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pdfMEDICAID SECTION 1115 DEMONSTRATIONS
Monitoring Metrics for Demonstrations with Community Engagement and Other
Eligibility and Coverage Policies
This document provides an overview of monitoring metrics for states with section 1115
demonstrations that include community engagement (CE), premium or other monthly payment,
marketplace-focused premium assistance, health behavior incentives, or retroactive eligibility
waiver policies. These demonstrations are collectively referred to as eligibility and coverage
demonstrations.
An important goal of monitoring eligibility and coverage demonstrations is to identify trends
that suggest the need for adjustments to improve demonstration performance and protect
beneficiaries. These metrics are designed to monitor demonstration performance while
minimizing state reporting burden. This set focuses on metrics that can be calculated from
Medicaid administrative data. Monitoring metrics may be useful to include in formal evaluations
along with more complex outcome measures and those that draw on non-administrative data
sources, including beneficiary surveys.
These monitoring metrics were developed with input from subject matter experts in the
Centers for Medicare & Medicaid Services (CMS). While most eligibility and coverage metrics
track administrative processes and monitor protections provided to beneficiaries, a few refer to
established quality measures. 1 Note that these metrics are not stand-alone quality measures
themselves and were not tested as such for the demonstrations. They are intended only for
monitoring progress of eligibility and coverage demonstrations.
The eligibility and coverage metrics are organized into six modules. States will be asked to
report the metrics in module 1 (any demonstration with eligibility and coverage policies) and
those in any additional modules corresponding to the policies included in their demonstration.
For example, a state with section 1115 authority for community engagement and premiums will
report the metrics in the corresponding modules (2 and 5), as well as the module for any
demonstration with eligibility and coverage policies (1). States will only be asked to report
metrics that are relevant given the state’s overall demonstration design. Depending on the
operational details of a state’s demonstration, some metrics may not be applicable. CMS will
work with states to align reporting requirements with specific state policies as needed.
The metrics are listed by module in the tables that follow, beginning with metrics for any
demonstration with eligibility and coverage policies (module 1), and followed by modules for
demonstrations with premiums, premium assistance, health behavior incentives, CE, and
retroactive eligibility waivers (modules 2 through 6). The table for each module includes the
following information:
•
Required or Recommended. Metrics are either required or recommended
-
Required metrics provide information that is critical for monitoring the success of
eligibility and coverage demonstrations and could be constructed with data that are
readily available to states.
1
Metrics AD_38 through AD_44 in module 1 refer to established quality measures. Metrics AD_38_A and AD_39
through AD_44 are Adult Core Set measures.
1
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.
MEDICAID SECTION 1115 DEMONSTRATIONS
•
•
Recommended metrics might be more difficult to obtain than required metrics, but still
provide important information on the operation of a demonstration.
Subpopulations. Some populations may be uniquely impacted by eligibility and coverage
demonstrations. When instructed by metric specifications, states should calculate and report
metrics separately for subpopulations, including:
-
Income groups includes reported income subpopulations defined as less than 50% of the
federal poverty level (FPL), 50-100% FPL, and more than 100% FPL. States should
report income subpopulations using these categories, unless states want to report finer
gradations for income groups along which a policy varies (e.g., 100-115% FPL and
115%+ FPL), in which case those should be reported instead.
-
Specific demographic groups includes age, sex, and race/ethnicity.
♦
Age is defined in groups as follows: 19-26, 27-35, 36-45, 46-55, or 56-64.
♦
Sex is defined as male or female.
♦
Race is defined as White, Black or African American, Asian, American Indian or
Alaskan Native, other, or unknown.
♦
Ethnicity is defined Hispanic, non-Hispanic, or unknown.
-
Exempt groups are in eligibility and income groups that are enrolled in the
demonstration but are not required to participate in elements of the demonstration (such
as community engagement requirements). For example, exempt groups may include
geographic exemptions, employer sponsored insurance exemptions, or exemptions due
to medical frailty. Exempt groups will vary by state based on the special terms and
conditions (STCs) authorizing a demonstration. Exempt groups are included in metrics
in the any demonstration module (module 1), but states are asked to report on them
separately.
-
Specific eligibility groups include section 1931 parents, the new adult group, transitional
medical assistance beneficiaries, and other Medicaid eligibility groups included in the
state’s demonstration. Eligibility groups will vary by state based on the STCs
authorizing a demonstration. Reporting by specific eligibility groups is required for
applicable metrics.
Measurement period. This parameter identifies the data collection time frame for each
metric. Measurement periods may be a month, quarter, or demonstration year or calendar
year. Calendar year metrics, which are the quality of care and health outcomes measures in
module 1, may have additional requirements, such as a continuous eligibility period that
begins in the prior year. Monthly metrics are reported to CMS in quarterly and annual
reports, according to specifications.
2
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 1: Overview of eligibility and coverage metrics standard across any demonstration with premiums,
Marketplace-focused premium assistance, health behavior incentives, community engagement
requirements, or retroactive eligibility waivers
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
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.
Required
X
X
X
X
Month
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.
Required
X
X
X
X
Month
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.
Required
X
X
X
X
Month
3
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 1 (continued)
Subpopulations
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Metric
Metric name and description
AD_4
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 reinstated) in the current measurement period by using a
state-defined pathway for re-enrollment (or reinstatement 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.
Required
X
X
X
X
Month
AD_5
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.
Required
X
X
X
X
Month
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).
Required
X
X
X
X
Month
Required
X
X
X
X
Month
Mid-year loss of demonstration eligibility
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.
4
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 1 (continued)
Subpopulations
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Metric
Metric name and description
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.
Required
X
X
X
X
Month
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.
Required
X
X
X
X
Month
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.
Required
X
X
X
X
Month
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.
Recommended
X
X
X
X
Month
Recommended
X
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.
5
Month
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 1 (continued)
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
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.
Recommended
X
Month
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.
Recommended
X
Month
Renewal
AD_15
Beneficiaries due for renewal. Total number of
beneficiaries enrolled in the demonstration who were
due for renewal during the measurement period.
Required
X
X
X
X
Month
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.
Required
X
X
X
X
Month
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.
Required
X
X
X
X
Month
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.
Required
X
X
X
X
Month
6
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 1 (continued)
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
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.
Required
X
X
X
X
Month
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.
Required
X
X
X
X
Month
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.
Required
X
X
X
X
Month
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.
Recommended
X
X
X
X
Month
Required
X
X
X
X
Month
Cost sharing limit
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.
Appeals and grievances
AD_24
Appeals, eligibility. Number of appeals filed by
beneficiaries enrolled in the demonstration during the
measurement period regarding Medicaid eligibility.
Recommended
7
Quarter
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 1 (continued)
Subpopulations
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Metric
Metric name and description
AD_25
Appeals, denial of benefits. Number of appeals filed
by beneficiaries enrolled in the demonstration during the
measurement period regarding denials of benefits.
Recommended
Quarter
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.
Recommended
Quarter
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).
Recommended
Quarter
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.
Recommended
Quarter
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.
Required
Quarter
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.
Required
Quarter
AD_31
Specialist provider availability. Number of specialists
enrolled to deliver Medicaid services at the end of the
measurement period.
Required
Quarter
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.
Required
Quarter
8
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 1 (continued)
Subpopulations
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Metric
Metric name and description
AD_33
Preventive care and office visit utilization. Total
utilization of preventative care and office visits per 1,000
demonstration beneficiary months during the
measurement period.
Recommended
X
X
X
X
Quarter
AD_34
Prescription drug use. Total utilization of 30-day
prescription fills per 1,000 demonstration beneficiary
months in the measurement period.
Recommended
X
X
X
X
Quarter
AD_35
Emergency department utilization, total. Total
number of emergency department (ED) visits per 1,000
demonstration beneficiary months during the
measurement period.
Recommended
X
X
X
X
Quarter
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/nonemergent copayments, then non-emergency visits
should be defined as all visits not categorized as
emergent using the method below.
Recommended
X
X
X
X
Quarter
AD_37
Inpatient admissions. Total number of inpatient
admissions per 1,000 demonstration beneficiary months
during the measurement period.
Recommended
X
X
X
X
Quarter
9
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 1 (continued)
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Quality of care and health outcomes
AD_38A
Medical Assistance with Smoking and Tobacco Use
Cessation (MSC-AD). 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
Required
(AD_38A or
AD_38B)
X
X
Calendar year
AD_38B
Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention. 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.
Required
(AD_38A or
AD_38B)
X
X
Calendar year
10
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 1 (continued)
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
AD_39-1
Follow-Up After Emergency Department Visit for
Alcohol and Other Drug Abuse or Dependence
(FUA-AD). Percentage of ED visits for beneficiaries age
18 and older who have a principal 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).
Required
X
X
Calendar year
AD_39-2
Follow-Up After Emergency Department Visit for
Mental Illness (FUM-AD). 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).
Required
X
X
Calendar year
11
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 1 (continued)
Subpopulations
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Metric
Metric name and description
AD_40
Initiation and Engagement of Alcohol and Other
Drug Abuse or Dependence Treatment (IET-AD).
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.
Required
X
X
Calendar year
AD_41
PQI 01: Diabetes Short-Term Complications
Admission Rate (PQI01-AD). 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.
Required
X
X
Calendar year
AD_42
PQI 05: Chronic Obstructive Pulmonary Disease
(COPD) or Asthma in Older Adults Admission Rate
(PQI05-AD). Number of inpatient hospital admissions
for chronic obstructive pulmonary disease (COPD) or
asthma per 100,000 beneficiary months for
beneficiaries age 40 and older.
Required
X
X
Calendar year
12
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 1 (continued)
Subpopulations
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Metric
Metric name and description
AD_43
PQI 08: Heart Failure Admission Rate (PQI08-AD).
Number of inpatient hospital admissions for heart failure
per 100,000 beneficiary months for beneficiaries age 18
and older.
Required
X
X
Calendar year
AD_44
PQI 15: Asthma in Younger Adults Admission Rate
(PQI15-AD). Number of inpatient hospital admissions
for asthma per 100,000 beneficiary months for
beneficiaries aged 18 to 39.
Required
X
X
Calendar year
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, and/or community
engagement.
Recommended
13
Demonstration
year
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 2: Additional metrics relevant for states that require premiums or account payments
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Enrollment by premium payment status
PR_1
Beneficiaries subject to premium policy (or account
contribution) during the month, not exempt. The number
of beneficiaries enrolled in the demonstration whose income
and eligibility group were subject to the premium policy (or
account contribution policy), regardless of whether they paid
or did not pay during the measurement period.
Required
X
X
Month
PR_2
Beneficiaries who were exempt from premiums for that
month. Among beneficiaries enrolled in the demonstration
who were subject to the premium (or account contribution)
policy on the basis of income or eligibility group, the count of
those exempt from owing premiums or other monthly
payments, and therefore not required to make payments. For
example, demonstration policies may exempt beneficiaries
who would otherwise be subject to premiums as health
behavior incentives or other activities.
Required
X
X
Month
PR_3
Beneficiaries who paid a premium during the month.
Among beneficiaries enrolled in the demonstration whose
income and eligibility group were subject to the premium (or
account contribution) policy, number of beneficiaries who paid
this month.
Required
X
X
Month
PR_4
Beneficiaries who were subject to premium policy but
declare hardship for that month. Among beneficiaries
enrolled in the demonstration whose income and eligibility
group were subject to the premium (or account contribution)
policy, number of beneficiaries who were able to claim
temporary hardship and were therefore not required to make
a payment in the measurement period.
Required
X
X
Month
PR_5
Beneficiaries in short-term arrears (grace period). Among
beneficiaries enrolled in the demonstration whose income and
eligibility group were subject to the premium (or account
contribution) policy, the number of those who did not pay in
the measurement period, but have not yet exceeded their
grace period.
Recommended
X
X
Month
14
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 2 (continued)
Subpopulations
Metric
Metric name and description
PR_6
Beneficiaries in long-term arrears. Among beneficiaries
enrolled in the demonstration whose income and eligibility
group were subject to the premium (or account contribution)
policy, number of beneficiaries who did not pay this month,
and who remain enrolled even though they have exceeded
the grace period.
PR_7
Beneficiaries with collectible debt. Among beneficiaries
enrolled in the demonstration whose income and eligibility
group were subject to the premium policy (or account
contribution policy), number of beneficiaries who had
collectible debt.
Specific
eligibility
groups
Measurement
period
X
X
Month
X
X
Month
Required or
recommended
Income
groups
Recommended
Required
Specific
demographic
groups
Exempt
groups
Cumulative enrollment duration in states with time-variant premium policies
PR_8
Beneficiaries in enrollment duration tier 1. Number of
beneficiaries enrolled in the demonstration and subject to
premium policies whose cumulative length of enrollment fell in
tier 1 - the shortest enrollment duration, during which
beneficiaries are subject to the first set of program rules and
requirements. Tiers are defined in terms of enrollment periods
that are distinguished by different premium or copayment
liabilities.
Recommended
X
X
Month
PR_9
Beneficiaries in enrollment duration tier 2. Number of
beneficiaries enrolled in the demonstration and subject to
premium policies whose cumulative length of enrollment fell in
tier 2 - the enrollment duration that follows tier 1, during which
beneficiaries are subject to the set of program rules and
requirements in effect after exceeding the enrollment duration
for tier 1. Tiers are defined in terms of enrollment periods that
are distinguished by different premium or copayment
liabilities.
Recommended
X
X
Month
15
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 2 (continued)
Subpopulations
Metric
Metric name and description
PR_10
Beneficiaries in enrollment duration tiers 3+. Number of
beneficiaries enrolled in the demonstration and subject to
premium policies whose cumulative length of enrollment fell in
tier 3 - the enrollment duration that follows tier 2, during which
beneficiaries are subject to the set of program rules and
requirements in effect after exceeding the enrollment duration
for tier 2. Tiers are defined in terms of enrollment periods that
are distinguished by different premium or copayment
liabilities.
States with more than three tiers of program rules should
calculate additional metrics to report enrollment counts for
current enrollees within each tier.
Specific
eligibility
groups
Measurement
period
X
X
Month
Required or
recommended
Income
groups
Recommended
Specific
demographic
groups
Exempt
groups
Mid-year change in circumstance by premium amount
PR_11
Beneficiaries for whom the state processed a mid-year
change in circumstance in household or income
information and who remained enrolled in the
demonstration. Among beneficiaries enrolled in the
demonstration who were not in their renewal month, number
of beneficiaries for whom the state processed a change in
household size or income during the measurement period and
who remained enrolled in the demonstration.
Recommended
X
X
Month
PR_12
No premium change following mid-year processing of a
change in household or income information. Among
beneficiaries enrolled in the demonstration who experienced a
change in household size or income during the month (not
their renewal month) and remained enrolled in the
demonstration as of the last day of the measurement period,
the number whose premium obligations or other monthly
payments did not change.
Recommended
X
X
Month
16
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 2 (continued)
Subpopulations
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Metric
Metric name and description
PR_13
Premium increase following mid-year processing of
change in household or income information. Among
beneficiaries enrolled in the demonstration who experienced a
change in household size or income during the month (not
their renewal month) and remained enrolled in the
demonstration as of the last day of the measurement period,
the number whose premium obligations or other monthly
payments increased.
Recommended
X
X
Month
PR_14
Premium decrease following mid-year processing of
change in household or income information. Among
beneficiaries enrolled in the demonstration who experienced a
change in household size or income during the month (not
their renewal month) and remained enrolled in the
demonstration as of the last day of the measurement period,
the number whose premium obligations or other monthly
payments decreased.
Recommended
X
X
Month
Disenrollment or suspension for failure to pay
PR_15
Beneficiaries disenrollment from the demonstration for
failure to pay and therefore disenrolled from Medicaid.
Number of demonstration beneficiaries disenrolled from
Medicaid as of the last day of the measurement period for
failure to pay premiums.
Required
X
X
X
Month
PR_16
Beneficiaries in a non-eligibility period who were
disenrolled for failure to pay and are prevented from reenrolling for a defined period of time. The number of prior
demonstration beneficiaries who were disenrolled from
Medicaid for failure to pay premiums and are in a noneligibility 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.
Required
X
X
X
Month
PR_17
Beneficiaries whose benefits are suspended for failure to
pay. Number of demonstration beneficiaries whose benefits
were suspended during the measurement period for failure to
pay premiums.
Required
X
X
X
Month
17
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 2 (continued)
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Renewal
PR_18
No premium change. Number of beneficiaries enrolled in the
demonstration due for renewal during the measurement
period who are redetermined as eligible for the demonstration
and remain in income and eligibility groups subject to
premiums, with no change in premiums or other monthly
payments.
Recommended
X
X
Month
PR_19
Premium increase. Number of beneficiaries enrolled in the
demonstration due for renewal during the measurement
period who were redetermined as eligible for the
demonstration and remain in income and eligibility groups
subject to premiums, with an increase in required premiums
or other monthly payments.
Recommended
X
X
Month
PR_20
Premium decrease. Number of beneficiaries enrolled in the
demonstration due for renewal during the measurement
period who were redetermined as eligible for the
demonstration and remained in income and eligibility groups
subject to the demonstration, with a decrease in required
premiums or other monthly payments.
Recommended
X
X
Month
Required
X
X
Month
Third party premium payment
PR_21
Third-party premium payment. Number of beneficiaries
enrolled in the demonstration who had any portion of their
premium or other monthly payments paid by a third party.
18
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 3: Additional metrics relevant for states with Marketplace-focused premium assistance programs
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Enrollment by premium payment status
PA_1
Beneficiaries who lost Medicaid eligibility due to mid-year
change in circumstance, and transitioned to a qualified
health plan offered in the Marketplace. Number of
demonstration beneficiaries who lost eligibility for Medicaid
during the measurement period due to a change in
circumstance who transitioned to a qualified health plan offered
in the Marketplace (Health Insurance Exchange).
Required
X
X
X
Month
PA_2
Beneficiaries who lost Medicaid eligibility at renewal, and
transitioned to a qualified health plan offered in the
Marketplace. Number of demonstration beneficiaries who lost
eligibility for Medicaid during the measurement period due to the
outcome of eligibility renewal processes and transitioned to a
qualified health plan offered in the Marketplace (Health
Insurance Exchange).
Required
X
X
X
Month
Recommended
X
X
X
Quarter
Access to care
PA_3
Wraparound service utilization, by service. Total utilization of
wraparound services during the measurement period per 1,000
demonstration beneficiary months during the measurement
period.
19
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 4: Additional metrics relevant for states with programs with health behavior incentives
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Specific
eligibility
groups
Measurement
period
Required
X
X
X
Quarter
Required
X
X
X
Quarter
Exempt
groups
Enrollment
HB_1
Total enrollment among beneficiaries subject to health
behavior incentives. Number of beneficiaries subject to health
behavior incentive policies who were enrolled in the
demonstration at any time during the measurement period.
Use of incentivized services: claims-based analysis
HB_2
Beneficiaries using incentivized services that can be
documented through claims, by service. Total number of
beneficiaries enrolled in the demonstration at any point during
the measurement period who utilized financially incentivized
services that can be documented through claims since the
beginning of their enrollment spell.
Other incentivized behaviors not documented through claims-based analysis
HB_3
Completion of incentivized health behavior(s) not
documented through claims analysis (i.e., health risk
assessments), by health behavior. Number of beneficiaries
enrolled in the demonstration at any point during the
measurement period who have completed each incentivized
health behavior not documented through claims analysis (i.e.
health risk assessments) since the beginning of their
enrollment spell.
Required
X
X
X
Quarter
HB_4
Completion of all incentivized health behaviors (both
claims-based and other), if there are multiple. Number of
beneficiaries enrolled in the demonstration at any point during
the measurement period who have completed all health
behaviors (including incentivized services documented through
claims and other health behaviors not documented through
claims) since the beginning of their enrollment spell.
Required
X
X
X
Quarter
20
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 4 (continued)
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Rewards granted for completion of incentivized health behaviors
HB_5
Beneficiaries granted a premium reduction for completion
of incentivized health behaviors. Number of beneficiaries
enrolled in the demonstration who were flagged for or granted
a reward related to premium obligations during the
measurement period, regardless of whether the premium
reduction occurs during the measurement period or in the
future.
Required
X
X
X
Quarter
HB_6
Beneficiaries granted a financial reward other than a
premium reduction for completion of incentivized health
behaviors. Number of beneficiaries enrolled in the
demonstration who were flagged for or granted a reward other
than a premium reduction during the measurement period,
regardless of when the reward is realized.
Required
X
X
X
Quarter
HB_7
Beneficiaries granted a reward in the form of additional
covered benefits for completion of incentivized health
behaviors. Number of beneficiaries enrolled in the
demonstration who were flagged for or granted a reward that
takes the form of an additional covered benefit or service, by
benefit or service type, during the measurement period.
Required
X
X
X
Quarter
21
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 5: Additional metrics relevant for states with community engagement requirements
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Community engagement enrollment
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.
Required
X
X
Month
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.
Required
X
X
Month
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.
Required
X
X
Month
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.
Required
X
X
Month
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.
Required
X
X
Month
22
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 5 (continued)
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
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.
Required
X
X
Month
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”
and therefore are not suspended (if state has this policy).
Required
X
X
Month
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
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.
Required
X
X
Month
Required
X
X
Month
Community engagement requirement qualifying activities
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.
23
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 5 (continued)
Subpopulations
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Metric
Metric name and description
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.
Required
X
X
Month
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, who were engaged in onthe-job training, job skills training, vocational education and
training, job search activities, job search training, a statesponsored workforce program, or similar activity.
Required
X
X
Month
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, who were engaged in education related
to employment, general education, accredited English-as-asecond-language education, accredited homeschooling, or a
state-designated class.
Required
X
X
Month
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.
Required
X
X
Month
24
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 5 (continued)
Subpopulations
Metric
Metric name and description
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.
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Required
X
X
Month
Basis of beneficiary exemptions from community engagement requirement
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.
Required
X
X
Month
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.
Required
X
X
Month
CE_17
Beneficiaries exempt from 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.
Required
X
X
Month
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.
Required
X
X
Month
25
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 5 (continued)
Subpopulations
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Metric
Metric name and description
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.
Required
X
X
Month
CE_20
Beneficiaries exempt from Medicaid community engagement
requirements due to 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.
Required
X
X
Month
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.
Required
X
X
Month
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.
Required
X
X
Month
CE_23
Beneficiaries exempt from 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.
Required
X
X
Month
26
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 5 (continued)
Subpopulations
Metric
Metric name and description
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.
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Required
X
X
Month
Required
X
X
Month
Supports and assistance
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.
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.
Recommended
X
X
Month
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.
Recommended
X
X
Month
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.
Recommended
X
X
Month
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.
Recommended
X
X
Month
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.
Recommended
X
X
Month
27
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 5 (continued)
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Reasonable modifications for beneficiaries with disabilities
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.
Recommended
X
X
Month
CE_32
Beneficiaries 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.
Recommended
X
X
Month
New suspensions and disenrollments during the measurement period
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).
Required
X
X
Month
CE_34
Beneficiaries newly disenrolled for noncompliance with
community engagement requirement. The number of
demonstration beneficiaries newly disenrolled for noncompliance
with community engagement requirements during the
measurement period.
Required
X
X
Month
Required
X
X
Month
Reinstatement of benefits after suspension
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.
28
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 5 (continued)
Subpopulations
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Metric
Metric name and description
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.
Recommended
X
X
Month
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.
Recommended
X
X
Month
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 stateapproved educational course.
Recommended
X
X
Month
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.
Recommended
X
X
Month
29
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 5 (continued)
Subpopulations
Metric
Metric name and description
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.
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
Recommended
X
X
Month
Re-entry after disenrollment
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.
Required
X
X
Month
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).
Recommended
X
X
Month
CE_43
Beneficiaries re-enrolling after completing “on-ramp”
activities other than qualifying community engagement
activities. Total number of demonstration beneficiaries reenrolled 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).
Recommended
X
X
Month
30
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 5 (continued)
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
CE_44
Beneficiaries re-enrolling after re-applying, subsequent to
being disenrolled for noncompliance with community
engagement requirements. The number of beneficiaries reenrolled 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.
Recommended
X
X
Month
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).
Recommended
X
X
Month
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).
Recommended
X
X
Month
31
MEDICAID SECTION 1115 DEMONSTRATIONS
Module 6: Additional metrics relevant for states with retroactive eligibility waivers
Subpopulations
Metric
Metric name and description
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement
period
At application
RW_1
Beneficiaries who indicated that they had unpaid medical
bills at the time of application. The number of demonstration
beneficiaries in income and eligibility groups that were subject
to the waiver of retroactive eligibility policy, who began a new
enrollment period in the reporting month, and who indicated at
the time of application for Medicaid that they had unpaid
medical bills from the past three months.
Required
Month
At renewal
RW_2
Beneficiaries who had a coverage gap at renewal. The
number of demonstration beneficiaries in income and eligibility
groups that were subject to the waiver of retroactive eligibility
policy and who re-enrolled in the demonstration within 90 days
after a previous enrollment spell in the demonstration ended
because the beneficiary did not comply with renewal processes
on time.
Required
Quarter
RW_3
Beneficiaries who had a coverage gap at renewal and had
claims denied. The number of demonstration beneficiaries in
income and eligibility groups that were subject to the waiver of
retroactive eligibility policy who re-enrolled in the demonstration
within 90 days after a previous enrollment spell in the
demonstration ended, and for whom claims were submitted for
services rendered during the period of disenrollment and were
denied by the state.
Required
Quarter
32
| File Type | application/pdf |
| File Title | Monitoring Metrics for Demonstrations with Community Engagement and Other Eligibility and Coverage Policies |
| Subject | eligibility, coverage, community engagement, monitoring, metrics, Section 1115" |
| Author | Centers for Medicare & Medicaid Services (CMS) |
| File Modified | 2019-09-20 |
| File Created | 2019-07-08 |