completeness or accuracy of your state’s reporting of the data. Annual Performance Objective for FFY 201 :9 Annual Performance Objective for FFY 20 :20 Annual Performance Objective for FFY 202:1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for : 2020FFY Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202 :3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Use of Preventative Care (Immunizations, Well Child Care) (Continued)

FFY 2018	FFY 2019	FFY 2020
Goal #3 (Describe)	Goal #3 (Describe)	Goal #3 (Describe)
Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:	Type of Goal: New/revised. Explain: Continuing. Discontinued. Explain:
Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:	Status of Data Reported: Provisional. Explanation of Provisional Data: Final. Same data as reported in a previous year’s annual report. Specify year of annual report in which data previously reported:
Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:	Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:	Measurement Specification: HEDIS. Specify version of HEDIS used: Other. Explain:
Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:	Data Source: Administrative (claims data). Hybrid (claims and medical record data). Survey data. Specify: Other. Specify:
Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of numerator: Definition of denominator: Denominator includes CHIP population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:
Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)	Date Range: From: (mm/yyyy) To: (mm/yyyy)
HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:	HEDIS Performance Measurement Data: (If reporting with HEDIS) Numerator: Denominator: Rate:
Deviations from Measure Specifications: .Explain Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,	Deviations from Measure Specifications: .Explain Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,	Deviations from Measure Specifications: .Explain Year of Data, .Explain Data Source, .Explain Numerator, .ExplainDenominator, .Explain Other,
Additional notes on measure:	Additional notes on measure:	Additional notes on measure:
Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:	Other Performance Measurement Data: (If reporting with another methodology) Numerator: Denominator: Rate: Additional notes on measure:
Explanation of Progress: How did performance in Annual Report? 7201the compare with the Annual Performance Objective documented in 2018	Explanation of Progress: How did performance in 201 Annual Report?2018the compare with the Annual Performance Objective documented in 9	Explanation of Progress: How did performance in Annual Report?9201the compare with the Annual Performance Objective documented in 2020
What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s	What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your goal?the ability to report on this measure, improve results for this measure, or make progress toward state’s
Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 201 :9 Annual Performance Objective for :20FFY 20 Annual Performance Objective for FFY 202 :1	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for :20FFY 20 Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2	Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.state’s Annual Performance Objective for FFY 202 :1 Annual Performance Objective for FFY 202 :2 Annual Performance Objective for FFY 202: 3
Explain how these objectives were set:	Explain how these objectives were set:	Explain how these objectives were set:
Other Comments on Measure:	Other Comments on Measure:	Other Comments on Measure:

Objectives Related to Use of Preventative Care (Immunizations, Well Child Care) (Continued)

1. What other strategies does your state use to measure and report on access to, quality, or outcomes of care received by your state’s CHIP population? What are the findings? [7500]

2. What strategies does your state’s CHIP program have for future measurement and reporting on access to, quality, or outcomes of care received by your state’s CHIP population? When will data be available? [7500]

3. Has your state conducted any focused quality studies on your state’s CHIP population, e.g., adolescents, attention deficit disorder, substance abuse, special heath care needs or other emerging health care needs? What are the findings? [7500]

4. Please attach any additional studies, analyses or other documents addressing outreach, enrollment, access, quality, utilization, costs, satisfaction, or other aspects of your state’s CHIP program’s performance. Please include any analyses or descriptions of any efforts designed to reduce the number of uncovered children in the state through a state health insurance connector program or support for innovative private health coverage initiatives. [7500]

[7500]

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

[7500]

Section III Assessment of State Plan and Program Operation

1. Section IIIA Program Outreach

Program outreach includes all efforts to increase awareness about the CHIP throughout sprogramand Medicaid [7500]

Which the state.

1. Ha
   done differently? has beenchanged outreach methods over the past federal fiscal year? If so, what s your state

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

If YES:

1. Have these efforts been successful?
   
   

2. How
   ? of these efforts measured the effectivenesshas the state

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

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. What is the data source?

5. Anything else to add about your state’s outreach efforts? [7500]

Section IIIB Substitution of Coverage (Crowd-out)

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 [7500]

coverage

such as CHIP.

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

No

Yes

, Medicaid Expansion CHIP only N/A

If YES:

1. How long does your
   program require a child to be uninsured before enrollment?state’s

2. Which population groups does the period of uninsurance apply to? (Include Federal Poverty Levels for each group.)
   
   

3. What exemptions apply to the period of uninsurance?
   
   

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

No

Yes

N/A

If YES:

1. Which database do you use?
   
   

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

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.
   
   
   

Does your

state

1. Has

5. track the number of individuals who have access to private insurance? No
   
   
   
   

Yes

If YES:

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

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

3. What percent of individuals that enrolled in CHIP had access to private health insurance when they applied?
   
   ] and multiply by 100[Divide 5a by 5b

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

Section IIIC Eligibility

This subsection should be completed by all states. Medicaid Expansion states should complete applicable responses and indicate those questions that are non-applicable with N/A.
Subpart A: Eligibility Renewal and Retention

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

No

Yes

, Medicaid Expansion CHIP only N/A

If YES:

1. What percent of children are presumptively enrolled in CHIP pending a full eligibility determination?
   
   

2. Of those children who are presumptively enrolled, what percent are determined fully eligible and enrolled in the program?
   
   

2. In an effort to retain more children in CHIP, do
   workers and outreach workers? conduct follow-up communication with families through caser state youes

No

Yes

3. Do
   reminder notices to families? send renewalr state youes

No

Yes

send to families before disenrolling a child from the program? state r youes a. How many notices do


If YES:

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

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

Table

5. Which retention strategies are the most effective?
   
   
   

6. How do measurer state youes the effectiveness? What data sources and methodology do
   
   use to track retention?r state youes

Subpart B: Eligibility Data

Table 1. Data on Denials of Title XXI Coverage in FFY 2020

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

Measure	Number	Percent
Total number of denials of title XXI coverage
Total number of procedural denials
Total number of eligibility denials
Total number of applicants denied for title XXI and enrolled in title XIX
(Check here if there are no additional categories) Total number of applicants denied for other reasons. Please indicate:

2. Please describe any limitations or restrictions on the data used in this table:

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).

   1. 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.).

   2. 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.)

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

   3. 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.

Redetermination Status of Children

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

Table 2a. Redetermination Status of Children Enrolled in Title XXI.

Please enter the data requested in the

table below in the “Number” column, and the template will automatically tabulate the percentages.

Please enter the data requested in the table below in the “Number” column, and the template will automatically tabulate the percentages.

Description	Number	Percent
Total number of children who are enrolled in title XXI and eligible to be redetermined		100%
Total number of children screened for redetermination for title XXI			100%
Total number of children retained in title XXI after the redetermination process
Total number of children disenrolled from title XXI after the redetermination process				100%
a. Total number of children disenrolled from title XXI for failure to comply with procedures
b. Total number of children disenrolled from title XXI for failure to meet eligibility criteria					100%
i Disenrolled from title XXI because income too high for title XXI) (If unable to provide the data, check here
ii Disenrolled from title XXI because income too low for title XXI) (If unable to provide the data, check here
iii Disenrolled from title XXI because application indicated access to private coverage or obtained private coverage) a title XXI Medicaid Expansion and this data is not relevant check here r state has (If unable to provide the data or if you
iv Disenrolled from title XXI for other eligibility reason(s) Please indicate: (If unable to provide the data check here )
c. Total number of children disenrolled from title XXI for other reason(s)) (Check here if there are no additional categories Please indicate:

5. If relevant, please describe any limitations or restrictions on the data entered into this table. Please describe any state policies or procedures that may have impacted the redetermination outcomes data [7500].

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 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.

   1. 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.).

   2. 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.

1. 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.

3. 
   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).

Table 2b. Redetermination Status of Children Enrolled in Title XIX.

Please enter the data requested in the table below in the “Number” column, and the template will automatically tabulate the percentages.

Description	Number	Percent
Total number of children who are enrolled in title XIX and eligible to be redetermined		100%
Total number of children screened for redetermination for title XIX			100%
Total number of children retained in title XIX after the redetermination process
Total number of children disenrolled from title XIX after the redetermination process				100%
a. Total number of children disenrolled from title XIX for failure to comply with procedures
b. Total number of children disenrolled from title XIX for failure to meet eligibility criteria					100%
i. Disenrolled from title XIX because income too high for title XIX) (If unable to provide the data, check here
ii. Disenrolled from title XIX for other eligibility reason(s)) (If unable to provide the data check here Please indicate:
c. Total number of children disenrolled from title XIX for other reason(s)) (Check here if there are no additional categories Please indicate:

5. If relevant, please describe any limitations or restrictions on the data entered into this table. Please describe any state policies or procedures that may have impacted the redetermination outcomes data .[7500]

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) , and did not age out (did not exceed the program’s maximum age requirement) of the program by or before redetermination. 2020This total number may include those children who are eligible to renew prior to their 12 month eligibility redetermination anniversary date.

1. 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 (i.e., ex parte redeterminations and administrative redeterminations, as well as those children whose families have returned redetermination forms to the state).FFY 2020

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

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

   2. The “total number of children disenrolled for failure to meet eligibility criteria” is defined as the total number of children disenrolled from title XIX for no longer meeting one or more of their state’s Medicaid eligibility criteria (i.e., income too high, etc.).

   3. The “total number of children disenrolled for other reason(s)” is defined as the total number of children disenrolled from title XIX 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 XIX (line 4).

Table 3.

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 20.20 CARTS report for the 12 and 18 month status of children newly identified in quarter 2 of FFY 201FFY 202 CARTS report. This same cohort of children will be reported on in the 20) for the 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 The next cohort of children will be identified in the second quarter of the FFY 2020 (January, February and March of 2020). report, data will be added to lines 5-10a.FFY 2020 report, no updates will be made to lines 1-4a. For the FFY 2020In the For the FFY 2018 report, States only reported on lines 1-4a of the tables. 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.FFY 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 Only enter a “0” (zero) if the data are known to be zero. If data are unknown or unavailable, leave the field blank. will also enter data on lines 8-10a related to the 18-month enrollment status of children identified on line 1. r state will enter data on lines 5-7a related to the 12-month enrollment status of children identified on line 1. Your state report youFFY 2020

Note that all data must sum correctly in order to save and move to the next pageRows 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.. 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.

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.)

Table 3a. Duration Measure, Title XIX	All Children Ages 0-16		Age Less than 12 months		Ages 1-5		Ages 6-12		Ages 13-16
	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent
Total number of children newly enrolled in title XIX in the second quarter of FFY 2020		100%		100%		100%		100%		100%
Enrollment status 6 months later
Total number of children continuously enrolled in title XIX
Total number of children with a break in title XIX coverage but re-enrolled in title XIX
3.a. Total number of children enrolled in CHIP (title XXI) during title XIX coverage break (If unable to provide the data, check here )
Total number of children disenrolled from title XIX
4.a. Total number of children enrolled in CHIP (title XXI) after being disenrolled from title XIX (If unable to provide the data, check here )
Enrollment status 12 months later
Total number of children continuously enrolled in title XIX
Total number of children with a break in title XIX coverage but re-enrolled in title XIX
Total number of children disenrolled from title XIX
7.a. Total number of children enrolled in CHIP (title XXI) after being disenrolled from title XIX (If unable to provide the data, check here )
Enrollment status 18 months later
Total number of children continuously enrolled in title XIX
Total number of children with a break in title XIX coverage but re-enrolled in title XIX
9.a. Total number of children enrolled in CHIP (title XXI) during title XIX coverage break (If unable to provide the data, check here )
10. Total number of children disenrolled from title XIX
10.a. Total number of children enrolled in CHIP (title XXI) after being disenrolled from title XIX (If unable to provide the data, check here )

Definitions:

Definitions:

1. 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.

1. The total number of children that were continuously enrolled in title XIX for 6 months is defined as the sum of:

the number of children with birthdates after July 2001, who were newly enrolled in January 2020 and who were continuously enrolled through

the end of June 20
20+ the number of children with birthdates after August 2001, who were newly enrolled in February 2020 and who were continuously enrolled through

2. the end of July 20
   20+ the number of children with birthdates after September 2001, who were newly enrolled in March 2020 and who were continuously enrolled through the end of August 2020

2. The total number who had a break in title XIX coverage during 6 months of enrollment (regardless of the number of breaks in coverage) but were re-enrolled in title XIX by the end of the 6 months, is defined as the sum of:

the number of children with birthdates after July 2001, who were newly enrolled in January 2020 and who disenrolled and re-enrolled in title XIX by

the end of June 20
20+ the number of children with birthdates after August 2001, who were newly enrolled in February 2020 and who disenrolled and re-enrolled in title XIX by

the end of July 20
20+ the number of children with birthdates after September 2001, who were newly enrolled in March 2020 and who disenrolled and re-enrolled in title XIX by

3. the end of August 20
   203.a. From the population in #3, provide the total number of children who were enrolled in title XXI during their break in coverage.

3. The total number who disenrolled from title XIX, 6 months after their enrollment month is defined as the sum of:

the number of children with birthdates after July 2001, who were newly enrolled in January 2020 and were disenrolled by

the end of June 20
20+ the number of children with birthdates after August 2001, who were newly enrolled in February 2020 and were disenrolled by

the end of July 2
020+ the number of children with birthdates after September 2001, who were newly enrolled in March 2020 and were disenrolled by

1. the end of August 20
   204.a. From the population in #4, provide the total number of children who were enrolled in title XIX in the month after their disenrollment from title XXI.

4. From the population in #4, provide the total number of children who were enrolled in title XXI in the month after their disenrollment from title XIX.

4. The total number of children who were continuously enrolled in title XIX for 12 months is defined as the sum of:

the number of children with birthdates after July 2001, who were newly enrolled in January 2020 and were continuously enrolled through

the end of December 20
20+ the number of children with birthdates after August 2001, who were newly enrolled in February 2020 and were continuously enrolled through

5. the end of January
   1202+ the number of children with birthdates after September 2001, who were newly enrolled in March 2020 and were continuously enrolled through the end of February 1202

5. The total number of children who had a break in title XIX coverage during 12 months of enrollment (regardless of the number of breaks in coverage), but were re-enrolled in title XIX by the end of the 12 months, is defined as the sum of:

the number of children with birthdates after July 2001, who were newly enrolled in January 2020 and who disenrolled and then re-enrolled in title XIX by

the end of December 20
20+ the number of children with birthdates after August 2001, who were newly enrolled in February 2020 and who disenrolled and then re-enrolled in title XIX by

the end of January
1202+ the number of children with birthdates after September 2001 who were newly enrolled in March 2020 and who disenrolled and then re-enrolled in title

2. XIX by the end of February
   12026.a. From the population in #6, provide the total number of children who were enrolled in title XIX during their break in coverage.

6. From the population in #6, provide the total number of children who were enrolled in title XXI during their break in coverage.

6. The total number of children who disenrolled from title XIX 12 months after their enrollment month is defined as the sum of:

the number of children with birthdates after July 2001, who were enrolled in January 28020 and were disenrolled by

7. the end of December 20
   20+ the number of children with birthdates after August 2001, who were enrolled in February 2020 and were disenrolled by the end of January
   7.a. From the population in #7, provide the total number of children, who were enrolled in title XXI in the month after their disenrollment from title XIX.1202 and were disenrolled by the end of February 20 + the number of children with birthdates after September 2001, who were enrolled in March 20
   1202

8. The total number of children who were continuously enrolled in title XIX for
   1202 + the number of children with birthdates after August 2001, who were newly enrolled in February 2018 and were continuously enrolled through the end of July
   1202 the number of children with birthdates after July 2001, who were newly enrolled in January 2018 and were continuously enrolled through the end of June
   is defined as the sum of:18 months+ the number of children with birthdates after September 2001, who were newly enrolled in March 2018 and were continuously enrolled through the end of August 1202

9. The total number of children who had a break in title XIX coverage during the number of children with birthdates after July 2001, who were newly enrolled in January 2018 and who
   of enrollment (regardless of the number of breaks in coverage), but were re-enrolled in title XIX by the end of the 18 months, is defined as the sum of:18 monthsdisenrolled and re-enrolled in title XIX by the end of June + the number of children with birthdates after September 2001, who were newly enrolled in
   1202 + the number of children with birthdates after August 2001, who were newly enrolled in February 2018 and who disenrolled and re-enrolled in title XIX by the end of July
   1202March 2018 and who disenrolled and re-enrolled in title XIX by the end of August
   9.a. From the population in #9, provide the total number of children who were enrolled in title XXI during their break in coverage.1202

10. The total number of children who were disenrolled from title XIX
    10.a. From the population in #10, provide the total number of children who were enrolled in title XXI (CHIP) in the month after their disenrollment from XIX.1202 and disenrolled by the end of August 20 + the number of children with birthdates after September 2001, who were newly enrolled in March 20
    1202 and disenrolled by the end of July 20 + the number of children with birthdates after August 2001, who were newly enrolled in February 20
    1202 and disenrolled by the end of June 20 the number of children with birthdates after July 2001, who were newly enrolled in January 20
    after their enrollment month is defined as the sum of:18 months

Table 3b. Duration Measure of Children Enrolled in Title XXI

Specify how your “newly enrolled” population is defined: state’s

, etc.) 9201, he/she would not be enrolled in either title XXI or title XIX in December 20 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 20

• 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 20, etc.)19, he/she would not be enrolled in title XXI in December 2020

Table 3b. Duration Measure, Title XXI	All Children Ages 0-16		Age Less than 12 months		Ages 1-5		Ages 6-12		Ages 13-16
	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent
Total number of children newly enrolled in title XXI in the second quarter of FFY 2020		100%		100%		100%		100%		100%
Enrollment status 6 months later
Total number of children continuously enrolled in title XXI
Total number of children with a break in title XXI coverage but re-enrolled in title XXI
3.a. Total number of children enrolled in Medicaid (title XIX) during title XXI coverage break (If unable to provide the data, check here )
Total number of children disenrolled from title XXI
4.a. Total number of children enrolled in Medicaid (title XIX) after being disenrolled from title XXI (If unable to provide the data, check here )
Enrollment status 12 months later
Total number of children continuously enrolled in title XXI
Total number of children with a break in title XXI coverage but re-enrolled in title XXI
6.a. Total number of children enrolled in Medicaid (title XIX) during title XXI coverage break (If unable to provide the data, check here )
Total number of children disenrolled from title XXI
7.a. Total number of children enrolled in Medicaid (title XIX) after being disenrolled from title XXI (If unable to provide the data, check here )
Enrollment status 18 months later
Total number of children continuously enrolled in title XXI
Total number of children with a break in title XXI coverage but re-enrolled in title XXI
9.a. Total number of children enrolled in Medicaid (title XIX) during title XXI coverage break (If unable to provide the data, check here )
Total number of children disenrolled from title XXI
10.aTotal number of children enrolled in Medicaid (title XIX) after being disenrolled from title XXI (If unable to provide the data, check here )

Definitions:

3. The “total number of children newly enrolled in title XXI in the second quarter of FFY 20 population of “newly enrolled” in the Instructions section. state’s” is defined as those children either new to public coverage or new to title XXI, in the month before enrollment. Please define your20

4. The total number of children that were continuously enrolled in title XXI for 20 and who were continuously enrolled through the end of August 2020 + the number of children with birthdates after September 2001, who were newly enrolled in March 20
   20 and who were continuously enrolled through the end of July 2020 + the number of children with birthdates after August 2001, who were newly enrolled in February 20
   20 and who were continuously enrolled through the end of June 2020 the number of children with birthdates after July 2001, who were newly enrolled in January 20
   is defined as the sum of:6 months

5. The total number who had a break in title XXI coverage during
   3.a. From the population in #3, provide the total number of children who were enrolled in title XIX during their break in coverage.20 and who disenrolled and re-enrolled in title XXI by the end of August 2020 + the number of children with birthdates after September 2001, who were newly enrolled in March 20
   20and who disenrolled and re-enrolled in title XXI by the end of July 2020 + the number of children with birthdates after August 2001, who were newly enrolled in February 20
   20 and who disenrolled and re-enrolled in title XXI by the end of June 2020 the number of children with birthdates after July 2001, who were newly enrolled in January 20
   of enrollment (regardless of the number of breaks in coverage) but were re-enrolled in title XXI by the end of the 6 months, is defined as the sum of:6 months

6. The total number who disenrolled from title XXI,
   4.a.20 and were disenrolled by the end of August 2020 + the number of children with birthdates after September 2001, who were newly enrolled in March 20
   20 and were disenrolled by the end of July 2020 + the number of children with birthdates after August 2001, who were newly enrolled in February 20
   20 and were disenrolled by the end of June 2020 the number of children with birthdates after July 2001, who were newly enrolled in January 20
   after their enrollment month is defined as the sum of:6 months From the population in #4, provide the total number of children who were enrolled in title XIX in the month after their disenrollment from title XXI.

7. The total number of children who were continuously enrolled in title XXI for 1202 and were continuously enrolled through the end of February 20 + the number of children with birthdates after September 2001, who were newly enrolled in March 20
   1202 and were continuously enrolled through the end of January 20 + the number of children with birthdates after August 2001, who were newly enrolled in February 20
   20 and were continuously enrolled through the end of December 2020 the number of children with birthdates after July 2001, who were newly enrolled in January 20
   is defined as the sum of:12 months

8. The total number of children who had a break in title XXI coverage during
   6.a.1202 and who disenrolled and then re-enrolled in title XXI by the end of February 20 + the number of children with birthdates after September 2001, who were newly enrolled in March 20
   1202 and who disenrolled and then re-enrolled in title XXI by the end of January 20 + the number of children with birthdates after August 2001, who were newly enrolled in February 20
   20 and who disenrolled and then re-enrolled in title XXI by the end of December 2020 the number of children with birthdates after July 2001, who were newly enrolled in January 20
   of enrollment (regardless of the number of breaks in coverage), but were re-enrolled in title XXI by the end of the 12 months, is defined as the sum of:12 months From the population in #6, provide the total number of children who were enrolled in title XIX during their break in coverage.

9. The total number of children who disenrolled from title XXI
   7.a.1202 and were disenrolled by the end of February 20 + the number of children with birthdates after September 2001, who were enrolled in March 20
   1202 and were disenrolled by the end of January 20 + the number of children with birthdates after August 2001, who were enrolled in February 20
   20 and were disenrolled by the end of December 2020 the number of children with birthdates after July 2001, who were enrolled in January 20
   after their enrollment month is defined as the sum of:12 months From the population in #7, provide the total number of children, who were enrolled in title XIX in the month after their disenrollment from title XXI.

7. The total number of children who were continuously enrolled in title XXI for 18 months is defined as the sum of:

the number of children with birthdates after July 2001, who were newly enrolled in January 2020 and were continuously enrolled through

the end of June
1202+ the number of children with birthdates after August 2001, who were newly enrolled in February 2020 and were continuously enrolled through

10. the end of July
    1202+ the number of children with birthdates after September 2001, who were newly enrolled in March 2020 and were continuously enrolled through the end of August 1202

8. The total number of children who had a break in title XXI coverage during 18 months of enrollment (regardless of the number of breaks in coverage), but were re-enrolled in title XXI by the end of the 18 months, is defined as the sum of:

the number of children with birthdates after July 2001, who were newly enrolled in January 2020 and who disenrolled and re-enrolled in title XXI by

the end of June
1202+ the number of children with birthdates after August 2001, who were newly enrolled in February 2020 and who disenrolled and re-enrolled in title XXI by

the end of July
1202+ the number of children with birthdates after September 2001, who were newly enrolled in March 20and20 who disenrolled and re-enrolled in title XXI by

11. the end of August
    12029.a. From the population in #9, provide the total number of children who were enrolled in title XIX during their break in coverage.

9. The total number of children who were disenrolled from title XXI 18 months after their enrollment month is defined as the sum of:

the number of children with birthdates after July 2001, who were newly enrolled in January 2020 and disenrolled by

the end of June
1202+ the number of children with birthdates after August 2001, who were newly enrolled in February 2020 and disenrolled by

12. the end of July
    1202+ the number of children with birthdates after September 2001, who were newly enrolled in March 2020 and disenrolled by the end of August 10.a. From the population in #10, provide the total number of children who were enrolled in title XIX (Medicaid) in the month after their disenrollment from XXI.
    1202

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

Section

IIID: Cost Sharing

1. 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)

1. 
   
   If the state uses the shoebox method, please describe informational tools provided to enrollees to track cost sharing. [7500]

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

2. When the family reaches the 5% cap, are premiums, copayments and other cost sharing ceased? Yes
   No

3. Please describe how providers are notified that no cost sharing should be charged to enrollees exceeding the 5% cap. [7500]

4. Please provide an estimate of the number of children that exceeded the 5 percent cap in the state’s CHIP program during the federal fiscal year. [500]

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

5. 
   
   Yes
   No

If so, what are the findings? [7500]

6. Has your state undertaken any assessment of the effects of cost sharing on utilization of health services in CHIP?
   No
   Yes
   
   
   

If so, what are the findings? [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]

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

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

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)

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

Parents and Caretaker Relatives

Pregnant Women

3. Briefly describe how your program operates (e.g., is your program an employer sponsored insurance program or a premium assistance program, how dor state youes coordinate assistance between the state and/or employer, who receives the subsidy if a subsidy is provided, etc.) [7500]

4. What benefit package does the ESI program use? [7500]

5. Are there any minimum coverage requirements for the benefit package?

Yes

No

6. Does the program provide wrap-around coverage for benefits?

Yes

No

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

Yes

No

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

Yes

No

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

No

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

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 adults ever-enrolled during the reporting period

Number of children ever-enrolled during the reporting period

11. Provide the average monthly enrollment of children and parents ever enrolled in the premium assistance program during FFY 2020.

Children

Parents

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

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

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]

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

Population	State	Employer	Employee
Child
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.

	Low	High
Children
Parent

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

19. Please provide the income levels of the children or families provided premium assistance.

Income level of	From	To
Children	% of FPL [5]	% of FPL [5]
Parents	% of FPL [5]	% of FPL [5]

20. Is there a required period of uninsurance before enrolling in premium assistance?

Yes

No

If yes, what is the period of uninsurance? [500]

21. Dor state youes have a waiting list for itsprogram?

s Ye

No

22. Does r state you cap enrollment for its program?

Yes

No

23. What strategies has the state found to be effective in reducing administrative barriers to the provision of premium assistance in ESI? [7500]

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

Section IIIF: Program Integrity

COMPLETE ONLY WITH REGARD TO SEPARATE CHIP PROGRAMS, I.E., THOSE THAT ARE NOT MEDICAID EXPANSIONS)

1. Does your state have a written plan that has safeguards and establishes methods and procedures for:

1. prevention:

Yes

No

2. investigation:

Yes

No

3. referral of cases of fraud and abuse?

Yes

No

Please explain: [7500]

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

Yes

No

Please Explain: [500]

2. For the reporting period, please report the

           Number of fair hearing appeals of eligibility denials

           Number of cases found in favor of beneficiary

3. For the reporting period, please indicate the number of cases investigated, and cases referred, regarding fraud and abuse in the following areas:

Provider Credentialing

           Number of cases investigated

           Number of cases referred to appropriate law enforcement officials

Provider Billing

           Number of cases investigated

           Number of cases referred to appropriate law enforcement officials

Beneficiary Eligibility

           Number of cases investigated

           Number of cases referred to appropriate law enforcement officials

Are these cases for:

CHIP

Medicaid and CHIP Combined

4. Does your state rely on contractors to perform the above functions?

Yes, please answer question below.

No

5. If your state relies on contractors to perform the above functions, how does your state provide oversight of those contractors? Please explain: [7500]

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

Yes

No

Please Explain: [500]

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

Section IIIG: Dental Benefits:

Please ONLY report data in this section for children in Separate CHIP programs. Reporting is required

for all states with Separate CHIP programs and

Combination programs. If your state has a Separate CHIP program but data are not reported in this section , please explain why.

Explain: [7500]

1. Information on daredental 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)

1. Annual dplease include ONLY(nrolled in Separate CHIP programs ehildren cable for tarticipation pental children receiving full CHIP benefits and supplemental benefits).

FFY	Total (All age groups)	<1 year	1 – 2 years	3 – 5 years	6 – 9 years	10–14 years	15–18 years
Total Individuals Enrolled for at Least 90 Continuous Days1
Total Enrollees Receiving Any Dental Services2 [7]
Total Enrollees Receiving Preventive Dental Services3 [7]
Total Enrollees Receiving Dental Treatment Services4 [7]

2. For the age grouping that includes children 8 years of age, what is the number of such children who have received a sealant on at least one permanent molar tooth⁵? [7]
   
   
   

2. Does the state provide supplemental dental coverage?

Yes

No

If yes, how many children are enrolled? [7]

What percent of the total number of enrolled children have supplemental dental coverage? [5]

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

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 HYPERLINK "https://www.medicaid.gov/medicaid/quality-of-care/downloads/cahpsfactsheet.pdf" \h

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1 Total Individuals Enrolled for at Least 90 Continuous Days – Enter the total unduplicated number of children who have been continuously enrolled in a separate CHIP program for at least 90 continuous days in the federal fiscal year, distributed by age. For example, if a child was enrolled January 1st to March 31st, this child is considered continuously enrolled for at least 90 continuous days in the federal fiscal year. If a child was enrolled from August 1st to September 30th and from October 1st to November 30th, the child would not be considered to have been enrolled for 90 continuous days in the federal fiscal year. Children should be counted in age groupings based on their age at the end of the fiscal year. For example, if a child turned 3 on September 15th, the child should be counted in the 3-6 age grouping.

2 Total Enrollees Receiving Any Dental Services - Enter the unduplicated number of children enrolled in a separate CHIP program for at least 90 continuous days who received at least one dental service by or under the supervision of a dentist as defined by HCPCS codes D0100 - D9999 (or equivalent CDT codes D0100 - D9999 or equivalent CPT codes) based on an unduplicated paid, unpaid, or denied claim.

3 Total Enrollees Receiving Preventive Dental Services - Enter the unduplicated number of children enrolled in a separate CHIP program for at least 90 continuous days who received at least one preventive dental service by or under the supervision of a dentist as defined by HCPCS codes D1000 - D1999 (or equivalent CDT codes D1000 - D1999 or equivalent CPT codes, that is, only those CPT codes that are for preventive dental services and only if provided by or under the supervision of a dentist), based on an unduplicated paid, unpaid, or denied claim.

4 Total Enrollees Receiving Dental Treatment Services - Enter the unduplicated number of children enrolled in a separate CHIP program for at least 90 continuous days who received at least one treatment service by or under the supervision of a dentist, as defined by HCPCS codes D2000 - D9999 (or equivalent CDT codes D2000 - D9999 or equivalent CPT codes, that is, only those CPT codes that involve periodontics, maxillofacial prosthetics, implants, oral and maxillofacial surgery, orthodontics, adjunctive general services, and only if provided by or under the supervision of a dentist), based on an unduplicated paid, unpaid, or denied claim.

Report all dental services data in the age category reflecting the child’s age at the end of the federal fiscal year even if the child received services while in two age categories. For example, if a child turned 10 on September 1st, but had a cleaning in April and a cavity filled in September, both the cleaning and the filling would be counted in the 10-14 age category.

5 Receiving a Sealant on a Permanent Molar Tooth -- Enter the unduplicated number of children enrolled in a separate CHIP program for 90 continuous days and in the age category of 6-9 who received a sealant on a permanent molar tooth, as defined by HCPCS code D1351 (or equivalent CDT code D1351), based on an unduplicated paid, unpaid, or denied claim. For this line, include sealants placed by any dental professional for whom placing a sealant is within his or her scope of practice. Permanent molars are teeth numbered 2, 3, 14, 15, 18, 19, 30, 31, and additionally, for those states that cover sealants on third molars, also known as wisdom teeth, the teeth numbered 1, 16, 17, 32.

Report all sealant data in the age category reflecting the child’s age at the end of the federal fiscal year even if the child was factually a different age on the date of service. For example, if a child turned 6 on September 1st, but had a sealant applied in July, the sealant would be counted in the age 6-9 category.

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CHIP Annual Report Template – FFY 2011 Version 12.01.2011 3