CROSSWALK: Statistical Enrollment Reports

Form

Old Version

New Version

Type of
change

Reason for Change

Burden of
change
(Yes or No)
Yes, reduced
burden

All forms
(CMS-21E;
CMS-64.21E;
CMS 64.EC;
CMS-21PW;
Gender, Race,
Ethnicity)
All forms
(CMS-21E;
CMS-64.21E;
CMS 64.EC;
CMS-21PW;
Gender, Race,
Ethnicity)
All forms
(CMS-21E;
CMS-64.21E;
CMS 64.EC;
CMS-21PW;
Gender, Race,
Ethnicity)
All forms
(CMS-21E;
CMS-64.21E;
CMS 64.EC;
CMS-21PW;
Gender, Race,
Ethnicity)
All forms
(CMS-21E;
CMS-64.21E;

The form collects data on children
enrolled in separate CHIP. The form is
broken out into separate pages for
each applicable age group, and a
separate summary form is included
that combines data reported for all of
the different age groups.
The data fields for each measure on the
form are included in one large table.

The form is displayed on one page, with
fields for each applicable age range on
separate tabs, and a separate tab for the
summary enrollment information.

Revision

This change was made in
response to feedback from
states that requested data for
each form reported on one
rather than several
pages/screens.

The data fields are broken out in separate Revision
tables for each measure.

Reformatting to improve user
interface.

No

The column headings for the data fields
on the form for each FPL category are
labeled with a letter (a,b,c,d,e,f).

The columns for the data fields on the
form for each FPL.

Revision

Assignment of special letter
for each FPL category not
needed.

No

The measures for each form are listed
in a statement format. Such as,
“Unduplicated number of children
ever-enrolled in the quarter.”

The measures for each form are listed in
a question format. Such as, “What is the
number of children ever enrolled in the
quarter?”

Revision

Plain language edits.

No

N/A

There is a field to ask the state if the form
applies to them, depending on the
programs the state operates.

Addition

This change was made so
states could indicate which

Yes, increased
burden

CMS 64.EC;
CMS-21PW;
Gender, Race,
Ethnicity)
CMS-21
Waiver

Waiver
Gender, Race,
Ethnicity
21E
Informational

64.21E
Informational

64.EC
Informational

form(s) are applicable to their
programs.
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.

N/A

Deletion

Information no longer needed. Yes, reduced
burden

N/A

Deletion

Information no longer needed. Yes, reduced
burden

This form collects employer sponsored
insurance (ESI) or dental wrap-around
enrollment data for separate CHIP. The
enrollment data is a subset of the
enrollment already reported on the
program that the child or eligible adult
is enrolled.
This form collects employer sponsored
insurance (ESI) or dental wrap-around
enrollment data for Medicaid
expansion CHIP. The enrollment data is
a subset of the enrollment already
reported on the program that the child
or eligible adult is enrolled.
This form collects employer sponsored
insurance (ESI) or dental wrap-around
enrollment data for Medicaid. The
enrollment data is a subset of the
enrollment already reported on the
program that the child or eligible adult
is enrolled.

N/A

Deletion

Information no longer needed. Yes, reduced
burden

N/A

Deletion

Information no longer needed. Yes, reduced
burden

N/A

Deletion

Information no longer needed. Yes, reduced
burden

This form collects gender, race and
ethnicity data for all enrollees
reported on the form CMS-21
Waiver.

21 Waiver
Informational

This form collects employer sponsored
insurance (ESI) or dental wrap-around
enrollment data for CHIP waivers. The
enrollment data is a subset of the
enrollment already reported on the
program that the child or eligible adult
is enrolled.

N/A

Deletion

Information no longer needed. Yes, reduced
burden