CMS-10398 #58 Monitoring Protocol - Planned Metrics

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

58 - Medicaid Section 1115 Eligibility and Coverage Demonstration Monitoring Protocol.xlsx

GenIC # 58 (New): Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan and Monitoring Reports Documents and Templates

OMB: 0938-1148

Document [xlsx]
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Overview

Protocol - Planned metrics (AD)
Protocol - Planned metrics (CE)
Report - Metrics reporting (AD)
Report - Metrics reporting (CE)
Data & Reporting Issues (AD)
Data & Reporting Issues (CE)
Version Notes

Sheet 1: Protocol - Planned metrics (AD)
Medicaid Section 1115 Eligibility and Coverage Demonstration Monitoring Protocol - Planned metrics (AD)


















State [Enter State Name]

















Demonstration Name [Enter Demonstration Name]

















Submitted on [Enter Date] (Format: MM/DD/YYYY)





































Standard information on CMS-provided metrics Baseline, annual goals, and demonstration target Alignment with CMS-provided technical specifications Initial reporting date
State will report (Y/N) Reporting topica Reporting priority # Metric name Metric description Data source Calculation lag Measurement period Reporting frequency Baseline reporting period (MM/DD/YYYY--MM/DD/YYYY) Annual goal Overall demonstration target Attest that planned reporting matches the CMS-provided specification (Y/N) Explanation of any deviations from the CMS-provided specifications. Could include different data sources or state-specific definitions, policies, codes, target populations, etc. Dates covered by first measurement period for metric (MM/DD/YYYY - MM/DD/YYYY) Report name of first report in which the metric will be submitted (Format: DY1 Q3 quarterly report) Submission date of first report in which the metric will be reported (MM/DD/YYYY) State plans to phase in reporting (Y/N) Explanation of any plans to phase in reporting over time

1.1.1 Enrollment Required AD_1 Total enrollment in the demonstration The unduplicated number of beneficiaries enrolled in the demonstration at any time during the measurement period. This indicator is a count of total program enrollment. It includes those newly enrolled during the measurement period and those whose enrollment continues from a prior period. This indicator is not a point-in-time count. It captures beneficiaries who were enrolled for at least one day during the measurement period. Administrative records 30 days Month Quarterly










1.1.1 Enrollment Required AD_2 Beneficiaries in suspension status for noncompliance The number of demonstration beneficiaries in suspension status for noncompliance with demonstration policies as of the last day of the measurement period Administrative records 30 days Month Quarterly










1.1.1 Enrollment Required AD_3 Beneficiaries in a non-eligibility period who are prevented from re-enrolling for a defined period of time The number of prior demonstration beneficiaries who are in a non-eligibility period, meaning they are prevented from re-enrolling for some defined period of time, because they were disenrolled for noncompliance with demonstration policies. The count should include those prevented from re-enrolling until their redetermination date. Administrative records 30 days Month Quarterly










1.1.1 Enrollment Required AD_4 New enrollees Number of beneficiaries in the demonstration who began a new enrollment spell during the measurement period, have not had Medicaid coverage within the prior 3 months and are not using a state-specific pathway for re-enrollment after being disenrolled for noncompliance Administrative records 30 days Month Quarterly










1.1.1 Enrollment Required for states with a defined re-enrollment or re-instatement pathway AD_5 Re-enrollments or re-instatements using defined pathways after disenrollment or suspension of benefits for noncompliance with demonstration policies Number of beneficiaries in the demonstration who began a new enrollment spell (or had benefits re-instated) in the current measurement period by using a state-defined pathway for re-enrollment (or re-instatement of benefits), i.e., meeting certain requirements, after being disenrolled (or having benefits suspended) for noncompliance with premium requirements, community engagement requirements, or other demonstration-specific requirements. Administrative records 30 days Month Quarterly










1.1.1 Enrollment Required AD_6 Re-enrollments or re-instatements for beneficiaries not using defined pathways after disenrollment or suspension of benefits for noncompliance Number of beneficiaries in the demonstration who began a new enrollment spell (or had benefits re-instated) in the current measurement period, have had Medicaid coverage within the prior 3 months and are not using a state-specific pathway for re-enrollment after being disenrolled for noncompliance (or re-instatement of benefits after being suspended for noncompliance) Administrative records 30 days Month Quarterly










1.1.2 Mid-year loss of demonstration eligibility Required AD_7 Beneficiaries determined ineligible for Medicaid, any reason, other than at renewal Total number of beneficiaries in the demonstration determined ineligible for Medicaid and disenrolled during the measurement period (separate reasons reported in other indicators), other than at renewal Administrative records 30 days Month Quarterly










1.1.2 Mid-year loss of demonstration eligibility Required AD_8 Beneficiaries no longer eligible for Medicaid, failure to provide timely change in circumstance information Number of beneficiaries enrolled in the demonstration and who lost eligibility for Medicaid during the measurement period due to failure to provide timely change in circumstance information Administrative records 30 days Month Quarterly










1.1.2 Mid-year loss of demonstration eligibility Required AD_9 Beneficiaries determined ineligible for Medicaid after state processes a change in circumstance reported by a beneficiary Number of beneficiaries who were enrolled in the demonstration and lost eligibility for Medicaid during the measurement period because they are determined ineligible after the state processes a change in circumstance Administrative records 30 days Month Quarterly










1.1.2 Mid-year loss of demonstration eligibility Required AD_10 Beneficiaries no longer eligible for the demonstration due to transfer to another Medicaid eligibility group Number of beneficiaries who were enrolled in the demonstration and transferred from the demonstration to a Medicaid eligibility group not included in the demonstration during the measurement period Administrative records 30 days Month Quarterly










1.1.2 Mid-year loss of demonstration eligibility Recommended AD_11 Beneficiaries no longer eligible for the demonstration due to transfer to CHIP Number of beneficiaries who were enrolled in the demonstration and transferred from the demonstration to CHIP during the measurement period Administrative records 30 days Month Quarterly










1.1.3 Enrollment duration at time of disenrollment Recommended AD_12 Enrollment duration, 0-3 months Number of demonstration beneficiaries who lost eligibility for Medicaid during the measurement period and whose enrollment spell had lasted 3 or fewer months at the time of disenrollment Administrative records 30 days Month Quarterly










1.1.3 Enrollment duration at time of disenrollment Recommended AD_13 Enrollment duration, 4-6 months Number of demonstration beneficiaries who lose eligibility for Medicaid during the measurement period whose enrollment spell had lasted between 4 and 6 months at the time of disenrollment Administrative records 30 days Month Quarterly










1.1.3 Enrollment duration at time of disenrollment Recommended AD_14 Enrollment duration 6-12 months Number of demonstration beneficiaries who lost eligibility for Medicaid during the measurement period whose enrollment spell had lasted 6 or more months (up to 12 months) at the time of disenrollment Administrative records 30 days Month Quarterly










1.1.4 Renewal Required AD_15 Beneficiaries due for renewal Total number of beneficiaries enrolled in the demonstration who were due for renewal during the measurement period Administrative records 30 days Month Quarterly










1.1.4 Renewal Required AD_16 Beneficiaries determined ineligible for the demonstration at renewal, disenrolled from Medicaid Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who complete the renewal process and are determined ineligible for Medicaid Administrative records 30 days Month Quarterly










1.1.4 Renewal Required AD_17 Beneficiaries determined ineligible for the demonstration at renewal, transfer to another Medicaid eligibility category Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who complete the renewal process and move from the demonstration to a Medicaid eligibility group not included in the demonstration Administrative records 30 days Month Quarterly










1.1.4 Renewal Required AD_18 Beneficiaries determined ineligible for the demonstration at renewal, transferred to CHIP Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who complete the renewal process, but move from the demonstration to CHIP Administrative records 30 days Month Quarterly










1.1.4 Renewal Required AD_19 Beneficiaries who did not complete renewal, disenrolled from Medicaid Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who are disenrolled from Medicaid for failure to complete the renewal process Administrative records 30 days Month Quarterly










1.1.4 Renewal Required AD_20 Beneficiaries who had pending/uncompleted renewals and were still enrolled Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period for whom the state had not completed renewal determination by the end of the measurement period and were still enrolled Administrative records 30 days Month Quarterly










1.1.4 Renewal Required AD_21 Beneficiaries who retained eligibility for the demonstration after completing renewal forms Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who remained enrolled in the demonstration after responding to renewal notices Administrative records 30 days Month Quarterly










1.1.4 Renewal Recommended AD_22 Beneficiaries who renewed ex parte Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who remained enrolled as determined by third-party data sources or available information, rather than beneficiary response to renewal notices Administrative records 30 days Month Quarterly










1.1.5 Cost sharing limit Required AD_23 Beneficiaries who reached 5% limit Number of beneficiaries enrolled in the demonstration who reached the 5% of income limit on cost sharing and premiums during the month Administrative records 30 days Month Quarterly










1.1.6 Appeals and grievances Recommended AD_24 Appeals, eligibility Number of appeals filed by beneficiaries enrolled in the demonstration during the measurement period regarding Medicaid eligibility Administrative records None Quarter Quarterly










1.1.6 Appeals and grievances Recommended AD_25 Appeals, denial of benefits Number of appeals filed by beneficiaries enrolled in the demonstration during the measurement period regarding denial of benefits Administrative records None Quarter Quarterly










1.1.6 Appeals and grievances Recommended AD_26 Grievances, care quality Number of grievances filed by beneficiaries enrolled in the demonstration during the measurement period regarding the quality of care or services provided Administrative records None Quarter Quarterly










1.1.6 Appeals and grievances Recommended AD_27 Grievances, provider or managed care entities Number of grievances filed by beneficiaries enrolled in the demonstration during the measurement period regarding a provider or managed care entity. Managed care entities include Managed Care Organizations (MCO), Prepaid Inpatient Health Plans (PIHP), and Prepaid Ambulatory Health Plans (PAHP). Administrative records None Quarter Quarterly










1.1.6 Appeals and grievances Recommended AD_28 Grievances, other Number of grievances filed by beneficiaries enrolled in the demonstration during the measurement period regarding other matters that are not subject to appeal Administrative records None Quarter Quarterly










1.1.7 Access to care Required AD_29 Primary care provider availability Number of primary care providers enrolled to deliver Medicaid services at the end of the measurement period Provider enrollment databases 90 days Quarter Quarterly










1.1.7 Access to care Required AD_30 Primary care provider active participation Number of primary care providers enrolled to deliver Medicaid services with service claims for 3 or more demonstration beneficiaries during the measurement period Provider enrollment databases and claims and encounters 90 days Quarter Quarterly










1.1.7 Access to care Required AD_31 Specialist provider availability Number of specialists enrolled to deliver Medicaid services at the end of the measurement period Provider enrollment databases 90 days Quarter Quarterly










1.1.7 Access to care Required AD_32 Specialist provider active participation Number of specialists enrolled to deliver Medicaid services with service claims for 3 or more demonstration beneficiaries during the measurement period Provider enrollment databases and claims and encounters 90 days Quarter Quarterly










1.1.7 Access to care Recommended AD_33 Preventive care and office visit utilization Total utilization of preventive care and office visits per 1,000 demonstration beneficiary months during the measurement period Claims and encounters and other administrative records 90 days Quarter Quarterly










1.1.7 Access to care Recommended AD_34 Prescription drug use Total utilization of 30-day prescription fills per 1,000 demonstration beneficiary months in the measurement period Claims and encounters; other administrative records 90 days Quarter Quarterly










1.1.7 Access to care Recommended AD_35 Emergency department utilization, total Total number of emergency department (ED) visits per 1,000 demonstration beneficiary months during the measurement period Claims and encounters; other administrative records 90 days Quarter Quarterly










1.1.7 Access to care Recommended. Required for states with copayments for non-emergency use. AD_36 Emergency department utilization, non-emergency Total number of ED visits for non-emergency conditions per 1,000 demonstration beneficiary months during the measurement period.
If the state differentiates emergent/non-emergent visit copayments, then non-emergency visits should be identified for monitoring purposes using the same criteria used to assess the differential copayment.
If the state does not differentiate emergent/non-emergent copayments, then non-emergency visits should be defined as all visits not categorized as emergent using the method below.
 Claims and encounters; other administrative records 90 days Quarter Quarterly










1.1.7 Access to care Recommended AD_37 Inpatient admissions Total number of inpatient admissions per 1,000 demonstration beneficiary months during the measurement period Claims and encounters; other administrative records 90 days Quarter Quarterly










1.1.8 Quality of care and health outcomes Required (AD_38A or AD_38B-1 - 3. States do not have to report both.) AD_38A Medical Assistance with Smoking and Tobacco Use Cessation (MSC-AD)

[NCQA; NQF #0027; Medicaid Adult Core Set; Adjusted HEDIS measure]		 This metric consists of the following components; each assesses different facets of providing medical assistance with smoking and tobacco use cessation:
• Advising smokers and tobacco users to quit
• Discussing cessation medications
• Discussing cessation strategies		 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan survey, Adult Version 90 days Calendar year Annually










1.1.8 Quality of care and health outcomes Required (AD_38A or AD_38B. States do not have to report both.) AD_38B Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (rate 1)

[PCPI Foundation; NQF #0028]		 This metric consists of the following components:
1. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use one or more times within 24 months
2. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use and identified as a tobacco user who received tobacco cessation intervention
3. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation intervention if identified as a tobacco user		 Claims and encounters 90 days Calendar year Annually










1.1.8 Quality of care and health outcomes Required AD_39-1 Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA-AD)

[NCQA; NQF # 2605; Medicaid adult Core Set; Adjusted HEDIS measure]		 Percentage of ED visits for beneficiaries age 18 and older who have a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, and who had a follow-up visit with a corresponding principal diagnosis for AOD. Two rates are reported:
1. Percentage of ED visits for AOD abuse or dependence for which the beneficiary received follow-up within 30 days of the ED visit (31 total days).
2. Percentage of ED visits for AOD abuse or dependence for which the beneficiary received follow-up within 7 days of the ED visit (8 total days). 		Claims and encounters 90 days Calendar year Annually










1.1.8 Quality of care and health outcomes Required AD_39-2 Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD)

[NCQA; NQF # 2605; Medicaid adult Core Set; Adjusted HEDIS measure]		 Percentage of ED visits for beneficiaries age 18 and older who have a principal diagnosis of mental illness or intentional self-harm, and who had a follow-up visit with a corresponding principal diagnosis for mental illness. Two rates are reported:
1. Percentage of ED visits for mental illness or intentional self-harm for which the beneficiary received follow-up within 30 days of the ED visit (31 total days).
2. Percentage of ED visits for mental illness or intentional self-harm for which the beneficiary received follow-up within 7 days of the ED visit (8 total days). 		Claims and encounters 90 days Calendar year Annually










1.1.8 Quality of care and health outcomes Required AD_40 Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET-AD)

[NCQA; NQF #0004; Medicaid Adult Core Set; Adjusted HEDIS measure]		 Percentage of beneficiaries age 18 and older with a new episode of AOD abuse or dependence who received the following:
1. Initiation of AOD Treatment. Percentage of beneficiaries who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, or medication assisted treatment (MAT) within 14 days of the diagnosis
2. Engagement of AOD Treatment. Percentage of beneficiaries who initiate treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

The following diagnosis cohorts are reported for each rate: (1) Alcohol abuse or dependence, (2) Opioid abuse or dependence, (3) Other drug abuse or dependence, and (4) Total AOD abuse or dependence. A total of 8 separate rates are reported for this measure.		 Claims and encounters or EHR 90 days Calendar year Annually










1.1.8 Quality of care and health outcomes Required AD_41 PQI 01: Diabetes Short-Term Complications Admission Rate (PQI01-AD)

[AHRQ; NQF #0272; Medicaid Adult Core Set]		 Number of inpatient hospital admissions for diabetes short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 beneficiary months for beneficiaries age 18 and older Claims and encounters 90 days Calendar year Annually










1.1.8 Quality of care and health outcomes Required AD_42 PQI 05: Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI05-AD)

[AHRQ; NQF #0275; Medicaid Adult Core Set]		 Number of inpatient hospital admissions for chronic obstructive pulmonary disease (COPD) or asthma per 100,000 beneficiary months for beneficiaries age 40 and older Claims and encounters 90 days Calendar year Annually










1.1.8 Quality of care and health outcomes Required AD_43 PQI 08: Heart Failure Admission Rate (PQI08-AD)

[AHRQ; NQF #0277; Medicaid Adult Core Set]		 Number of inpatient hospital admissions for heart failure per 100,000 beneficiary months for beneficiaries age 18 and older Claims and encounters 90 days Calendar year Annually










1.1.8 Quality of care and health outcomes Required AD_44 PQI 15: Asthma in Younger Adults Admission Rate (PQI15-AD)

[AHRQ; NQF #0283; Medicaid Adult Core Set]		 Number of inpatient hospital admissions for asthma per 100,000 beneficiary months for beneficiaries aged 18 to 39 Claims and encounters 90 days Calendar year Annually










1.1.9 Administrative cost Recommended AD_45 Administrative cost of demonstration operation Cost of contracts or contract amendments and staff time equivalents required to administer demonstration policies, including premium collection, health behavior incentives, premium assistance, community engagement requirements and/or retroactive eligibility waivers Administrative records None Demonstration year Annually









Add rows for any additional state-identified metrics






































a The reporting topics correspond to the prompts for reporting topic AD.Mod_1 in the monitoring report template.


















End of workbook


















PRA Disclosure Statement - This information is being collected to assist the Centers for Medicare & Medicaid Services in program monitoring of Medicaid Section 1115 Eligibility and Coverage Demonstrations. This mandatory information collection (42 CFR § 431.428) will be used to support more efficient, timely and accurate review of states’ eligibility and coverage 1115 demonstrations monitoring reports submissions to support consistency of monitoring and evaluation of Medicaid Section 1115 Eligibility and Coverage Demonstrations, increase in reporting accuracy, and reduce timeframes required for monitoring and evaluation. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 # 58). Public burden for all of the collection of information requirements under this control number is estimated to take about 12 hours per response. 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.












Sheet 2: Protocol - Planned metrics (CE)
Medicaid Section 1115 Eligibility and Coverage Demonstration Monitoring Protocol - Planned metrics (CE)


















State [Enter State Name]

















Demonstration Name [Enter Demonstration Name]

















Submitted on [Enter Date] (Format: MM/DD/YYYY)





































Standard information on CMS-provided metrics Baseline, annual goals, and demonstration target Alignment with CMS-provided technical specifications Initial reporting date
State will report (Y/N) Reporting Topica Reporting priority # Metric name Metric description Data source Calculation lag Measurement period Reporting frequency Baseline reporting period (MM/DD/YYYY--MM/DD/YYYY) Annual goal Overall demonstration target Attest that planned reporting matches the CMS-provided specification (Y/N) Explanation of any deviations from the CMS-provided specifications. Could include different data sources or state-specific definitions, policies, codes, target populations, etc. Dates covered by first measurement period for metric (MM/DD/YYYY - MM/DD/YYYY) Report name of first report in which the metric will be submitted (Format: DY1 Q3 quarterly report) Submission date of first report in which the metric will be reported (MM/DD/YYYY) State plans to phase in reporting (Y/N) Explanation of any plans to phase in
reporting over time

CE.Mod_1: Specify community engagement policies Required CE_1 Total beneficiaries subject to the community engagement requirement, not exempt The number of beneficiaries enrolled in the demonstration whose income and eligibility group were subject to the community engagement requirement and who did not have an individual exemption from the requirement or an approved good cause circumstance Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_2 Total beneficiaries who were exempt from the community engagement requirement in the month The number of beneficiaries enrolled in income and eligibility groups that were subject to the community engagement requirement, but had an individual exemption from the policy. This excludes circumstances that give rise to good cause. Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_3 Beneficiaries with approved good cause circumstances The number of beneficiaries enrolled in the demonstration who met the state criteria for good cause circumstances, such as serious illness, birth or death of a family member, severe weather, family emergencies, or life-changing event Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_4 Beneficiaries subject to the community engagement requirement and in suspension status due to failure to meet requirement The number of demonstration beneficiaries in suspension status due to failure to meet the community engagement requirement, including those newly suspended for noncompliance during the measurement period Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_5 Beneficiaries subject to the community engagement requirement and receiving benefits who met the requirement for qualifying activities The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement and met the requirement by engaging in qualifying activities Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_6 Beneficiaries subject to the community engagement requirement and receiving benefits, but in a grace period or allowable month of noncompliance The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement, but did not meet the requirement. This includes beneficiaries who have not yet begun qualifying activities and those who logged some hours, but failed to meet total required hours. Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_7 Beneficiaries who successfully completed make-up hours or other activities to retain active benefit status after failing to meet the community engagement requirement in a previous month The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement and met additional requirements to retain active benefit status after previously failing to meet the requirement. This captures beneficiaries who successfully satisfy the “opportunity to cure” requirement and therefore are not suspended (if state has this policy). Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_8 Beneficiaries in a non-eligibility period who were disenrolled for noncompliance with the community engagement requirement and are prevented from re-enrolling for a defined period of time The number of prior demonstration beneficiaries who were disenrolled from Medicaid for noncompliance with the community engagement requirement and are in a non-eligibility period, meaning they are prevented from re-enrolling for some defined period of time. The count should include those prevented from re-enrolling until their redetermination date. Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_9 Beneficiaries who met the community engagement requirement by satisfying requirements of other programs The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement and met the requirement by satisfying requirements in other programs such as SNAP or TANF, regardless of whether they are “deemed” by the state to be in compliance with Medicaid requirements or must take reporting action Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_10 Beneficiaries who met the community engagement requirement through employment for the majority of their required hours The number of beneficiaries enrolled in the demonstration who were subject to and met the community engagement requirement, who were self-employed or employed in subsidized and/or unsubsidized settings. Includes both those “deemed” by the state to be in compliance with Medicaid requirements because they are working more than the number of required hours and those who must report their hours. Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_11 Beneficiaries who met the community engagement requirement through job training or job search for the majority of their required hours The number of beneficiaries enrolled in the demonstration who were subject to and met the community engagement requirement by engaging in on-the-job training, job skills training, vocational education and training, job search activities, job search training, a state-sponsored workforce program, or similar activity Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_12 Beneficiaries who met the community engagement requirement through educational activity for the majority of their required hours The number of beneficiaries enrolled in the demonstration who were subject to and met the community engagement requirement by engaging in education related to employment, general education, accredited English-as-a-second-language education, accredited homeschooling, or a state-designated class Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_13 Beneficiaries who met the community engagement requirement who were engaged in other qualifying activity for the majority of their required hours The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement and met the requirement through a state-specified activity not captured by other reporting categories, including community work experience, community service/public service, volunteer work, caregiving for a dependent, participation in substance use disorder treatment, enrollment in Medicaid employer-sponsored insurance premium assistance, or other activity Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_14 Beneficiaries who met the community engagement requirement by combining two or more activities The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement and met the requirement by engaging in a combination of activities defined in metrics CE_10 through CE_13, such as a combination of employment and education Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_15 Beneficiaries exempt from Medicaid community engagement requirements because they were exempt from requirements of SNAP and/or TANF The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they were exempt from the SNAP and/or TANF work requirements. This does not include beneficiaries who are meeting SNAP and/or TANF work requirements. Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_16 Beneficiaries exempt from Medicaid community engagement requirements on the basis of pregnancy The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are pregnant Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_17 Beneficiaries exempt from Medicaid community engagement requirements due to former foster youth status The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they were formerly part of the foster care system Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_18 Beneficiaries exempt from Medicaid community engagement requirements due to medical frailty The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are identified as medically frail Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_19 Beneficiaries exempt from Medicaid community engagement requirements on the basis of caretaker status The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are primary caregiver of a dependent child or incapacitated/disabled household member Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_20 Beneficiaries exempt from Medicaid community engagement requirements on the basis of unemployment insurance compensation The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are receiving unemployment insurance compensation Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_21 Beneficiaries exempt from Medicaid community engagement requirements due to substance abuse treatment status The number of beneficiaries enrolled in the demonstration who were exempt the community engagement requirement because they are participating in a drug or alcohol treatment and rehabilitation program Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_22 Beneficiaries exempt from Medicaid community engagement requirements due to student status The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are a student enrolled a number of hours/week, defined by state Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_23 Beneficiaries exempt from Medicaid community engagement requirements because they were excused by a medical professional The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because a medical professional determined the beneficiary had an acute medical condition separate from disability or frailty Administrative records 30 days Month Quarterly










CE.Mod_1: Specify community engagement policies Required CE_24 Beneficiaries exempt from Medicaid community engagement requirements, other The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are exempt for another reason not captured by other reporting categories, including age above the upper limit defined by the state and enrollment in employer-sponsored insurance through premium assistance Administrative records 30 days Month Quarterly










CE.Mod_2: Establish beneficiary supports and modifications Required CE_25 Total beneficiaries receiving supports to participate and placement assistance The number of beneficiaries enrolled in the demonstration who were given supports to enable them to participate, including supports due to disability and assistance from other agencies and entities complementing Medicaid efforts Administrative records 30 days Month Quarterly










CE.Mod_2: Establish beneficiary supports and modifications Recommended CE_26 Beneficiaries provided with transportation assistance The number of beneficiaries enrolled in the demonstration who were given transportation assistance to enable participation in community engagement activities Administrative records 30 days Month Quarterly










CE.Mod_2: Establish beneficiary supports and modifications Recommended CE_27 Beneficiaries provided with childcare assistance The number of beneficiaries enrolled in the demonstration who were given childcare assistance to enable participation in community engagement activities Administrative records 30 days Month Quarterly










CE.Mod_2: Establish beneficiary supports and modifications Recommended CE_28 Beneficiaries provided with language supports The number of beneficiaries enrolled in the demonstration who were given language supports to enable participation in community engagement activities Administrative records 30 days Month Quarterly










CE.Mod_2: Establish beneficiary supports and modifications Recommended CE_29 Beneficiaries assisted with placement in community engagement activities The number of beneficiaries enrolled in the demonstration who were given placement assistance, including through state department of labor support centers Administrative records 30 days Month Quarterly










CE.Mod_2: Establish beneficiary supports and modifications Recommended CE_30 Beneficiaries provided with other non-Medicaid assistance The number of beneficiaries enrolled in the demonstration who were given other assistance, including assistance from other agencies and entities complementing Medicaid efforts, to participate in community engagement activities Administrative records 30 days Month Quarterly










CE.Mod_2: Establish beneficiary supports and modifications Recommended CE_31 Beneficiaries who requested reasonable modifications to community engagement processes or requirements due to disability The number of beneficiaries enrolled in the demonstration who requested a reasonable modification of community engagement processes (such as assistance with exemption requests or appeals) or requirements (such as the number of hours) due to disability Administrative records 30 days Month Quarterly










CE.Mod_2: Establish beneficiary supports and modifications Recommended CE_32 Beneficiaries who were granted reasonable modifications to community engagement processes or requirements due to disability The number of beneficiaries enrolled in the demonstration who were granted a modification of community engagement processes (such as assistance with exemption requests or appeals) or requirements (such as the number of hours) due to disability Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Required CE_33 Beneficiaries newly suspended for failure to complete community engagement requirements The number of demonstration beneficiaries newly suspended for noncompliance during the measurement period (if state has a suspension policy) Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Required CE_34 Beneficiaries newly disenrolled for failure to complete community engagement requirements The number of demonstration beneficiaries newly disenrolled for noncompliance with community engagement requirements during the measurement period Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Required if state has a suspension policy CE_35 Total beneficiaries whose benefits were reinstated after being in suspended status for noncompliance The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements, including those reinstated due to compliance, determination of exemption, and successful appeal or good cause circumstances Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Recommended CE_36 Beneficiaries whose benefits were reinstated because their time-limited suspension period ended The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements (if state has a suspension policy), because a defined suspension period ended Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Recommended CE_37 Beneficiaries whose benefits were reinstated because they completed required community engagement activities The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements (if state has a suspension policy), because they completed qualifying activities Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Recommended CE_38 Beneficiaries whose benefits were reinstated because they completed “on-ramp” activities other than qualifying community engagement activities The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements (if state has a suspension policy) because they used a special pathway for re-enrollment such as a state-approved educational course Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Recommended CE_39 Beneficiaries whose benefits were reinstated because they newly meet community engagement exemption criteria or had a good cause circumstance  The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements (if state has a suspension policy) because they were newly determined exempt or had a good cause circumstance Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Recommended CE_40 Beneficiaries whose benefits were reinstated after successful appeal of suspension for noncompliance The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements (if state has a suspension policy) because they successfully appealed Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Required CE_41 Total beneficiaries re-enrolling after disenrollment for noncompliance Total number of beneficiaries re-enrolled in the demonstration during the measurement period after disenrollment in the last 12 months for noncompliance or because they were in suspended status on their redetermination date (depending on state policy), including those re-enrolling after being determined exempt or after successful appeal Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Recommended CE_42 Beneficiaries re-enrolling after completing required community engagement activities Total number of beneficiaries re-enrolled in the demonstration during the measurement period because they completed qualifying activities, subsequent to disenrollment in the last 12 months for noncompliance or because they were in suspended status on their redetermination date (depending on state policy) Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Recommended CE_43 Beneficiaries re-enrolling after completing “on-ramp” activities other than qualifying community engagement activities Total number of demonstration beneficiaries re-enrolled during the measurement period because they used a special pathway for re-enrollment such as a state-approved educational course, subsequent to disenrollment in the last 12 months for noncompliance or because they were in suspended status on their redetermination date (depending on state policy) Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Recommended CE_44 Beneficiaries re-enrolling after re-applying, subsequent to being disenrolled for noncompliance with community engagement requirements The number of beneficiaries re-enrolled in the demonstration during the measurement period because they re-applied, subsequent to disenrollment in the last 12 months for noncompliance (or because they were in suspended status on their redetermination date). This includes those who re-applied immediately after disenrollment and those who did so after a disenrollment (non-eligibility) period. Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Recommended CE_45 Beneficiaries re-enrolling because they newly met community engagement exemption criteria or had a good cause circumstance The number of beneficiaries re-enrolled in the demonstration during the measurement period because they were newly determined exempt, subsequent to disenrollment in the last 12 months for noncompliance (or because they were in suspended status on their redetermination date) Administrative records 30 days Month Quarterly










CE.Mod_4: Operationalize strategies for noncompliance Recommended CE_46 Beneficiaries re-enrolling after successful appeal of disenrollment for noncompliance The number of beneficiaries re-enrolled in the demonstration during the measurement period after successful appeal (including retroactive determination of a good cause circumstance by the state), subsequent to disenrollment in the last 12 months for noncompliance (or because they were in suspended status on their redetermination date) Administrative records 30 days Month Quarterly









Add rows for any additional state-identified metrics






































a The reporting topics correspond to the reporting topics in section CE.Mod_1 of the monitoring report template.


















End of workbook


















Sheet 3: Report - Metrics reporting (AD)
Medicaid Section 1115 Eligibility and Coverage Demonstration Report - Metrics reporting (AD)









































































State [Enter State Name]








































































Demonstration Name [Enter Demonstration Name]








































































Demonstration Year (DY) [Enter Demonstration Year] (Format: DY1, DY2, DY3, etc.)








































































Calendar Dates for DY [Enter Calendar Dates for Demonstration Year] (Format: MM/DD/YYYY - MM/DD/YYYY)








































































Reporting Period [Enter Reporting Period] (Format: Q1, Q2, Q3, Q4)








































































Calendar Dates for Reporting Period [Enter Calendar Dates for Reporting Period (Format: MM/DD/YYYY - MM/DD/YYYY)








































































Submitted on [Enter Date] (Format: MM/DD/YYYY)



















































































































































Eligibility and Coverage Demonstration Metrics (AD)a












































































Demonstration < 50% FPLf 50-100% FPLf >100% FPLf Age 19-26 Age 27-35 Age 36-45 Age 46-55 Age 56-64 Male Female White Black or African American Asian American Indian or Alaskan Native Other race Unknown race Hispanic ethnicity Non-Hispanic ethnicity Unknown ethnicity Exempt groupsg Specific eligibility groupsh Phase-in cohort (if applicable)i
Reporting topicb # Metric name Metric description Data source Calculation lag Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee
1.1.1 Enrollment AD_1 Total enrollment in the demonstration The unduplicated number of beneficiaries enrolled in the demonstration at any time during the measurement period. This indicator is a count of total program enrollment. It includes those newly enrolled during the measurement period and those whose enrollment continues from a prior period. This indicator is not a point-in-time count. It captures beneficiaries who were enrolled for at least one day during the measurement period. Administrative records 30 days














































































































































































































1.1.1 Enrollment AD_2 Beneficiaries in suspension status for noncompliance The number of demonstration beneficiaries in suspension status for noncompliance with demonstration policies as of the last day of the measurement period Administrative records 30 days














































































































































































































1.1.1 Enrollment AD_3 Beneficiaries in a non-eligibility period who are prevented from re-enrolling for a defined period of time The number of prior demonstration beneficiaries who are in a non-eligibility period, meaning they are prevented from re-enrolling for some defined period of time, because they were disenrolled for noncompliance with demonstration policies. The count should include those prevented from re-enrolling until their redetermination date. Administrative records 30 days














































































































































































































1.1.1 Enrollment AD_4 New enrollees Number of beneficiaries in the demonstration who began a new enrollment spell during the measurement period, have not had Medicaid coverage within the prior 3 months and are not using a state-specific pathway for re-enrollment after being disenrolled for noncompliance Administrative records 30 days














































































































































































































1.1.1 Enrollment AD_5 Re-enrollments or re-instatements using defined pathways after disenrollment or suspension of benefits for noncompliance with demonstration policies Number of beneficiaries in the demonstration who began a new enrollment spell (or had benefits re-instated) in the current measurement period by using a state-defined pathway for re-enrollment (or re-instatement of benefits), i.e., meeting certain requirements, after being disenrolled (or having benefits suspended) for noncompliance with premium requirements, community engagement requirements, or other demonstration-specific requirements. Administrative records 30 days














































































































































































































1.1.1 Enrollment AD_6 Re-enrollments or re-instatements for beneficiaries not using defined pathways after disenrollment or suspension of benefits for noncompliance Number of beneficiaries in the demonstration who began a new enrollment spell (or had benefits re-instated) in the current measurement period who have had Medicaid coverage within the prior 3 months and are not using a state-specific pathway for re-enrollment after being disenrolled for noncompliance (or re-instatement of benefits after being suspended for noncompliance). Administrative records 30 days














































































































































































































1.1.2 Mid-year loss of demonstration eligibility AD_7 Monthly count of beneficiaries determined ineligible for Medicaid, any reason, other than at renewal Beneficiaries determined ineligible for Medicaid, any reason, other than at renewal Administrative records 30 days














































































































































































































1.1.2 Mid-year loss of demonstration eligibility AD_8 Monthly count of beneficiaries determined ineligible for Medicaid after state processes a change in circumstance reported by a beneficiary Beneficiaries no longer eligible for Medicaid, failure to provide timely change in circumstance information Administrative records 30 days














































































































































































































1.1.2 Mid-year loss of demonstration eligibility AD_9 Monthly count of beneficiaries determined ineligible for Medicaid after state processes a change in circumstance reported by a beneficiary Beneficiaries determined ineligible for Medicaid after state processes a change in circumstance reported by a beneficiary Administrative records 30 days














































































































































































































1.1.2 Mid-year loss of demonstration eligibility AD_10 Monthly count of beneficiaries no longer eligible for the demonstration due to transfer to another Medicaid eligibility group Beneficiaries no longer eligible for the demonstration due to transfer to another Medicaid eligibility group Administrative records 30 days














































































































































































































1.1.2 Mid-year loss of demonstration eligibility AD_11 Monthly count of beneficiaries no longer eligible for the demonstration due to transfer to CHIP Beneficiaries no longer eligible for the demonstration due to transfer to CHIP Administrative records 30 days














































































































































































































1.1.3 Enrollment duration at time of disenrollment AD_12 Enrollment duration 0-3 months Number of demonstration beneficiaries who lost eligibility for Medicaid during the measurement period and whose enrollment spell had lasted 3 or fewer months at the time of disenrollment Administrative records 30 days














































































































































































































1.1.3 Enrollment duration at time of disenrollment AD_13 Enrollment duration 4-6 months Number of demonstration beneficiaries who lose eligibility for Medicaid during the measurement period whose enrollment spell had lasted between 4 and 6 months at the time of disenrollment Administrative records 30 days














































































































































































































1.1.3 Enrollment duration at time of disenrollment AD_14 Enrollment duration 6-12 months Number of demonstration beneficiaries who lost eligibility for Medicaid during the measurement period whose enrollment spell had lasted 6 or more months (up to 12 months) at the time of disenrollment Administrative records 30 days














































































































































































































1.1.4 Renewal AD_15 Beneficiaries due for renewal Total number of beneficiaries enrolled in the demonstration who were due for renewal during the measurement period Administrative records 30 days














































































































































































































1.1.4 Renewal AD_16 Beneficiaries determined ineligible for the demonstration at renewal, disenrolled from Medicaid Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who complete the renewal process and are determined ineligible for Medicaid Administrative records 30 days














































































































































































































1.1.4 Renewal AD_17 Beneficiaries determined ineligible for the demonstration at renewal, transfer to another Medicaid eligibility category Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who complete the renewal process and move from the demonstration to a Medicaid eligibility group not included in the demonstration Administrative records 30 days














































































































































































































1.1.4 Renewal AD_18 Beneficiaries determined ineligible for the demonstration at renewal, transferred to CHIP Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who complete the renewal process but move from the demonstration to CHIP Administrative records 30 days














































































































































































































1.1.4 Renewal AD_19 Beneficiaries who did not complete renewal, disenrolled from Medicaid Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who are disenrolled from Medicaid for failure to complete the renewal process Administrative records 30 days














































































































































































































1.1.4 Renewal AD_20 Beneficiaries who had pending/uncompleted renewals and were still enrolled Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period for whom the state had not completed renewal determination by the end of the measurement period and were still enrolled Administrative records 30 days














































































































































































































1.1.4 Renewal AD_21 Beneficiaries who retained eligibility for the demonstration after completing renewal forms Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who remained enrolled in the demonstration after responding to renewal notices Administrative records 30 days














































































































































































































1.1.4 Renewal AD_22 Beneficiaries who renewed ex parte Number of beneficiaries enrolled in the demonstration and due for renewal during the measurement period who remained enrolled as determined by third-party data sources or available information, rather than beneficiary response to renewal notices Administrative records 30 days














































































































































































































1.1.5 Cost sharing limit AD_23 Monthly count of beneficiaries who reached 5% limit Beneficiaries who reached 5% limit Administrative records 30 days














































































































































































































1.1.6 Appeals and grievances AD_24 Appeals, eligibility Number of appeals filed by beneficiaries enrolled in the demonstration during the measurement period regarding Medicaid eligibility Administrative records None




































































1.1.6 Appeals and grievances AD_25 Appeals, denial of benefits Number of appeals filed by beneficiaries enrolled in the demonstration during the measurement period regarding denial of benefits Administrative records None




































































1.1.6 Appeals and grievances AD_26 Grievances, care quality Number of grievances filed by beneficiaries enrolled in the demonstration during the measurement period regarding the quality of care or services provided Administrative records None




































































1.1.6 Appeals and grievances AD_27 Grievances, provider or managed care entities Number of grievances filed by beneficiaries enrolled in the demonstration during the measurement period regarding a provider or managed care entity. Managed care entities include Managed Care Organizations (MCO), Prepaid Inpatient Health Plans (PIHP), and Prepaid Ambulatory Health Plans  (PAHP). Administrative records None




































































1.1.6 Appeals and grievances AD_28 Grievances, other Number of grievances filed by beneficiaries enrolled in the demonstration during the measurement period regarding other matters that are not subject to appeal Administrative records None




































































1.1.7 Access to care AD_29 Primary care provider availability Number of primary care providers enrolled to deliver Medicaid services at the end of the measurement period Provider enrollment databases 90 days




































































1.1.7 Access to care AD_30 Primary care provider active participation Number of primary care providers enrolled to deliver Medicaid services with service claims for 3 or more demonstration beneficiaries during the measurement period Provider enrollment databases and claims and encounters 90 days




































































1.1.7 Access to care AD_31 Specialist provider availability Number of specialists enrolled to deliver Medicaid services at the end of the measurement period Provider enrollment databases 90 days




































































1.1.7 Access to care AD_32 Specialist provider active participation Number of specialists enrolled to deliver Medicaid services with service claims for 3 or more demonstration beneficiaries during the measurement period Provider enrollment databases and claims and encounters 90 days




































































1.1.7 Access to care AD_33 Preventive care and office visit utilization Total utilization of preventive care and office visits per 1,000 demonstration beneficiary months during the measurement period Claims and encounters and other administrative records 90 days




































































1.1.7 Access to care AD_34 Prescription drug use Total utilization of 30-day prescription fills per 1,000 demonstration beneficiary months in the measurement period. Claims and encounters; other administrative records 90 days




































































1.1.7 Access to care AD_35 Emergency department utilization, total Total number of emergency department (ED) visits per 1,000 demonstration beneficiary months during the measurement period Claims and encounters; other administrative records 90 days




































































1.1.7 Access to care AD_36 Emergency department utilization, non-emergency Total number of ED visits for non-emergency conditions per 1,000 demonstration beneficiary months during the measurement period.
If the state differentiates emergent/non-emergent visit copayments, then non-emergency visits should be identified for monitoring purposes using the same criteria used to assess the differential copayment.
If the state does not differentiate emergent/non-emergent copayments, then non-emergency visits should be defined as all visits not categorized as emergent using the method below.
 Claims and encounters; other administrative records 90 days




































































1.1.7 Access to care AD_37 Inpatient admissions Total number of inpatient admissions per 1,000 demonstration beneficiary months during the measurement period Claims and encounters; other administrative records 90 days




































































1.1.8 Quality of care and health outcomes AD_38A Medical Assistance with Smoking and Tobacco Use Cessation (MSC-AD)

[NCQA; NQF #0027; Medicaid Adult Core Set; Adjusted HEDIS measure]j		 This metric consists of the following components; each assesses different facets of providing medical assistance with smoking and tobacco use cessation:
• Advising smokers and tobacco users to quit
• Discussing cessation medications
• Discussing cessation strategies		 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan survey, Adult Version 90 days




































































1.1.8 Quality of care and health outcomes AD_38B Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

[PCPI Foundation; NQF #0028]		 This metric consists of the following components:
1. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use one or more times within 24 months
2. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use and identified as a tobacco user who received tobacco cessation intervention
3. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation intervention if identified as a tobacco user		 -- --




































































1. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use one or more times within 24 months Claims and encounters or registry data 90 days




































































2. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use and identified as a tobacco user who received tobacco cessation intervention Claims and encounters or registry data 90 days




































































3. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation intervention if identified as a tobacco user Claims and encounters or registry data 90 days




































































1.1.8 Quality of care and health outcomes AD_39-1 Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA-AD)

[NCQA; NQF # 2605; Medicaid adult Core Set; Adjusted HEDIS measure]j		 Percentage of ED visits for beneficiaries age 18 and older who have a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, and who had a follow-up visit with a corresponding principal diagnosis for AOD. Two rates are reported: -- --




































































1. Percentage of ED visits for AOD abuse or dependence for which the beneficiary received follow-up within 30 days of the ED visit (31 total days) Claims and encounters 90 days




































































2. Percentage of ED visits for AOD abuse or dependence for which the beneficiary received follow-up within 7 days of the ED visit (8 total days) Claims and encounters 90 days




































































1.1.8 Quality of care and health outcomes AD_39-2 Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD)

[NCQA; NQF # 2605; Medicaid adult Core Set; Adjusted HEDIS measure]j		 Percentage of ED visits for beneficiaries age 18 and older who have a principal diagnosis of mental illness or intentional self-harm, and who had a follow-up visit with a corresponding principal diagnosis for mental illness. Two rates are reported: -- --




































































1. Percentage of ED visits for mental illness or intentional self-harm for which the beneficiary received follow-up within 30 days of the ED visit (31 total days) Claims and encounters 90 days




































































2. Percentage of ED visits for mental illness or intentional self-harm for which the beneficiary received follow-up within 7 days of the ED visit (8 total days) Claims and encounters 90 days




































































1.1.8 Quality of care and health outcomes AD_40 Initiation of Alcohol and Other Drug Abuse or Dependence Treatment (IET-AD)

[NCQA; NQF #0004; Medicaid Adult Core Set; Adjusted HEDIS measure]j		 Percentage of beneficiaries age 18 and older with a new episode of AOD abuse or dependence who received the following:
1. Initiation of AOD Treatment. Percentage of beneficiaries who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, or medication assisted treatment (MAT) within 14 days of the diagnosis
2. Engagement of AOD Treatment. Percentage of beneficiaries who initiate treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit

The following diagnosis cohorts are reported for each rate: (1) Alcohol abuse or dependence, (2) Opioid abuse or dependence, (3) Other drug abuse or dependence, and (4) Total AOD abuse or dependence. A total of 8 separate rates are reported for this measure.		 -- --




































































1. Initiation of AOD Treatment - Alcohol abuse or dependence (rate 1, cohort 1) Claims and encounters or EHR 90 days




































































2. Initiation of AOD Treatment - Opioid abuse or dependence (rate 1, cohort 2) Claims and encounters or EHR 90 days




































































3. Initiation of AOD Treatment - Other drug abuse or dependence (rate 1, cohort 3) Claims and encounters or EHR 90 days




































































4. Initiation of AOD Treatment - Total AOD abuse or dependence (rate 1, cohort 4) Claims and encounters or EHR 90 days




































































5. Engagement of AOD Treatment - Alcohol drug abuse or dependence (rate 2 cohort 1) Claims and encounters or EHR 90 days




































































6. Engagement of AOD Treatment - Opioid drug abuse or dependence (rate 2, cohort 2) Claims and encounters or EHR 90 days




































































7. Engagement of AOD Treatment - Other AOD abuse or dependence (rate 2, cohort 3) Claims and encounters or EHR 90 days




































































8. Engagement of AOD Treatment - Total AOD abuse or dependence (rate 2, cohort 4) Claims and encounters or EHR 90 days




































































1.1.8 Quality of care and health outcomes AD_41 PQI 01: Diabetes Short-Term Complications Admission Rate (PQI01-AD)

[AHRQ; NQF #0272; Medicaid Adult Core Set]		 Number of inpatient hospital admissions for diabetes short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 beneficiary months for beneficiaries age 18 and older Claims and encounters 90 days




































































1.1.8 Quality of care and health outcomes AD_42 PQI 05: Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI05-AD)

[AHRQ; NQF #0275; Medicaid Adult Core Set]		 Number of inpatient hospital admissions for chronic obstructive pulmonary disease (COPD) or asthma per 100,000 beneficiary months for beneficiaries age 40 and older. Claims and encounters 90 days




































































1.1.8 Quality of care and health outcomes AD_43 PQI 08: Heart Failure Admission Rate (PQI08-AD)

[AHRQ; NQF #0277; Medicaid Adult Core Set]		 Number of inpatient hospital admissions for heart failure per 100,000 beneficiary months for beneficiaries age 18 and older Claims and encounters 90 days




































































1.1.8 Quality of care and health outcomes AD_44 PQI 15: Asthma in Younger Adults Admission Rate (PQI15-AD)

[AHRQ; NQF #0283; Medicaid Adult Core Set]		 Number of inpatient hospital admissions for asthma per 100,000 beneficiary months for beneficiaries aged 18 to 39. Claims and encounters 90 days




































































1.1.9 Administrative cost AD_45 Administrative cost of demonstration operation Cost of contracts or contract amendments and staff time equivalents required to administer demonstration policies, including premium collection, health behavior incentives, premium assistance, community engagement requirements and/or retroactive eligibility waivers Administrative records None




































































Add rows for any additional state-identified metrics




















































































































































Note: States must prominently display the following notice on any display of Measure rates:

The MSC-AD, FUA-AD, FUM-AD, and IET_AD measures (metrics AD_38A, AD_39, and AD_40) are Healthcare Effectiveness Data and Information Set (“HEDIS®”) measures that are owned and copyrighted by the National Committee for Quality Assurance (“NCQA”). NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications.

The measure specification methodology used by CMS is different from NCQA’s methodology. NCQA has not validated the adjusted measure specifications but has granted CMS permission to adjust. Calculated measure results, based on the adjusted HEDIS specifications, may be called only “Uncertified, Unaudited HEDIS rates.”

Certain non-NCQA measures in the CMS 1115 eligibility and coverage demonstration contain HEDIS Value Sets (VS) developed by and included with the permission of the NCQA. Proprietary coding is contained in the VS. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. NCQA disclaims all liability for use or accuracy of the VS with the non-NCQA measures and any coding contained in the VS.





































































a States should create a new metrics report for each reporting quarter.









































































b The reporting topics correspond to the prompts for reporting topic AD.Mod_1 in the monitoring report template.









































































c Report metrics that are one annual value for a demonstration year only in the report specified in the reporting schedule.









































































d Report count metrics in the numerator column. Administrative costs (AD_45) should also be reported in the numerator column.









































































e If applicable. See CMS-provided technical specifications.









































































f Add columns as necessary to report additional income groups.









































































g Add columns as necessary to report exempt groups.









































































h Add columns as necessary to report specific edibility groups.









































































i Add columns as necessary to report phase-in cohorts, if applicable.









































































j Rates for these metrics reflect Uncertified, Unaudited HEDIS rates.





















































































































































Checks:









































































AD_8, AD_9, AD_11, AD_12, AD_13, AD_14 should each be less than or equal to AD_7









































































AD_15 should equal the sum of AD_16 - AD_22









































































Counts for a subpopulation (e.g. male, female) should sum approximately to counts for the overall demonstration.








































































End of workbook









































































Sheet 4: Report - Metrics reporting (CE)
Medicaid Section 1115 Eligibility and Coverage Demonstration Report - Metrics reporting (CE)














































































State [Enter State Name]













































































Demonstration Name [Enter Demonstration Name]













































































Demonstration Year (DY) [Enter Demonstration Year] (Format: DY1, DY2, DY3, etc.)













































































Calendar Dates for DY [Enter Calendar Dates for Demonstration Year] (Format: MM/DD/YYYY - MM/DD/YYYY)













































































Reporting Period [Enter Reporting Period] (Format: Q1, Q2, Q3, Q4)













































































Calendar Dates for Reporting Period [Enter Calendar Dates for Reporting Period (Format: MM/DD/YYYY - MM/DD/YYYY)













































































Submitted on [Enter Date] (Format: MM/DD/YYYY)





























































































































































Eligibility and Coverage Demonstration Metrics (CE)a






















































































Demonstration < 50% FPLf 50-100% FPLf >100% FPLf Age 19-26 Age 27-35 Age 36-45 Age 46-55 Age 56-64 Male Female White Black or African American Asian American Indian or Alaskan Native Other race Unknown race Hispanic ethnicity Non-Hispanic ethnicity Unknown ethnicity Exempt groupsg Specific eligibility groupsh Phase-in cohort (if applicable)i
Reporting Topicb # Metric name Metric description Data source Calculation lag Attest that reporting matches CMS-provided specification (Y/N) Describe any deviations from CMS-provided measure specifications Reporting issue (Y/N)
(further describe in the data and reporting issues tab [CE])		 Measurement period (month, quarter, yearc) Dates covered by measurement period (MM/DD/YYYY-MM/DD/YYYY) Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratorc Rate/Percentaged Denominator Numeratorc Rate/Percentaged Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee Denominator Numeratord Rate/Percentagee
CE.Mod_1: Specify community engagement policies CE_1 Total beneficiaries subject to the community engagement requirement, not exempt The number of beneficiaries enrolled in the demonstration whose income and eligibility group were subject to the community engagement requirement and who did not have an individual exemption from the requirement. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_2 Total beneficiaries who were exempt from the community engagement requirement in the month The number of beneficiaries enrolled in income and eligibility groups that were subject to the community engagement requirement, but had an individual exemption from the policy. This excludes circumstances that give rise to good cause. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_3 Beneficiaries with approved good cause circumstances The number of beneficiaries enrolled in the demonstration who met the state criteria for good cause circumstances, such as serious illness, birth or death of a family member, severe weather, family emergencies, or life-changing event Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_4 Beneficiaries subject to the community engagement requirement and in suspension status due to failure to meet requirement The number of demonstration beneficiaries in suspension status due to failure to meet the community engagement requirement, including those newly suspended for noncompliance during the measurement period Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_5 Beneficiaries subject to the community engagement requirement and receiving benefits who met the requirement for qualifying activities The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement and met the requirement by engaging in qualifying activities Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_6 Beneficiaries subject to the community engagement requirement and receiving benefits but in a grace period or allowable month of noncompliance The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement but did not meet the requirement. This includes beneficiaries who have not yet begun qualifying activities and those who logged some hours, but failed to meet total required hours. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_7 Beneficiaries who successfully completed make-up hours or other activities to retain active benefit status after failing to meet the community engagement requirement in a previous month The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement and met additional requirements to retain active benefit status after previously failing to meet the requirement. This captures beneficiaries who successfully satisfy the “opportunity to cure” requirement and therefore are not suspended (if state has this policy). Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_8 Beneficiaries in a non-eligibility period who were disenrolled for noncompliance with community engagement requirement and are prevented from re-enrolling for a defined period of time The number of prior demonstration beneficiaries who were disenrolled from Medicaid for noncompliance with the community engagement requirement and are in a non-eligibility period, meaning they are prevented from re-enrolling for some defined period of time. The count should include those prevented from re-enrolling until their redetermination date. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_9 Beneficiaries who met the community engagement requirement by satisfying requirements of other programs The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement and met the requirement by satisfying requirements in other programs such as SNAP or TANF, regardless of whether they are “deemed” by the state to be in compliance with Medicaid requirements or must take reporting action Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_10 Beneficiaries who met the community engagement requirement through employment for the majority of their required hours The number of beneficiaries enrolled in the demonstration who were subject to and met the community engagement requirement, who were self-employed or employed in subsidized and/or unsubsidized settings. Includes both those “deemed” by the state to be in compliance with Medicaid requirements because they are working more than the number of required hours and those who must report their hours. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_11 Beneficiaries who met the community engagement requirement through job training or job search for the majority of their required hours The number of beneficiaries enrolled in the demonstration who were subject to and met the community engagement requirement by engaging in on-the-job training, job skills training, vocational education and training, job search activities, job search training, a state-sponsored workforce program, or similar activity Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies AD_12 Beneficiaries who met the community engagement requirement through educational activity for the majority of their required hours The number of beneficiaries enrolled in the demonstration who were subject to and met the community engagement requirement by engaging in education related to employment, general education, accredited English-as-a-second-language education, accredited homeschooling, or a state-designated class Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_13 Beneficiaries who met the community engagement requirement who were engaged in other qualifying activity for the majority of their required hours The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement and met the requirement through a state-specified activity not captured by other reporting categories, including community work experience, community service/public service, volunteer work, caregiving for a dependent, participation in substance use disorder treatment, enrollment in Medicaid employer-sponsored insurance premium assistance, or other activity. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_14 Beneficiaries who met the community engagement requirement by combining two or more activities The number of beneficiaries enrolled in the demonstration who were subject to the community engagement requirement and met the requirement by engaging in a combination of activities defined in metrics CE_35 through CE_38, such as a combination of employment and education Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_15 Beneficiaries exempt from Medicaid community engagement requirements because they were exempt from requirements of SNAP and/or TANF The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they were exempt from the Supplemental Nutrition Assistance Program (SNAP) and/or Temporary Assistance to Needy Families (TANF) work requirements. This does not include beneficiaries who are meeting SNAP and/or TANF work requirements Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_16 Beneficiaries exempt from Medicaid community engagement requirements on the basis of pregnancy The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are pregnant Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_17 Beneficiaries exempt from Medicaid community engagement requirements due to former foster youth status The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they were formerly part of the foster care system Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_18 Beneficiaries exempt from Medicaid community engagement requirements due to medical frailty The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are identified as medically frail Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_19 Beneficiaries exempt from Medicaid community engagement requirements on the basis of caretaker status The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are primary caregiver of a dependent child or incapacitated/disabled household member Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_20 Beneficiaries exempt from Medicaid community engagement requirements on the basis of unemployment insurance compensation The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are receiving unemployment insurance compensation. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_21 Beneficiaries exempt from Medicaid community engagement requirements due to substance abuse treatment status The number of beneficiaries enrolled in the demonstration who were exempt the community engagement requirement because they are participating in a drug or alcohol treatment and rehabilitation program. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_22 Beneficiaries exempt from Medicaid community engagement requirements due to student status The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are a student enrolled a number of hours/week, defined by state Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_23 Beneficiaries exempt from Medicaid community engagement requirements because they were excused by a medical professional The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because a medical professional determined the beneficiary had an acute medical condition separate from disability or frailty Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_1: Specify community engagement policies CE_24 Beneficiaries exempt from Medicaid community engagement requirements, other The number of beneficiaries enrolled in the demonstration who were exempt from the community engagement requirement because they are exempt for another reason not captured by other reporting categories, including age above the upper limit defined by the state and enrollment in employer-sponsored insurance through premium assistance. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_2: Establish beneficiary supports and modifications CE_25 Total beneficiaries receiving supports to participate and placement assistance The number of beneficiaries enrolled in the demonstration who were given supports to enable them to participate, including non-Medicaid supports and supports due to disability Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_2: Establish beneficiary supports and modifications CE_26 Beneficiaries provided with transportation assistance The number of beneficiaries enrolled in the demonstration who were given transportation assistance to enable participation in community engagement activities Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_2: Establish beneficiary supports and modifications CE_27 Beneficiaries provided with childcare assistance The number of beneficiaries enrolled in the demonstration who were given childcare assistance to enable participation in community engagement activities. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_2: Establish beneficiary supports and modifications CE_28 Beneficiaries provided with language supports The number of beneficiaries enrolled in the demonstration who were given language supports to enable participation in community engagement activities Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_2: Establish beneficiary supports and modifications CE_29 Beneficiaries assisted with placement in community engagement activities The number of beneficiaries enrolled in the demonstration who were given placement assistance, including through Department of Labor support centers. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_2: Establish beneficiary supports and modifications CE_30 Beneficiaries provided with other non-Medicaid assistance The number of beneficiaries enrolled in the demonstration who were given other non-Medicaid assistance to participate in community engagement activities Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_2: Establish beneficiary supports and modifications CE_31 Beneficiaries who requested reasonable modifications to community engagement processes or requirements due to disability The number of beneficiaries enrolled in the demonstration who requested a reasonable modification of community engagement processes (such as assistance with exemption requests or appeals) or requirements (such as the number of hours) due to disability Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_2: Establish beneficiary supports and modifications CE_32 Beneficiaries who were granted reasonable modifications to community engagement processes or requirements due to disability The number of beneficiaries enrolled in the demonstration who were granted a modification of community engagement processes (such as assistance with exemption requests or appeals) or requirements (such as the number of hours) due to disability Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_33 Beneficiaries newly suspended for failure to complete community engagement requirements The number of demonstration beneficiaries newly suspended for noncompliance during the measurement period (if state has a suspension policy) Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_34 Beneficiaries newly disenrolled for failure to complete community engagement requirements The number of demonstration beneficiaries newly disenrolled for noncompliance with community engagement requirements during the measurement period Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_35 Total beneficiaries whose benefits were reinstated after being in suspended status for noncompliance The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements, including those reinstated due to compliance, determination of exemption, and successful appeal or good cause circumstances Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_36 Beneficiaries whose benefits were reinstated because their time-limited suspension period ended The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements (if state has a suspension policy), because a defined suspension period ended. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_37 Beneficiaries whose benefits were reinstated because they completed required community engagement activities The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements (if state has a suspension policy), because they completed qualifying activities Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_38 Beneficiaries whose benefits were reinstated because they completed “on-ramp” activities other than qualifying community engagement activities The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements (if state has a suspension policy), because they used a special pathway for re-enrollment such as a state-approved educational course Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_39 Beneficiaries whose benefits were reinstated because they newly meet community engagement exemption criteria or had a good cause circumstance  The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements (if state has a suspension policy) because they were newly determined exempt or had a good cause circumstance Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_40 Beneficiaries whose benefits were reinstated after successful appeal of suspension for noncompliance The number of demonstration beneficiaries whose benefits were reinstated during the measurement period after suspension in a prior month triggered by noncompliance with community engagement requirements (if state has a suspension policy) because they successfully appealed Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_41 Total beneficiaries re-enrolling after disenrollment for noncompliance Total number of beneficiaries re-enrolled in the demonstration during the measurement period after disenrollment in the last 12 months for noncompliance or because they were in suspended status on their redetermination date (depending on state policy), including those re-enrolling after being determined exempt or after successful appeal. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_42 Beneficiaries re-enrolling after completing required community engagement activities Total number of beneficiaries re-enrolled in the demonstration during the measurement period because they completed qualifying activities, subsequent to disenrollment in the last 12 months for noncompliance or because they were in suspended status on their redetermination date (depending on state policy). Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_43 Beneficiaries re-enrolling after completing “on-ramp” activities other than qualifying community engagement activities Total number of demonstration beneficiaries re-enrolled during the measurement period because they used a special pathway for re-enrollment such as a state-approved educational course, subsequent to disenrollment in the last 12 months for noncompliance or because they were in suspended status on their redetermination date (depending on state policy). Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_44 Beneficiaries re-enrolling after re-applying, subsequent to being disenrolled for noncompliance with community engagement requirements The number of beneficiaries re-enrolled in the demonstration during the measurement period because they re-applied, subsequent to disenrollment in the last 12 months for noncompliance (or because they were in suspended status on their redetermination date). This includes those who re-applied immediately after disenrollment and those who did so after a disenrollment (non-eligibility) period. Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_45 Beneficiaries re-enrolling because they newly met community engagement exemption criteria or had a good cause circumstance The number of beneficiaries re-enrolled in the demonstration during the measurement period because they were newly determined exempt, subsequent to disenrollment in the last 12 months for noncompliance (or because they were in suspended status on their redetermination date). Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































CE.Mod_4: Operationalize strategies for noncompliance CE_46 Beneficiaries re-enrolling after successful appeal of disenrollment for noncompliance The number of beneficiaries re-enrolled in the demonstration during the measurement period after successful appeal (including retroactive determination of a good cause exemption by the state), subsequent to disenrollment in the last 12 months for noncompliance (or because they were in suspended status on their redetermination date) Administrative records 30 days


Month 1





































































Month 2





































































Month 3





































































Add rows for any additional state-identified metrics






























































































































































a States should create a new metrics report for each reporting quarter.














































































b The reporting topics correspond to the reporting topics in the CE.Mod_1 section of the monitoring report template.














































































c The reporting topics correspond to the reporting topics in section CE.Mod_1 of the monitoring report template.














































































d Report count metrics in the numerator column.














































































e If applicable. See CMS-provided technical specifications.














































































f Add columns as necessary to report additional income groups.














































































g Add columns as necessary to report exempt groups.














































































h Add columns as necessary to report specific eligibility groups.














































































i Add columns as necessary to report phase-in cohorts, if applicable.































































































































































Checks:














































































CE_1 should be less than or equal to AD_1














































































CE_1 should be equal to the sum of metrics CE_5 and CE_6














































































CE_4 should be less than or equal to AD_2














































































CE_8 should be less than or equal to AD_3














































































CE_2 should be equal to the sum of metrics CE_15 - CE_24














































































CE_35 should be equal the sum of metrics CE_36 - CE_40














































































CE_41 should be equal to the sum of metrics CE_42 - CE_46














































































Counts for a subpopulation (e.g. male, female) should sum approximately to counts for the overall demonstration.













































































End of workbook














































































Sheet 5: Data & Reporting Issues (AD)
Medicaid Section 1115 Eligibility and Coverage Demonstration Report - Data and reporting issues (AD)





State [Enter State Name]




Demonstration Name [Enter Demonstration Name]




Demonstration Year (DY) [Enter Demonstration Year] (Format: DY1, DY2, DY3, etc.)




Calendar Dates for DY [Enter Calendar Dates for Demonstration Year] (Format: MM/DD/YYYY - MM/DD/YYYY)




Reporting Period [Enter Reporting Period] (Format: Q1, Q2, Q3, Q4)




Calendar Dates for Reporting Period [Enter Calendar Dates for Reporting Period (Format: MM/DD/YYYY - MM/DD/YYYY)




Submitted on [Enter Date] (Format: MM/DD/YYYY)


















Data Reporting Issues (AD)


Category Metric(s) impacted Summary of issue Date and report in which issue was first reported Estimated number of impacted beneficiaries Known or suspected cause(s) of issue (if applicable) Remediation plan and timeline for resolution (if applicable)/Status update if issue previously reported
EXAMPLE: Appeals and grievances
(Delete row before submitting)		 EXAMPLE:
AD_23 Grievance, other		 EXAMPLE:
Difficulty collecting data for metric AD_23.		 EXAMPLE:
8/1/18; DY 1 Qtr. 1		 EXAMPLE:
24		 EXAMPLE:
Grievances are submitted via hardcopy through the mail to regional field offices. Often the field offices are slow to report the number of grievances they have received to the central office. 		EXAMPLE:
Central office is working on an electronic grievance filing system. That system will be completed by the end of the calendar year, and we will be able to quickly generate monthly, quarterly and yearly reports regarding grievances.
Enrollment [Add rows as needed]






















Renewal [Add rows as needed]








Cost sharing limit [Add rows as needed]











Appeals and grievances [Add rows as needed]











Access to care [Add rows as needed]











Quality of care and health outcomes [Add rows as needed]











Administrative cost [Add rows as needed]











Note: States must prominently display the following notice on any display of Measure rates:

The MSC-AD, FUA-AD, FUM-AD, and IET_AD measures (metrics AD_38A, AD_39, and AD_40) are Healthcare Effectiveness Data and Information Set (“HEDIS®”) measures that are owned and copyrighted by the National Committee for Quality Assurance (“NCQA”). NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications.

The measure specification methodology used by CMS is different from NCQA’s methodology. NCQA has not validated the adjusted measure specifications but has granted CMS permission to adjust. Calculated measure results, based on the adjusted HEDIS specifications, may be called only “Uncertified, Unaudited HEDIS rates.”

Certain non-NCQA measures in the CMS 1115 eligibility and coverage demonstration contain HEDIS Value Sets (VS) developed by and included with the permission of the NCQA. Proprietary coding is contained in the VS. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. NCQA disclaims all liability for use or accuracy of the VS with the non-NCQA measures and any coding contained in the VS.



a The state should also use this column to provide updates on any data or reporting issues described in previous reports. When applicable, the state should note when issues are resolved. If an issue was noted as resolved in the previous report, it should not be reported in the current report.





End of workbook






Sheet 6: Data & Reporting Issues (CE)
Medicaid Section 1115 Eligibility and Coverage Demonstration Report - Data and reporting issues (CE)





State [Enter State Name]




Demonstration Name [Enter Demonstration Name]




Demonstration Year (DY) [Enter Demonstration Year] (Format: DY1, DY2, DY3, etc.)




Calendar Dates for DY [Enter Calendar Dates for Demonstration Year] (Format: MM/DD/YYYY - MM/DD/YYYY)




Reporting Period [Enter Reporting Period] (Format: Q1, Q2, Q3, Q4)




Calendar Dates for Reporting Period [Enter Calendar Dates for Reporting Period (Format: MM/DD/YYYY - MM/DD/YYYY)




Submitted on [Enter Date] (Format: MM/DD/YYYY)


















Data Reporting Issues (CE)


Reporting Topic Metric(s) impacted Summary of issue Date and report in which issue was first reported Estimated number of impacted beneficiaries Known or suspected cause(s) of issue (if applicable) Remediation plan and timeline for resolution (if applicable)/Status update if issue previously reported
EXAMPLE: CE.Mod_2: Establish beneficiary supports and modifications
(Delete before submitting)		 EXAMPLE:
CE_32 Beneficiaries exempt from Medicaid community engagement requirements for good cause		 EXAMPLE:
Awaiting additional data for metric CE_32 for September 2018. 		EXAMPLE:
8/1/18; DY 1 Qtr. 1		 EXAMPLE:
100		 EXAMPLE:
Good cause exemption requests filed for the September 2018 are still being processed. 		EXAMPLE:
Good cause exemption processing for September 2018 will be completed in November and at that time we will be able to report this metric accurately. An additional case worker is being assigned to these requests for more timely processing in the future.
CE.Mod_1: Specify community engagement policies [Add rows as needed]


















CE.Mod_4: Operationalize strategies for noncompliance [Add rows as needed]













Sheet 7: Version Notes
Version 1.0.
End of workbook
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