Form CMS-10657 State Flexibility Grant Annual Report Template

The State Flexibility to Stabilize the Market Grant Program
Annual Report Template

OMB control number: 0938-NEW
Expiration date: XX/XX/XXXX

Report Date
Organization Information
State
Project Title
Grant Project Director
(Name and Title)
Phone/Email
Grant Authorizing
Representative
Phone/Email
Grant Information
Date Grant Awarded
Amount Granted
Project Reporting Period
(Example: Annual Report
8/20/2018-8/19/2019)
The purpose of the Annual Grant Reports is to:
•
•
•

Describe the planning and/or implementation for several of the market reforms under Part A of Title
XXVII of the Public Health Service Act (PHS Act) over the prior year.
Summarize the initiatives of the Patient Protection Affordable Care Act (PPACA) market reform
provisions funded through the grant program.
Provide grantees participating in the State Flexibility to Stabilize the Market Grant Program with the
opportunity to share information, highlight successes and reflect upon the progress of their programs

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The State Flexibility to Stabilize the Market Grant Program
Annual Report Template
Grant Performance Period: August 20, 2018 - August 19, 2020
The provisions in Part A of title XXVII of the PHS Act include market-wide reforms in the group and
individual private health insurance markets intended to protect consumers, increase transparency, and
regulate health insurance industry practices.
One of the goals of the State Flexibility to Stabilize the Market Grant is to provide States with the
opportunity to ensure their laws, regulations, and procedures are in line with Federal law, and enhance
the States’ ability to effectively regulate their respective health insurance markets through innovative
measures that support the pre-selected market reforms and consumer protections under Part A of Title
XXVII of the PHS Act.
States are required to submit an annual progress report to CMS. The annual progress report summarizes
the significant advancements made towards the State’s goal of planning and/or implementing the preselected market reforms provisions under Part A of Title XXVII of the PHS Act, over the course of the
Grant Program.
Funding under the State Flexibility to Stabilize the Market Grant Program is available to States for
activities related to planning and implementing the following provisions of Part A of title XXVII of the
PHS Act:
Section 2702 – Guaranteed Availability of Coverage
Section 2703 – Guaranteed Renewability of Coverage
Section 2707 – Non-discrimination under Comprehensive Health Insurance Coverage (Essential Health
Benefits Package)
The annual report is due ninety days following the end of a 12 month period (August 20, 2018 - August
19, 2019). For example, the annual report is due by November 19, 2019. All annual reports must be
submitted electronically through the Health Insurance Oversight System (HIOS). For the final year of
the grant period, the final report will replace the annual report.
The following reporting guidelines are intended as a framework and can be modified when agreed upon
by CMS and the State. A complete annual progress report must detail how grant funds are being utilized,
describe program progress, barriers, and provide an update on the measurable objectives of the grant
program.

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The State Flexibility to Stabilize the Market Grant Program
Annual Report Template
PART I: NARRATIVE REPORT FORMAT
Introduction:
The Annual Narrative Report represents the culmination of activities and accomplishments
throughout the past twelve months of the grant program. In the Annual Narrative Report, please
support your explanation of grant progress with quantitative data when available and provide
other evidence to illustrate the success of your State Flexibility to Stabilize the Market Grant
Program.
In order to provide metrics for CMS to monitor the progress of each activity, grantees are
required to report quantitative measurements using the following Progress Metrics Guide:
Level of Stages

Description of Stages

Stage 0

No work has begun on stated goal.

Stage 1

Project Plan has been created and staff has
been assigned to task. The work on achieving
the goal has initially begun.

Stage 2

Goal of the Project Plan is underway, and any
refinements or adjustments to original Project
Plan were made.

Stage 3

Goal of the Project Plan is half way complete
and continuously being worked on.

Stage 4

Deliverables are beginning to finalize and
proposed goals are nearly completed.

Stage 5

100% of stated goal has been completely
achieved.

EXAMPLE: Objective 1 was to hire additional staff to conduct formulary reviews: “We worked
throughout the past 12 months to hire two clinicians to conduct formulary review. We achieved
this objective when we were able to successfully hire two clinicians. Objective 1: Stage 5”.
Please use this guide when answering the following questions. In addition, please use charts
and graphs to highlight progress when appropriate.

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The State Flexibility to Stabilize the Market Grant Program
Annual Report Template

Annual Program Implementation Status: Include a thorough discussion and update on
progress towards the following:
1. Accomplishments to Date: Describe achieved implementation milestones and outcomes,
include Progress Metrics towards each stated goal, objective and milestone outlined in
the State Flexibility to Stabilize the Market Grant Work Plan.
2. Challenges faced this year: Provide a detailed description of any encountered challenges
in implementing your program, the response and the outcome. Please include a list of any
proposed grant activities that were not completed during the prior twelve months. Please
include Progress Metrics for each activity not completed. Describe future plans to
complete the originally proposed grant activities.
3. Variations of Work Plan and Timeline: List any required variations from the original
State Flexibility to Stabilize the Market Grant Work Plan and companion timeline.
Provide explanation for variations and provide Progress Metrics measurements where
necessary.
Significant Activities: Undertaken and Planned
Please list the most significant activities that occurred during the past year, or are anticipated to
occur in the near future. Please include Progress Metrics to illustrate progress.
Operational/Policy Developments/Issues
Identify all significant program developments/issues/problems that have occurred in the past
twelve months and proposed ways to rectify the barriers.
Public Access Activities
Summarize activities and/or promising practices undertaken during the previous twelve months,
working towards increased public access and awareness from the pre-selected PPACA market
reforms activities for your State. To illustrate progress, please include Progress Metrics for each
activity or practice.
Materials Produced
Discuss all materials produced and/or developed over the past twelve months, including website
upgrades, consumer materials, reports/studies, and any other relevant documents. Please provide
detail where available. For example, if a new website related to the pre-selected PPACA market
reforms was developed, please provide the link, date the website went live, number of visitors to
the website (total or monthly). Additionally, please include Progress Metrics for each material
produced or developed.
Annual Impact of the State Flexibility to Stabilize the Market Grant Program
Summarize the overall impact that the State Flexibility to Stabilize the Market Grant Program
grant funds had on planning and/or implementing the pre-selected PPACA market reforms over
the past twelve months. Include data on how the grant program enhanced the public’s
understanding of the pre-selected PPACA market reforms. Provide evidence when available.
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The State Flexibility to Stabilize the Market Grant Program
Annual Report Template

Examples may include dollar amounts, statistics, personal stories, anecdotal evidence, media
articles/mentions, etc.
Annual Lessons Learned
Provide additional information on lessons learned and any promising practices. For example,
what approaches in your planning and/or implementation strategy worked/are working and why?
Annual Updated Budget
Provide a detailed account of expenditures to date and describe whether the current allocation of
funds follows the progression of the detailed budget provided in your original application. Also,
provide any unforeseen expense and a brief description of the event that led to its occurrence.
Attach an updated detailed budget, including an updated SF-424A as necessary, with the State’s
annual report submission.
Updated Annual Work Plan and Timeline with Progress Metrics
Provide an updated State Flexibility to Stabilize the Market Grant Work Plan and Timeline with
Progress Metrics to reflect the events of the previous year. Highlight any additional time frames
or items that were not included on the State’s original submission as well as completion of
milestones. Please continue to use the Progress Metrics guide, and assign a measurement to each
objective outlined in the work plan.
Updated Evaluation Plan
Please provide an update to the Evaluation Plan originally described in the State Flexibility to
Stabilize the Market Grant application, including updates to the established measurable
objectives, key indicators, and methods and/or resources to monitor progress. If contracting for
an evaluation, discuss progress with the contract.
Annual Report Summary Statistics:
Please fill in the data below for all grant activity occurring during the State Flexibility to
Stabilize the Market Grant Program.
Annual Statistics

FFY18
Quarter 4

FFY19
Quarter 1

Funds Expended
Number of Staff Hired with
Grant Funds
Number of Contracts in
place with Grant Funds
Number of PPACA Market
Reforms Provision Funded
by Grant. List Provisions

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FFY19
Quarter 2

FFY19
Quarter 3

Total

The State Flexibility to Stabilize the Market Grant Program
Annual Report Template

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