Form CMS-10657 State Flexibility Grant Annual Report Template

OMB control number: 0938-1366/Expiration date: XX/XX/XXXX

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

State
Project Title
Grant Project Director
(Name and Title)
Phone/Email
Grant Authorizing
Representative
Phone/Email

Date Grant Awarded
Amount Granted
Project Reporting Period
(Example: Annual Report
9/15/2021-9/14/2022)

Organization Information

Grant Information

The purpose of the Annual Grant Reports is to:
•

•

Provide the Centers for Medicare and Medicaid Services (CMS) with a better understanding
of the States’ progress towards planning and/or implementing several of the Patient
Protection and Affordable Care Act (PPACA) market reforms under Part A of Title XXVII
of the Public Health Service Act (PHS Act) funded through this grant program over the past
year
Provide States participating in the State Flexibility to Stabilize the Market Cycle II 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 Cycle II Grant Program Annual
Report Template

Grant Performance Period: September 15, 2021- September 14, 2023

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 Cycle II Grant is to provide
States with the opportunity to ensure their laws, regulations, and procedures are in line with
Federal requirements and that States are able to effectively oversee and enforce the identified
PHS Act title XXVII Part A market reforms and consumer protections with respect to health
insurance issuers.
States are required to submit an annual progress report to CMS’s State Flexibility to Stabilize the
Market Cycle II Grant Program. The annual progress report summarizes the significant
advancements made towards the State’s goal of planning and/or implementing the pre-selected
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 Cycle II 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 120 days following the end of a 12-month period. For example, the
annual report is due by January 12, 2023. All annual reports must be submitted electronically
through the Health Insurance Oversight System (HIOS). For the final grant year, 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 the 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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OMB control number: 0938-1366/Expiration date: XX/XX/XXXX

The State Flexibility to Stabilize the Market Cycle II 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 explanations of grant progress with quantitative data when available and other
evidence to support the success of your State Flexibility to Stabilize the Market Cycle II 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.
Annual Program Implementation Status: Include a thorough discussion and update on
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The State Flexibility to Stabilize the Market Cycle II Grant Program Annual
Report Template

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 Cycle II 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 Cycle II Grant Work Plan and companion
timeline. Provide explanation for variations and provide Progress Metrics measurements
where necessary.
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 Cycle II Grant Program
Summarize the overall impact that the State Flexibility to Stabilize the Market Cycle II 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. 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,
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The State Flexibility to Stabilize the Market Cycle II Grant Program Annual
Report Template

what approaches in your planning and/or implementation strategy worked/are working and why?
Annual Updated Budget Expenditures
Please use the below chart to provide a detailed account of expenditures for each of the grant
Activities/Projects the you originally outlined in the State Flexibility to Stabilize the Market
Cycle II Grant Work Plan, in order to illustrate the funds spent on each Activity/Project during
the past 12 months. The total amount in the Amount Budgeted in Application Column should add
up to the total amount of grant dollars you were awarded for the State Flexibility to Stabilize the
Market Cycle II Grant.

Budget Category
Personnel
Fringe Benefits
Travel
Equipment
Supplies
Contractual

Construction
Other

Amount
Budgeted in
Application
$0
$0
$0
$0
$0
$22,000

Amount Spent
in the past 12
months

Total
Amount
Spent to
Date

$1,000

$5,000

Consultant Fee for Network Design Study

$30,000

$1,000

$10,000

Consultant Fee for Study of Expansion of
Catastrophic Plan Eligibility
N/A
Data and Hosting Costs (Obtaining claims
data form APCD)

$20,000

$1,000

$5,000

$3,000

$20,000

N/A
N/A
N/A
N/A
N/A

Activity/Project

Consultant Fee for study of Reinsurance
Program and Geographic Tiering and
Funding Options

Total

$0
$15,000
$87,000

Updated Annual Work Plan and Timeline with Progress Metrics
Provide an updated State Flexibility to Stabilize the Market Cycle II 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 Cycle II 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
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The State Flexibility to Stabilize the Market Cycle II Grant Program Annual
Report Template

Stabilize the Market Cycle II Grant Program.
Annual Statistics
Funds Expended

FFY22
FFY22
FFY22
FFY22
Quarter 1 Quarter 2 Quarter 3 Quarter 4

Total

Number of Staff Hired
with Grant Funds
Number of Contracts in
place 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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