CMS-10398 #7 HEALTHY KIDS Cycle Vb: Monthly Report (quantitative repo

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Overview

Instructions
Cover sheet
A. Child data
B. Child dashboard
C. Parent data
D. Parent dashboard
E. Main activities

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Sheet 1: Instructions

	Term	Definition	Applicable data tabs and column numbers
	Child	Individuals who were age-eligible to be enrolled in Medicaid or Children’s Health Insurance Program (CHIP) children’s coverage when your organization assisted them. Upper age limits vary by state and range from 18 to 21 years.
			A, all columns
		Include pregnant women if they are age-eligible for Medicaid or CHIP children’s health coverage. Only include children who are not yet born if the state provides coverage to unborn children under CHIP.
	Parent	Individuals who:
		Were above the age limit for children’s Medicaid or CHIP in your state when your organization assisted them (age limits vary by state and range from 18 to 21 years)
		AND	C, all colums
		Were a parent or caretaker relative of a child who was within your state’s age limit for Medicaid or CHIP children’s coverage when your organization assisted them.
		Include pregnant women who already have other children as parents. Do not count pregnant women who are pregnant with their first child as parents.
	Insurance affordability program	CHIP, Medicaid, Qualified Health Plans with Premium Tax Credits sold via state-based or federally facilitated marketplaces, or a Basic Health Program (MinnesotaCare in Minnesota or the Essential Plan in New York).	C, all columns
	Applied as a direct result of project activities	Individuals who meet the following criteria:
		They, or someone acting on their behalf, received substantial interactive assistance on or after January 1, 2019,
		AND
		They submitted (or someone submitted on their behalf) an application for health coverage to the state Medicaid or CHIP agency, to a state-based marketplace, or to the federally facilitated Marketplace between the first and last days of the current reporting month, after receiving substantial interactive assistance	A and C, columns 1 - 3
		Do not count individuals in these data if you have reported or will be reporting them as applicants assisted under another funding source.
	New applications	Applications submitted by individuals who:
		Applied for CHIP/Medicaid (for children) or for any insurance affordability program (for parents) as a result of your MACRA project activities	A and C, column 1
		AND
		Were not enrolled in Medicaid or CHIP (for children) or in any insurance affordability program (for parents) when they applied.
	Renewal applications	Applications submitted by individuals who:
		Applied for CHIP/Medicaid (for children) or for any insurance affordability program (for parents) as a result of your MACRA project activities
		AND	A and C, column 2
		Were already enrolled in Medicaid or CHIP (for children) or in any insurance affordability program (for parents) when they applied for coverage
		AND
		They did not benefit from an Ex Parte or automatic renewal.
	Substantial interactive assistance	Person-to-person assistance provided in person, by phone, or online, by a member of your organization or project partner, resulting from funding from the Centers for Medicare and Medicaid Services (CMS) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This does not include sending mailings or emails or calling people with pre-recorded messages.	A and C, all columns
		This definition of substantial interactive assistance is relevant to the definitions of applied as a direct result of project activities, enrolled as a direct result of project activities, and renewed as a direct result of project activities.
	Enrolled as a direct result of project activities	Individuals who meet the following criteria:
		They, or someone acting on their behalf, received substantial interactive assistance on or after January 1, 2019,
		AND
		They were not already enrolled in Medicaid or CHIP (for children) or in any insurance affordability program (for parents) when they received substantial interactive assistance
		AND
		They were newly enrolled in Medicaid or CHIP (for children) or in any insurance affordability program (for parents) between January 1, 2019 and the last day of the current reporting month, after receiving substantial interactive assistance.	A and C, column 4, column 6
		Only count full eligibility determinations: do not count individuals benefitting from ‘presumptive eligibility’ unless a full determination has subsequently been made.
		Enrollment data should be verified by state or county enrollment records. If you are unable to verify, explain in the data limitations note how you calculated new enrollments.
		Do not count individuals in these data if you have reported or will be reporting them as applicants enrolled under another funding source.
	Renewed as a direct result of project activities	Individuals who meet the following criteria:
		They, or someone acting on their behalf, received substantial interactive assistance on or after January 1, 2019,
		AND
		They were already enrolled in Medicaid or CHIP (for children) or in any insurance affordability program (for parents) when they received substantial interactive assistance
		AND
		They were renewed in Medicaid or CHIP (for children) or in any insurance affordability program (for parents) between January 1, 2019 and the last day of the current reporting month, after receiving substantial interactive assistance	A and C, column 5, column 6
		AND
		They did not benefit from an Ex Parte or automatic renewal.
		Renewals data should be verified by state or county enrollment records. If you are unable to verify, explain in the data limitations note how you calculated renewals.
		Do not count individuals in these data if you have reported or will be reporting them as renewed under another funding source.

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Sheet 2: Cover sheet

Connecting Kids to Coverage: Monthly Report
	Complete the boxes below. Select from drop-down menu where applicable.	Notes
Grantee Name
Project Director
Target for new child enrollments (from grant application)
Target for child renewals (from grant application)
Target for child enrollments and renewals combined
Target for new parent enrollments (from grant application)
Target for parent renewals (from grant application)
Target for parent enrollments and renewals combined
Grant start month (drop-down)	Jul-19
Grant end month (drop-down)	Jun-22
Current Reporting Month (drop-down)	Aug-19
Check this box if all applications, enrollments and renewals counted in this report resulted from assistance by staff 100% funded by your CKC grant. If they did not, please estimate the shares of applications, enrollments and renewals reported that are attributable to CKC funding, and explain how you arrived at this estimate, in the 'data limitations' fields on tabs A and B.
Check this box if all applications, enrollments and renewals counted in this report are reported consistently with the data definitions on the instructions tab. If they are not, please explain how they differ in the 'data limitations' field on tabs A and B.
Check this box if all enrollments and renewals counted in this report were verified.
PRA Disclosure Statement This information is being collected to assist the Centers for Medicare & Medicaid Services (CMS) with the data needed to reflect the aggregate goals and accomplishments for this cooperative agreement program. This mandatory information collection (42 U.S.C. 1396a) will be used to demonstrate the outcomes that result directly from this funding opportunity, and will also be used to help evaluate the success of outreach and enrollment strategies and identify areas that need improvement or mid-course corrections. This request does not collect personally identifiable information. Consequently, the Privacy Act of 1974 does not apply. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #7). Public burden for all of the collection of information requirements under this control number is estimated to range from 16 to 20 hours per response, including the time reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Sheet 3: A. Child data

Please review the instructions tab, including data definitions, before completing this table. Then enter data in the row for the current reporting month, which you selected on the Cover Sheet and is shaded gray below. Enter data in the columns in order, starting with column 1.

Enter the number of children for whom a Medicaid/ CHIP application was submitted during the current reporting month, as a direct result of your CKC grant activities. If you can identify which children were already covered by Medicaid or CHIP when you provided them with substantial interactive assistance, enter data in columns 1 and 2; column 3 will calculate automatically. If you cannot identify which children were already covered, enter data in column 3, and leave columns 1 and 2 blank. If you completed no applications this month, enter 0 in columns 1 and 2.

Enter the number of children for whom a Medicaid/ CHIP new enrollment or renewal was verified , between the start of the grant and the end of the current reporting month, as a direct result of your CKC grant activities. If you can identify which children were already covered by Medicaid or CHIP when you provided them with substantial interactive assistance, enter data in columns 4 and 5; column 6 will calculate automatically. If you cannot identify which children were already covered, enter data in column 6, and leave columns 4 and 5 blank. If you have verified no new enrollments or renewals to date, enter 0 in columns 4 and 5.

Month

1 Number of children for whom a new application was submitted during the month

2 Number of children for whom a renewal application was submitted during the month

3 Total: number of children applying this month

4 Number of children newly enrolled to date

5 Number of children renewed to date

6 Total: Number of children enrolled or renewed to date

Data limitations. Explain any limitations that may help us understand these data, such as reasons the data reported do not reflect the true number of applications submitted, or enrollments or renewals completed, that were funded by this grant.

Jul-19

Aug-19

Sep-19

Type here

Oct-19

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Sheet 4: B. Child dashboard

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Sheet 5: C. Parent data

Please review the instructions tab, including data definitions, before completing this table. Then enter data in the row for the current reporting month, which you selected on the Cover Sheet and is shaded gray below. Enter data in the columns in order, starting with column 1.

Enter the number of parents for whom an insurance affordability program application was submitted during the current reporting month, as a direct result of your CKC grant activities. If you can identify which parents were already covered by an insurance affordability program when you provided them with substantial interactive assistance, enter data in columns 1 and 2; column 3 will calculate automatically. If you cannot identify which parents were already covered, enter data in column 3, and leave columns 1 and 2 blank. If you completed no applications this month, enter 0 in columns 1 and 2.

Enter the number of parents for whom a new enrollment or renewal in an insurance affordability program was verified, between the start of the grant and the end of the current reporting month, as a direct result of your CKC grant activities. If you can identify which parents were already covered by an insurance affordability program when you provided them with substantial interactive assistance, enter data in columns 4 and 5; column 6 will calculate automatically. If you cannot identify which parents were already covered, enter data in column 6, and leave columns 4 and 5 blank. If you have verified no new enrollments or renewals to date, enter 0 in columns 4 and 5.

Month

1 Number of parents for whom a new application was submitted during the month

2 Number of parents for whom a renewal application was submitted during the month

3 Total: number of parents applying this month

4 Number of parents newly enrolled to date

5 Number of parents renewed to date

6 Total: Number of parents enrolled or renewed to date

Data limitations. Explain any limitations that may help us understand these data, such as reasons the data reported do not reflect the true number of applications submitted, or enrollments or renewals completed, that were funded by this grant.

Jul-19

Aug-19

Sep-19

Type here

Oct-19

Nov-19

Dec-19

Jan-20

Feb-20

Mar-20

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Sheet 6: D. Parent dashboard

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Sheet 7: E. Main activities

Tab E. Major activities, achievements, challenges, and help topics this month
Instructions: Describe 1 - 6 major activities, achievements and challenges that you experienced on this grant project during the current reporting period. Enter up to 6 topics that you would like help with. Each cell is limited to 1,000 characters.
Table E.1 Major activities, achievements and challenges			Table E.2. Help topics
Major activities, achievements and challenges	Description/details		I need help with…	Description/details