CROSSWALK: SEDS Instructions for Data Entry

Section

Old Version

New Version

Multiple
Sections/Pages

He/she language used to refer
to children/adults for which
data are reported for in the
system.
References to waiver adults
and waiver forms

Language changed to be gender
neutral such as “the child/the
pregnant woman/the individual/
they”, etc.
No references to waiver adults
and waiver forms

The link to SEDS included is
And the date of the document
is February 2015

The new link to SEDS included is
and the date of the document
updated to July 2021
N/A

Revision

“States must designate whether
their enrollment report is
preliminary or final, when they
submit their enrollment data.
States that submit preliminary
data will be able to return to

Multiple
Sections/Pages
Title Page
I. Introduction,
page 1

II. Submission
of Data, page 1

“Also included in the
system are forms that
gather further
information about the
enrolled populations
reported on the
statistical forms. These
informational forms
gather data on employer
sponsored insurance
(ESI), dental wraparound benefits and
other optional benefits.”
N/A

Type of
change
Revision

Reason for Change

Revision

Removed information
pertaining to forms that states
will no longer be required to
report on
To reflect the most current
information

No

Deletion

Removed information
pertaining to forms that states
will no longer be required to
report on.

No

Addition

Included additional instruction
to reflect the updated
submission process.

No

To include gender neutral
rather than gender specific
language

Burden of change
(Yes or No)
No

No

III. Reporting
Forms, page 2

III. Reporting
Forms, page 2

“Use one (1) copy of this form
to report data for each
separate child health program
and/or operational entity. If,
for example, a state operates
one separate child health
program that serves children
with disabilities and a second
separate child health program
that serves other children, the
state should submit two (2)
Form CMS-21Es. The system
will combine data from all
forms to create an aggregate
separate child health program
report. States with a separate
program for children eligible
due to the loss of Medicaid
based on the loss of income
disregards (the 2101(f)
protection) should report
those enrollments on this
form, but should not use an
additional copy of the form.”
“All of the above forms collect
enrollment data by age
category, CMS-defined income
levels, and type of service
delivery system. Each report
consists of screens (pages),

modify the data submission. Once
the data are finalized, the report is
locked for editing unless it is
uncertified.”
“Use one (1) copy of this form to
report data for all separate child
health programs. If, for example, a
state operates one separate child
health program that serves
children with disabilities and a
second separate child health
program that serves other
children, the single CMS-21E
should contain data for both
programs.”

“All of the above forms collect
enrollment data by age category,
CMS-defined income levels, and
type of service delivery system.
Each form consists of tabs, one for
each specified age group and a

Revision

Revised to reflect update for
states to use one form for all
separate CHIP data, rather than
multiple forms for different
CHIP programs.

No

Revision

Revised to reflect the changes
to formatting of forms in the
SEDS system from different
pages for each age group to
multiple tabs for each age
group all on one page.

No

III. Reporting
Forms, page 3

III. Reporting
Forms, page 3

III. Reporting
Forms, page 3

one for each specified age
group. Separate columns are
designated for each income
group, and separate rows for
each type of delivery system
in which enrollees may receive
health program benefits.”
“
• Form CMS-21 Waiver.
This form collects data
on adults enrolled in a
CHIP section 1115
waiver for whom the
state receives the title
XXI federal matching
rate for at least some of
the expenditures.
”
“
• Form Waiver Gender,
Race, Ethnicity. This
form collects gender,
race and ethnicity data
for all enrollees
reported on the form
CMS-21 Waiver.
”
• “Informational Forms
21E, 21PW, 64.21E,
64EC, 21 Waiver. These
forms currently collect
employer sponsored
insurance (ESI) or dental
wrap-around

summary tab with data for all age
groups combined. Separate
columns are designated for each
income group, and separate rows
for each type of delivery system in
which enrollees may receive
health program benefits.”
N/A

Deletion

Removed information
pertaining to forms that states
are no longer required to
collect data for

No

N/A

Deletion

Removed information
pertaining to forms that states
are no longer required to
collect data for

No

N/A

Deletion

Removed information
pertaining to forms that states
are no longer required to
collect data for

No

enrollment data for the
applicable program.
Other future categories
of interest may also be
added as an
informational form. The
enrollment data is a
subset of the
enrollment already
reported on the
program that the child
or eligible adult is
enrolled. (Aggregate
enrollment reports
count only the program
forms, not
informational forms.)
For example: If the state
reports 1,000 children
on the CMS- 21E, and,
of that total, 60 children
are enrolled in an ESI
program, then the state
would additionally
report on a CMS-21EI
form indicating the 60
children enrolled in the
ESI program.

III. Reporting
Forms, page 3

”
“Note on the “CHIPRA 214”
lawfully residing option: Some
states have elected the option
provided by section 214 of the
Children’s Health Insurance

“Note on the “CHIPRA 214”
lawfully residing option: Some
states have elected the option
provided by section 214 of the
Children’s Health Insurance

Deletion

Removing information about
reporting separate CHIP groups
on multiple forms since the
new system will only have one

No

Program Reauthorization Act
of 2009 to lift the 5-year bar
on coverage in Medicaid or
CHIP for certain pregnant
women and/or children who
are lawfully residing in the
United States. For those states
that cover such lawfully
residing children in Medicaid
or CHIP, or pregnant women
in CHIP (pregnant women in
Medicaid are not captured in
SEDS), those enrolled
individuals should be reported
in the same categories as
other children and pregnant
women. For children enrolled
in a separate CHIP, it is not
necessary to use an additional
copy of the form to report
lawfully residing children’s
enrollment.”
IV. Reporting
“The Affordable Care Act
Changes
(ACA) makes many changes to
Associated
eligibility and enrollment that
with the
affect both Medicaid and
Affordable
CHIP. Starting January 1, 2014,
Care Act, pages the law requires the
4-5 of old
application of new,
version
standardized income counting
rules based on Modified
Adjusted Gross Income
(MAGI), which may cause
some shifts in eligibility;

Program Reauthorization Act of
2009 to lift the 5-year bar on
coverage in Medicaid or CHIP for
certain pregnant women and/or
children who are lawfully residing
in the United States. For those
states that cover such lawfully
residing children in Medicaid or
CHIP, or pregnant women in CHIP
(pregnant women in Medicaid are
not captured in SEDS), those
enrolled individuals should be
reported in the same categories as
other children and pregnant
women”

N/A

form for all separate CHIP
programs.

Deletion

Removing outdated
information

No

increases the mandatory
Medicaid upper income limit
for children from ages 6 up to
19 years old, which may cause
some CHIP children to
transition to Medicaid;
protects certain children who
lose Medicaid as a result of
the loss of income disregards
(2101(f) protection); and
requires the use of a new,
streamlined application for
health benefits that includes
more granular racial and
ethnic categories. These
changes may affect the way in
which states currently report
data into SEDS. The changes
are summarized in Table 1
below.
To align with MAGI-based
eligibility methodologies,
effective with the second
fiscal quarter of 2014, all SEDS
forms that gather enrollment
data based on income use the
MAGI income and household
methodologies. Enrollments
are to be grouped based on
the percent of FPL as
determined using MAGI
methods, rather than
including the previous income
disregards. In addition, we

understand that because
MAGI rules took effect during
a fiscal year that the year 2014
will necessarily have
inconsistent enrollment data
between first fiscal quarter
and the three following
quarters.
States that covered children
with family income below 133
percent of the FPL in a
separate CHIP through
calendar year 2013 must
transition these children to
Medicaid in 2014. Because
expenditures for these
children are still funded
through CHIP, enrollment data
must be entered on the CMS64.21E for Medicaid
Expansion. And a few states
that enroll children protected
by 2101(f) in a separate CHIP
but do not otherwise use the
CMS-21E form for separate
child health program must
enter 2101(f) children on this
form.
States should begin to
implement the changes in
reporting to account for
MAGI- based rules,
transitioning children to
Medicaid expansion and the

2101(f) protection effective at
the beginning of the second
federal fiscal quarter of 2014
(January 1 through March 31,
2014), for which reporting was
due April 30, 2014. We are
directing states that have
already certified data for
Quarter 2 and later to go back
in the forms to make any
necessary revisions to
enrollment data and then
recertify the data.
In addition, we are taking this
opportunity to revise the
income range groups on all of
the forms such that the first
group is now 0-133 percent
FPL and the second group is
now 134-200 percent FPL. The
other income groups are
unchanged. We have also
modified the Gender, Race,
Ethnicity form to give states
the opportunity to report
additional granularity for the
Hispanic, Asian, and Native
Hawaiian or Other Pacific
Islander categories. Please see
Section V on Definitions and
Rules below for more detail on

the reporting changes
associated with the ACA.
Changes to the income range
groups on all forms and the
categories and definitions for
the Form Gender, Race,
Ethnicity are effective as of a
different date: the first fiscal
quarter of 2015 (October 1
through December 31, 2014),
for which reporting is due
January 30, 2015.”
IV. Reporting
Changes
Associated
with the
Affordable
Care Act, page
6 of old
version
Definitions and
Rules – V, page
7 (old version);
IV, page 4
(new version)

Table 1 includes information
about ACA policy
considerations for SEDS,
Programmatic Changes,
Reporting Considerations, and
Effective Dates

N/A

Deletion

Removing outdated
information

No

“Quarter and Year. Enter the
quarter (1-4) and the Federal
Fiscal Year (FFY) to which the
data pertain. The FFY runs
from October 1 through
September 30. For example,
the first quarter of FFY 2015 is
October 1 through December
31, 2014; the second quarter
is January 1 through March
31, 2015; the third quarter is
April 1 through June 30, 2015;

“Quarter and Year. Select the
quarter (1-4) and the Federal
Fiscal Year (FFY) to which the data
pertain. The FFY runs from
October 1 through September 30.
For example, the first quarter of
FFY 2021 is October 1 through
December 31, 2020; the second
quarter is January 1 through
March 31, 2021; the third quarter
is April 1 through June 30, 2021;

Revision

Updated to make dates more
current

No

Definitions and
Rules – V, page
7 (old version)

and the fourth quarter is July
1 through September 30,
2015.”
“Program Code. (This item
appears only on Form CMS21E, the separate child health
program form.) States should
report enrollment data for
each separate child health
program and/or operational
entity on a separate copy of
Form CMS-21E. The program
code uniquely identifies the
separate child health program
to which the report pertains.
To create a program code,
enter the two-letter state
abbreviation followed by a
descriptive letter or number
from 1 to 9. For example, the
State of Florida would enter
FL1, for its first separate child
health program, FL2 for its
second separate child health
program, and so forth.
Type of Eligible. (This item
appears only on Form CMS64.21E, the Medicaid
expansion form.) This twocharacter code identifies the
Medicaid expansion group or
groups to which the data
pertain.

and the fourth quarter is July 1
through September 30, 2021.”
N/A

Deletion

Removal of information that is
no longer applicable

No

Definitions and
Rules – V, page
7 (old version);
IV, page 4
(new version)

U2. Select “U2" if the state’s
Medicaid expansion covers
only the 1905(u)(2) expansion
group, optional targeted low
income children. These are
uninsured children under age
19 who meet Title XXI
eligibility requirements who
would not be eligible for
traditional Medicaid under the
state plan in effect on
3/31/97. Note: U3 is no longer
a valid selection.
”
“Age of Children or Pregnant
Women. Each reporting form
has screens (pages) for each
age group of eligible
individuals. The age groups
are defined as follows:
• “Under 0”:
conception to birth
(CMS-21E only);
• “0-1”: infants from
birth to under age
one (up to the first
birthday);
• “1-5”: age one
through age five;
• “6-12”: age six
through age 12;
• “13-18”: age 13
through age 18
inclusive (up to but

“Age of Children or Pregnant
Women. Each reporting form has
tabs for each age group of eligible
individuals. The age groups are
defined as follows:
• “Under 0”: conception
to birth (CMS-21E only);
• “0-1”: infants from birth
to under age one (up to
the first birthday);
• “1-5”: age one through
age five;
• “6-12”: age six through
age 12;
• “13-18”: age 13 through
age 18 inclusive (up to
but not including age
19);
• “19-20”: age 19 through
age 21 inclusive (up to

Revision

Updated instructions to reflect
changes to formatting of forms
and removed reference to
forms that are no longer
required.

No

•

•

Definitions and
Rules – V, page
8 (old version);
IV, page 5
(new version)

not including age
19);
“19-20”: age 19
through age 21
inclusive (up to but
not including age
21) (CMS-64EC
only); and
“19-64”: age 19
through age 64
(CMS-21PW and 21
Waiver only).

”
“Family Income. States report
data separately for all income
range groups, as applicable.
Each income range group is
specified in relation to the
federal poverty level (FPL).
Beginning in the second
federal fiscal quarter of 2014,
the FPL is determined using
MAGI-based income counting
and household composition
rules.
Each form provides five (5)
columns, to allow states to
report data in the five (5)
income range groups defined
as a percent of the FPL using
MAGI. For all quarters through
the fourth federal fiscal
quarter of 2014 (July 1
through September 30, 2014),

•
”

but not including age
21) (CMS-64EC only);
and
“19-64”: age 19 through
age 64 (CMS-21PW
only).

“Family Income. States report data Revision
separately for all income range
groups, as applicable. Each income
range group is specified in relation
to the federal poverty level (FPL).
The FPL is determined using
Modified Adjusted Gross Income
(MAGI) based income counting
and household composition rules.
Each form provides five (5)
columns, to allow states to report
data in the five (5) income range
groups defined as a percent of the
FPL using MAGI. The income
groups appear on each form as
follows:
• 0-133;
• 134-200;
• 201-250;
• 251-300;

Removal of outdated
information about previous FPL
ranges and additional clarifying
instructions included

No

the income groups are as
follows:
• 0-100;
• 101-200;
• 201-250;
• 251-300;
• 301-state specified.
Beginning in the first federal
fiscal quarter of 2015 (October
1 through December 31,
2014), for which reporting is
due January 30, 2015, the 100
percent break point is
modified to 133 percent.
Beginning in this quarter, the
income groups appear on
each form as follows:
• 0-133;
• 134-200;
• 201-250;
• 251-300;
• 301-state specified.
Please note that the upper
limit in income range group 5
is state-defined. Therefore,
each state with a maximum
income level exceeding 300
percent of the FPL must enter
the maximum income level as
approved in the state plan.
For example, if a state
program has a MAGI upper
income limit of 228 percent of

• 301-state specified.
Please note that the upper limit in
income range group 5 is statedefined. Therefore, each state
with a maximum income level
exceeding 300 percent of the FPL
must enter the maximum income
level as approved in the state
plan.
For example, if a state program
has a MAGI upper income limit of
228 percent of the FPL, then an
enrollee with a MAGI family
income at 220 percent of the FPL
is counted in the 201-250 FPL
group and an enrollee with a
MAGI family income at 182
percent of the FPL is counted in
the 134-200 FPL group.
If a state is unable to provide
enrollment data by the above FPL
groups, please report enrollment
in the lowest applicable income
category.
”

Definitions and
Rules – V, page
10 (old
version); IV,
page 6 (new
version)

Definitions and
Rules – V, page
10 (old
version); IV,
page 6 (new
version)

the FPL, then an enrollee with
a MAGI family income at 220
percent of the FPL is counted
in the 201-250 FPL group and
an enrollee with a MAGI
family income at 182 percent
of the FPL is counted in the
134-200 FPL group.
”
“Quarter and Year. Enter the
quarter (1-4) and the Federal
Fiscal Year (FFY) to which the
data pertain. The FFY runs
from October 1 through
September 30. For example,
the first quarter of FFY 2015 is
October 1 through December
31, 2014; the second quarter
is January 1 through March
31, 2015; the third quarter is
April 1 through June 30, 2015;
and the fourth quarter is July
1 through September 30,
2015.
”
“Program Forms. States must
report each enrollee’s gender,
race, and ethnicity on the
Gender, Race, Ethnicity forms.
Each of these forms have five
(5) columns, the first column
“21E Enrolled”, the second
column “64.21E Enrolled”, the
third column “Total CHIP

“Quarter and Year. Enter the
quarter (1-4) and the Federal
Fiscal Year (FFY) to which the data
pertain. The FFY runs from
October 1 through September 30.
For example, the first quarter of
FFY 2021 is October 1 through
December 31, 2020; the second
quarter is January 1 through
March 31, 2021; the third quarter
is April 1 through June 30, 2021;
and the fourth quarter is July 1
through September 30, 2021.
”

Revision

Updated to make dates more
current

No

“Program Forms. States must
report each enrollee’s gender,
race, and ethnicity on the Gender,
Race, Ethnicity forms. Each of
these forms have five (5) columns,
the first column “21E Enrolled”,
the second column “64.21E
Enrolled”, the third column “Total
CHIP Enrolled”, totals the first two

Revision

Removed information that is no No
longer applicable

Appendix,
page 1

Enrolled”, totals the first two
columns, and the fourth
column “64EC Enrolled”, the
fifth column “21PW Enrolled”.
However, the Gender, Race,
Ethnicity form for waivers has
only one (1) column, “Waiver
Adults.”
”
• “Effective January 1,
2014, each form that
gathers enrollment data
based on income uses
MAGI-based
methodologies for
income counting and
household composition.
States must report
enrollments in the
income groups based on
income as a percent of
FPL determined using
MAGI methods.
Effective October 1,
2014, the income range
groups on all of these
forms are revised such
that the first group is
now 0-133 percent FPL
and the second group is
now 134-200 percent
FPL.
”

columns, and the fourth column
“64EC Enrolled”, the fifth column
“21PW Enrolled”.
”

•

”

“Each form that gathers
enrollment data based on
income uses MAGI-based
methodologies for income
counting and household
composition. States must
report enrollments in the
income groups based on
income as a percent of FPL
determined using MAGI
methods. If a state is not
able to provide enrollment
data by the specified FPL
range breakouts, the state
should report all enrollment
in the lowest applicable
income category.

Revision

Removal of outdated
information and additional
clarifying information included

No

Appendix,
page 1

Appendix,
pages 1-2 (old
version) and
page 2 (new
version)

“•
States transitioning
children with family income
below 133 percent of the FPL
from a separate CHIP to a
Medicaid Expansion must
report these enrollments on
the CMS- 64-21E form. States
with a separate program for
children eligible due to the
loss of Medicaid based on the
loss of income disregards (the
2101(f) protection) should
report those enrollments on
the CMS-21E form. Both
effective January 1, 2014.”
“•
Children, pregnant
women, or waiver adults
whose eligibility is retroactive
to an earlier quarter should be
reported as new enrollees in
the quarter in which their
coverage became effective,
not in the quarter in which
they applied. They should be
reported as ever enrolled in
both quarters.”

N/A

Deletion

Removed outdated information

No

“
•
Children or pregnant
women whose eligibility is
retroactive to an earlier quarter
should be reported as new
enrollees in the quarter in which
their coverage became effective,
not in the quarter in which they
applied. They should be reported
as ever enrolled in both quarters.”

Revision

Removed language regarding
waiver populations that is no
longer applicable.

No