| Form Information | |
| Form Name | State Exchange Improper Payment Measurement (SEIPM) Data Request Form (DRF) |
| Form Number | TBD |
| Revision Date | 1/3/2021 |
| OMB Disclosure Statement | According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX (Expires XX/XX/XXXX). This is a mandatory information collection. The time required to complete this information collection is estimated to average 719 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Peter Calhoun at [email protected]. |
| SEIPM Data Request Form Background |
| Per the Patient Protection and Affordable Care Act (ACA) (Pub. L. 111–148), the Health Care and Education Reconciliation Act (Pub. L. 111–152), and the Payment Integrity Information Act (PIIA) (Pub. L. 116-117), The Centers for Medicare & Medicaid Services (CMS) are to use a systematic method to conduct improper payments measurements for the Health Insurance Exchanges. This includes the Federally Facilitated Exchanges (FFE), State Exchanges using the Federal Platform (SE-FPs) and State Partnership Exchanges (SPEs). This also includes independent state Exchanges (SEs). For the SEs, this program is known as the State Exchange Improper Payments Measurement (SEIPM) Program. To facilitate SEIPM, CMS is requesting that the state Exchange provide (1) Pre-sampling Information and (2) Sampled Unit Data in a uniform format through the use of this SEIPM Data Request Form (DRF). Pre-sampling Information will be used to understand the application population for each state Exchange so that an appropriate sample set can be selected that best represents the application population. After CMS selects the sample, CMS will request Sampled Unit Data and supporting documentation for each selected sample which includes information on verification, eligibility, enrollment, and plan management. The Sampled Unit Data will be used to conduct the SEIPM reviews to determine SE compliance with federal regulations. |
| Change History | ||
| Change Date | Changed By | Change Description |
| 9/29/2021 | Dell Conate | * Created a "Change History" tab to track changes to the form * Compiled instructions in "Instructions" tab * Under Instructions" tab, (1) provided clarification on how Phase 1 pre-sampling data will be used for Phase 2 data collection (2) Provided clarification on how copies of the consumer documents listed in the 'Verification Inconsistency' tab will be requested and uploaded into CMS Box (3) added note regarding SE Specific Defined fields * Inserted Data Dictionary into this workbook as a tab * Under "Data Dictionary" tab, added (1) Incarceration field definitions (2) Residency field definitions (3) Pre-sampling form definitions (4) SE Defined fields definitions * Under "Pre-sampling" tab, (1) clarified field title that "Exchange Assigned Policy ID" will be filled in by CMS (2) added "Selected For Sample (Filled Out by CMS)" * Under "Verification Events" tab, added Incarceration Verification and Residency Verification fields * Under each Phase 2 Sampled Unit Data Collection tab, added SE Specific Defined Field placeholders |
| 10/11/2021 | Dell Conate | * Under "Verification Inconsistency" tab, deleted "Mode of Receipt", "Doc Received Date" as it’s the same information requested in "All Consumer Documents" and "Relevant Consumer Documents" |
| 10/17/2021 | Dell Conate | Removed State Exchange (SE) defined fields from each tab |
| 11/8/2021 | Dell Conate | * Added Form Information tab * Moved OMB Disclosure to Form Information tab * Revised Background tab description * Revised Instructions tab to have specific steps for each tab request * Revised Data Dictionary to include (1) "N/A" in blank Element Detail field (2) Remove references to FFE (3) reduce lengthy descriptions (4) take out "e.g." (5) provide same format/values for similar fields (6) Put values in quotes (7) Add dollar signs for values (8) Eliminate exact timeframe from regulations reference * Moved Data Dictionary to the end of workbook * Added hyper-link from column to Data Dictionary |
| Instructions | |
| Phase 1: Pre-Sampling Data | |
| Note: Pre-sampling data is used to associate the units to be sampled with all policy identification numbers that received an APTC within the benefit year under review. | |
| Tab Name | Instructions |
| Pre-Sampling | The State Exchange (SE) will be given a list of all policies under Column A "Exchange Assigned Policy ID (Filled Out By CMS)". These are policies that were transmitted to CMS as part of the State Based Marketplace Inbound (SBMI) process which had an Applied APTC payments greater than $0 over the course of the Plan Year. Please provide the following information associated with these policies under the designated columns within the tab: 1) Map the policies to their associated tax households using a unique identifier, providing the mapping under Column B "Tax Household Grouping Identifier". Note: if the SE does not have a designated system identifier for tax households, please generate a proxy identifier that can represent the tax household. 2) Provide the count of verification inconsistencies by their inconsistency type in Columns C through G. It's acceptable to have values of "Y/N" to indicate whether an inconsistency exists if the SE is not able to provide specific inconsistency counts. 3) Provide the number of tax household members in Column H "Number of Tax Household Members" for each tax household in the list. Note: Column I "Selected For Sample (Filled Out By CMS)" will be filled in by CMS after it has received the requested pre-sampling information from the SE. CMS will evaluate the requested data and will select a sample that can best represent the applicant population. |
| Phase 2: Sampled Unit Data Collection | |
| Note: Information for Phase 2 will be requested after CMS selects the samples based on the information provided by the SE from Phase 1. The selected samples will be indicated by a "Y" flag under field "Selected For Sample (Filled Out By CMS)" in the "Pre-Sampling" tab | |
| Tab Name | Instructions |
| Policy | 1) Refer back to Column I "Selected for Sample (Filled Out By CMS)" in the "Pre-Sampling" tab and find the line items where it has been marked by CMS with a "Y". Note the "Tax Household Grouping Identifier" which will be used to populate the columns within this tab. 2) For each of the noted "Tax Household Grouping Identifier", provide all "Application ID", "Application Version", "Application Submission Date", and "Person Tracking Number" that were submitted for that tax household within the Plan Year. These five columns constitute the primary key that organizes the tax household by their application submissions for each of their members. It will also be used to link information provided in the other tabs of this workbook. 3) For each of the "Person Tracking Number", with consideration in the context of their "Application ID", "Application Version" and "Application Submission Date", provide the requested Policy Information in Columns F through Column N. Note: the "Data Dictionary" tab provides the definitions for each of the requested information elements |
| Tax Filing | 1) Refer back to Column I "Selected for Sample (Filled Out By CMS)" in the "Pre-Sampling" tab and find the line items where it has been marked by CMS with a "Y". Note the "Tax Household Grouping Identifier" which will be used to populate the columns within this tab. 2) For each of the noted "Tax Household Grouping Identifier", provide all "Application ID", "Application Version", "Application Submission Date", and "Person Tracking Number" that were submitted for that tax household within the Plan Year. These five columns constitute the primary key that organizes the tax household by their application submissions for each of their members. It will also be used to link information provided in the other tabs of this workbook. 3) For each of the "Person Tracking Number", with consideration in the context of their "Application ID", "Application Version" and "Application Submission Date", provide the requested Tax Filing Information in Columns F through Column J. Note: the "Data Dictionary" tab provides the definitions for each of the requested information elements |
| Member Demographics | 1) Refer back to Column I "Selected for Sample (Filled Out By CMS)" in the "Pre-Sampling" tab and find the line items where it has been marked by CMS with a "Y". Note the "Tax Household Grouping Identifier" which will be used to populate the columns within this tab. 2) For each of the noted "Tax Household Grouping Identifier", provide all "Application ID", "Application Version", "Application Submission Date", and "Person Tracking Number" that were submitted for that tax household within the Plan Year. These five columns constitute the primary key that organizes the tax household by their application submissions for each of their members. It will also be used to link information provided in the other tabs of this workbook. 3) For each of the "Person Tracking Number", with consideration in the context of their "Application ID", "Application Version" and "Application Submission Date", provide the requested Member Demographic Information in Columns F through Column X. Note: the "Data Dictionary" tab provides the definitions for each of the requested information elements |
| Verification Events | 1) Refer back to Column I "Selected for Sample (Filled Out By CMS)" in the "Pre-Sampling" tab and find the line items where it has been marked by CMS with a "Y". Note the "Tax Household Grouping Identifier" which will be used to populate the columns within this tab. 2) For each of the noted "Tax Household Grouping Identifier", provide all "Application ID", "Application Version", "Application Submission Date", and "Person Tracking Number" that were submitted for that tax household within the Plan Year. These five columns constitute the primary key that organizes the tax household by their application submissions for each of their members. It will also be used to link information provided in the other tabs of this workbook. 3) For each of the "Person Tracking Number", with consideration in the context of their "Application ID", "Application Version" and "Application Submission Date", provide the requested Verification Events Information in Columns F through Column CA. Note: the "Data Dictionary" tab provides the definitions for each of the requested information elements |
| Verification Inconsistency | 1) Refer back to Column I "Selected for Sample (Filled Out By CMS)" in the "Pre-Sampling" tab and find the line items where it has been marked by CMS with a "Y". Note the "Tax Household Grouping Identifier" which will be used to populate the columns within this tab. 2) For each of the noted "Tax Household Grouping Identifier", provide all "Application ID", "Application Version", "Application Submission Date", and "Person Tracking Number" that were submitted for that tax household within the Plan Year. These five columns constitute the primary key that organizes the tax household by their application submissions for each of their members. It will also be used to link information provided in the other tabs of this workbook. 3) For each of the "Person Tracking Number", with consideration in the context of their "Application ID", "Application Version" and "Application Submission Date", provide the requested Verification Inconsistency Information in Columns G through Column AL. 4) For fields "Relevant Consumer Documents" and "All Consumer Documents", CMS is requesting information on the relevant consumer documents that were used to resolve the inconsistency as well as all consumer documents that were submitted by the consumer regardless of whether it was used for resolution, respectively. CMS would like to receive copies of these consumer documents for review and will work with the SE to submit data via a secured method. Note: the "Data Dictionary" tab provides the definitions for each of the requested information elements |
| Eligibility Events | 1) Refer back to Column I "Selected for Sample (Filled Out By CMS)" in the "Pre-Sampling" tab and find the line items where it has been marked by CMS with a "Y". Note the "Tax Household Grouping Identifier" which will be used to populate the columns within this tab. 2) For each of the noted "Tax Household Grouping Identifier", provide all "Application ID", "Application Version", "Application Submission Date", and "Person Tracking Number" that were submitted for that tax household within the Plan Year. These five columns constitute the primary key that organizes the tax household by their application submissions for each of their members. It will also be used to link information provided in the other tabs of this workbook. 3) For each of the "Person Tracking Number", with consideration in the context of their "Application ID", "Application Version" and "Application Submission Date", provide the requested Eligibility Events Information in Columns F through Column AE. Note: the "Data Dictionary" tab provides the definitions for each of the requested information elements |
| SEP Manual | 1) Refer back to Column I "Selected for Sample (Filled Out By CMS)" in the "Pre-Sampling" tab and find the line items where it has been marked by CMS with a "Y". Note the "Tax Household Grouping Identifier" which will be used to populate the columns within this tab. 2) For each of the noted "Tax Household Grouping Identifier", provide all "Application ID", "Application Version", "Application Submission Date", and "Person Tracking Number" that were submitted for that tax household within the Plan Year. These five columns constitute the primary key that organizes the tax household by their application submissions for each of their members. It will also be used to link information provided in the other tabs of this workbook. 3) For each of the "Person Tracking Number", with consideration in the context of their "Application ID", "Application Version" and "Application Submission Date", provide the requested SEP Manual Verification Information in Columns F through Column T. 4) For fields "Relevant Consumer Documents" and "All Consumer Documents", CMS is requesting information on the relevant consumer documents that were used to resolve the SEP manual verification as well as all consumer documents that were submitted by the consumer regardless on whether it was used for resolution, respectively. CMS would like to receive copies of these consumer documents for review and will work with the SE to submit data via a secured method. Note: the "Data Dictionary" tab provides the definitions for each of the requested information elements |
| Redetermination Events | 1) Refer back to Column I "Selected for Sample (Filled Out By CMS)" in the "Pre-Sampling" tab and find the line items where it has been marked by CMS with a "Y". Note the "Tax Household Grouping Identifier" which will be used to populate the columns within this tab. 2) For each of the noted "Tax Household Grouping Identifier", provide all "Application ID", "Application Version", "Application Submission Date", and "Person Tracking Number" that were submitted for that tax household within the Plan Year. These five columns constitute the primary key that organizes the tax household by their application submissions for each of their members. It will also be used to link information provided in the other tabs of this workbook. 3) For each of the "Person Tracking Number", with consideration in the context of their "Application ID", "Application Version" and "Application Submission Date", provide the requested Redetermination Event Information in Columns F through Column X. Note: the "Data Dictionary" tab provides the definitions for each of the requested information elements |
| Enrollment Reconciliation | 1) Refer back to Column I "Selected for Sample (Filled Out By CMS)" in the "Pre-Sampling" tab and find the line items where it has been marked by CMS with a "Y". Note the "Tax Household Grouping Identifier" which will be used to populate the columns within this tab. 2) For each of the noted "Tax Household Grouping Identifier", provide all "Application ID", "Application Version", "Application Submission Date", and "Person Tracking Number" that were submitted for that tax household within the Plan Year. These five columns constitute the primary key that organizes the tax household by their application submissions for each of their members. It will also be used to link information provided in the other tabs of this workbook. 3) For each of the "Person Tracking Number", with consideration in the context of their "Application ID", "Application Version" and "Application Submission Date", provide the requested Enrollment Reconciliation Event Information in Columns F through Column V. Note: the "Data Dictionary" tab provides the definitions for each of the requested information elements |
| Plan Management | 1) Refer back to Column I "Selected for Sample (Filled Out By CMS)" in the "Pre-Sampling" tab and find the line items where it has been marked by CMS with a "Y". Note the "Tax Household Grouping Identifier" which will be used to populate the columns within this tab. 2) For each of the noted "Tax Household Grouping Identifier", provide all "Application ID", "Application Version", "Application Submission Date", and "Person Tracking Number" that were submitted for that tax household within the Plan Year. These five columns constitute the primary key that organizes the tax household by their application submissions for each of their members. It will also be used to link information provided in the other tabs of this workbook. 3) For each of the "Person Tracking Number", with consideration in the context of their "Application ID", "Application Version" and "Application Submission Date", provide the requested QHP Information in Columns F through Column K. Note: the "Data Dictionary" tab provides the definitions for each of the requested information elements |
| Data Dictionary | Definitions for the requested information on any of the tabs can be found by searching under Column A "Information Element". The definition for each Information Element can also be accessed using hyperlinks throughout this workbook. |
| Tax Filing Information | |||||||||
| Primary Key | Tax Filing Information | ||||||||
| Tax Household Grouping Identifier | Application Identifier | Application Version | Application Submission Date | Person Tracking Number | Multiple Tax Household Indicator | Tax Filing Status | Tax Filer Indicator | Tax Dependent Indicator | Member Association Role Type |
| Data Dictionary | |||||
| Information Element | Element Definition | Element Detail | Format | Length | Example |
| Adjudication History | A description of the history of adjudicating an inconsistency. | This is a free text field that provides a narrative of the end-to-end chronology of events associated with an inconsistency to enhance the interpretation of the events related to adjudicating the inconsistency. The field will contain, but are not limited to the following elements: - The current status of the inconsistency type being reviewed. - The date the issue was submitted. - The inconsistency that was created and the Clock End Date that was associate with the task. - The list of documents that were submitted by the consumer and the dates they were submitted. - The Adjudication Date. |
Alphanumeric | 1000 | "This inconsistency was resolved on 01-01-2020 using an I-551 card. DHS SAVE was not used." |
| Adjusted FPL Percentage | Application member's annual income as percentage of the Federal Poverty Level (FPL) amount, calculated per advanced payment tax credit rule published by the Treasury. This value will be populated after an event related to the computation of the rating engine that occurs in relationship with the specific applicant application. | This data element will be a number between 0.00 and 400.00 representing 0% to 400% of the federal poverty level, respectively. | Numeric | 8 | "229%" |
| Aggregated APTC Payment from Prior Year | Sum of payments made to the prior year application which is linked to the tax household being evaluated for the present benefit year. | N/A | Decimal | 10 | "10000" |
| Alien ID Indicator | Indicates whether the consumer provided an Alien ID. | Indicator of whether the DMI was adjudicated using the consumer Alien ID. Possible values are: - "Yes – Alien ID number was used to resolve the issue." - "No – Alien ID number was not used to resolve the issue." |
Alphanumeric | 100 | "Yes – Alien ID number was used to resolve the issue", "No – Alien ID number was not used to resolve the issue" |
| All Consumer Documents | A list of all consumer documents received by the Exchange associated to the members of an application, including the type(s) of documents received, the date(s) the documents were received and the mode they were received. If providing multiple documents, please separate document by semi-colon |
N/A | Alphanumeric | 1000 | "I-551 Card (Received on 01-01-2020) via Mailroom, Passport (Received on 02-01-2020) uploaded to web site, 1040 (Received on 03-01-2020) via Mailroom" |
| Annual Income Inconsistency | The number of annual income verification inconsistencies that were associated to a tax household for a given plan year. Note: if SE cannot provide a specific count, then a "Y/N" value is acceptable to indicate that an inconsistency type exists for the tax household | N/A | Numeric | 3 | "1", "8", "Y", "N" |
| Applicant Attested Qualifying Life Event | List of life events and associated dates that applicant attested to. | N/A | Alphanumeric | 100 | "Newborn SEP (11/11/2021)" |
| Application Creation Date | A field that is used to reflect the date that an application was created prior to being submitted. | This date associates to a unique application version. | Date | 8 | "12JAN2021" |
| Application Enrollment Period Type | The enrollment period for the creation of the application. | Enrollment period includes: - Open Enrollment - Special Enrollment |
Alphanumeric | 100 | "Open Enrollment", "Special Enrollment" |
| Application Event Source | The origin event that led to the creation or change, update to an application. | The application can be originated from any of the following sources: - Consumer online submission - Issuer direct enrollment - Submission from third parties - Inbound account transfer - Manual verification worker - Appeals group - Other Note: Application submission from third parties include those events originated from agents, brokers, navigators or assisters, call center workers etc.. |
Alphanumeric | 100 | "Consumer online submission" |
| Application Event Type | The different types of events that led to the creation or change, update to an application. | Application events types include: - Initial Application - Change in Circumstances (aka. Change Report) - Period Data Matching (PDM) for Death - PDM for Medicare - PDM for Medicaid and CHIP - PDM for Failure to Reconcile (FTR) - Auto Re-enrollment - Updates as a result of manual verification - Updates as a result of appeal - Other |
Alphanumeric | 100 | "Initial Application" |
| Application Identifier | A unique identifier for an application household (or households) during a given Plan / Benefit Year. |
In the event that a given tax household is represented among two or more applications or policies for QHP/APTC eligibility within a specific Plan / Benefit Year, CMS would want to be able to map all related applications pertaining to the same tax household. If an Exchange does not have such an identifier at the household level, this identifier should be created for each sample. The EIPM will be providing sampled Policy Identifiers (Exchange assigned). The Exchange is expected to identify all related Policies from the same household. |
Alphanumeric | 100 | "A123456", "12345678", "A1-2024-MD" -- (an example of a generated Application Identifier for the Plan Year 2024 review for the state of MD) |
| Application Member Identifier | An identifier assigned to each member of an application. | Any time a new application is submitted, a new application member ID is provided for each member of the application. This member ID should stay with the member in subsequent versions of the application . |
Alphanumeric | 10 | "1", "2", "3" |
| Application Submission Date | A field that is used to reflect the date that an application was submitted. | This date associates to a unique application. | Date | 8 | "12JAN2021" |
| Application Submission Date for Current Version used use AR_RU3 | Application Submission Date for Current Version used use AR_RU3. | N/A | Date | 8 | "12JAN2021" |
| Application Submission Date for Prior Version used use AR_RU3 | Application Submission Date for Prior Version used use AR_RU3. | N/A | Date | 8 | "12JAN2021" |
| Application Version | A sequence number that is used to distinguish various events for an application, i.e. the creation and subsequent changes or updates made to an application during a Plan / Benefit Year. | There are often multiple application versions that associate to a given application due to any number of events that may occur throughout the Plan / Benefit Year (e.g. reports of Change in Circumstance, Periodic Data Matching, Redeterminations of Eligibility, etc.). In the event an Exchange uses unique identifiers, such as Physical and Logical Application and Policy IDs, to distinguish these events from the same household, the Exchange is expected to apply sequence numbers for each of these events. An alternative might be using dates for the new policies resulted from application events. |
Alphanumeric | 100 | "1", "2", "01/22/2020" |
| Application Version Deleted Flag for Current Version used use AR_RU3 | Based Deleted Flag indicator for Current version used in AR_RU3. | N/A | Character | 5 | "True", "False", "Yes", "No", "Y", "N" |
| Application Version Deleted Flag for Prior Version used use AR_RU3 | Based Deleted Flag indicator for prior version used in AR_RU3. | N/A | Character | 5 | "True", "False", "Yes", "No", "Y", "N" |
| APTC Eligibility Date | Date when the APTC eligibility was determined for an application member. | N/A | Date | 8 | "12JAN2021" |
| APTC Eligibility Indicator | Indicates if member is eligible for APTC. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| APTC Eligibility Indicator for Current Version used use AR_RU3 | APTC Eligibility for Current application version used for AR_RU3. | The indication whether the applicant APTC eligibility was successful. | Character | 5 | "True", "False", "Yes", "No", "Y", "N" |
| APTC Eligibility Indicator for Prior Version used use AR_RU3 | APTC Eligibility for prior application version used for AR_RU3. | The indication whether the applicant APTC eligibility was successful. | Character | 5 | "True", "False", "Yes", "No", "Y", "N" |
| APTC Eligibility Reason | Reason for how the given APTC eligibility determination was reached. | N/A | Alphanumeric | 100 | "Applicant has employee sponsored coverage (ESC)", "Income is out of FPL range", "Applicant meets all APTC eligibility criteria" |
| Attempt Made to DHS SAVE Indicator | Indicates whether the ESW made an attempt to DHS SAVE. | Indicator of whether the DMI was adjudicated per a search in DHS SAVE using the consumer provided Alien ID or I-94 number. Values for this field are: - Yes – DHS SAVE was used to resolve the issue. - No – DHS SAVE was not used to resolve the issue. |
Alphanumeric | 100 | "Yes – DHS SAVE was used to resolve the issue", "No – DHS SAVE was not used to resolve the issue" |
| Attested Non-ESC MEC Type | The applicant's attestation of the specific Non-ESC MEC type that they currently hold or plan to hold during the benefit year. | N/A | Alphanumeric | 100 | "VA", "Medicaid/CHIP", "Medicare", "Peace Corp", "Tricare" |
| Attested Annual Household Income | The amount of annual income an applicant attested to on the application. | N/A | Decimal | 10 | "60000" |
| Attested Circumstance Change Date | The date the circumstance change occurred. | N/A | Date | 8 | "12JAN2021" |
| Attested Circumstance Change Type | The circumstance change type attested by the applicant. |
N/A | Alphanumeric | 100 | "Adoption", "Newborn", "Marriage", "Relocation", "Loss of MEC" |
| Attested Citizenship Status Indicator | Indicates whether applicant attests he/she is a US citizen. | This indicator associates to each unique member on the application. | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested Coverage Request | An indicator that the application member attested to applying for coverage. | This indicator associates to each unique member on the application. | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested ESC Offer | Indicates whether an applicant is eligible for Employer Sponsored health coverage. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested Financial Assistance Request | An indicator that the application member attested to requesting financial assistance. | This indicator associates to the tax household on the application. | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested Household Income Level | Attested annual tax household income amount. | N/A | Decimal | 10 | "60000" |
| Attested Incarceration Pending Disposition Indicator | Indicates whether an applicant attested to being in pending disposition for incarceration. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested Incarceration Status Indicator | Indicates whether an applicant attested to being incarcerated. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested Information Change Reported Indicator | Indicates that the insurance applicant understands that changed information needs to be reported. | Changed information can include but not limited to: * Member demographic information * Life events (e.g., marriage, adoption) * Annual income increase/decrease * Lawful presence status change |
Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested Lawfully Present Status Indicator | Indicates whether an applicant attests to being lawfully present. | This indicator associates to each unique member on the application. | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested No Fixed Address | Indicates whether an applicant has no fixed address. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested Non-ESC MEC Offer | Indicates whether the applicant attests to being enrolled in non-employer sponsored health coverage. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested Non-Perjury Indicator | Indicates that the insurance applicant certifies that attestations are true under penalty of perjury. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested Person Recognized Tribe Indicator | Indicates if a person attested to being a member of a federally recognized tribe, band, nation, or community. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Attested Tax Household Size | Attested number of individuals in the application related to tax filer members. | N/A | Integer | 10 | "2" |
| Attested Temporary Absence | Indicates whether this application member attests to living outside of the state temporarily. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Auto Re-enrolled for past 2 Benefit Years | Indicator that applicant was auto re-enrolled in the past two benefit years. | Derived by RC examining past 2 benefit years and determining whether those applications originated from auto re-enrollments. | Character | 5 | "True", "False", "Yes", "No", "Y", "N" |
| Auto Re-Enrollment Denial Reason | The reason an application member was denied auto re-enrollment and QHP Eligibility and APTC Eligibility is terminated. | N/A | Alphanumeric | 100 | "Failure to provide sufficient documentation to allow Auto-reenrollment" |
| Auto Re-Enrollment Eligible Indicator | Indicates whether an application member has passed the state exchange's auto re-enrollment criteria. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Birth Date | Birth date of an application member. | N/A | Date | 8 | "12JAN2021" |
| Medicaid/ CHIP Benefits End Date | The date that the application Medicaid/ CHIP state health benefits eligibility ended or will end. | N/A | Date | 8 | "12JAN2021" |
| Chosen for ESC Sampling | Applicant was selected as a part of the statistically significant subset and will be verified via the sampling process. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Citizenship Inconsistency | The number of citizenship verification inconsistencies that were associated to a tax household for a given plan year. Note: if SE cannot provide a specific count, then a "Y/N" value is acceptable to indicate that an inconsistency type exists for the tax household | N/A | Numeric | 3 | "1", "8", "Y", "N" |
| Citizenship Inconsistency Manual Adjudication Conducted | Indicates whether a citizenship verification inconsistency was manually adjudicated. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Citizenship Status Verification Event ID | The event ID of the citizenship status verification event. | This field may not be applicable to all Exchanges. |
Alphanumeric | 100 | "12345678" |
| Citizenship Verification Date | Date when verification of citizenship attestation was conducted. | This date associates to each unique member on the application. | Date | 8 | "12JAN2021" |
| Citizenship Verification Reason | The findings used to set the final verification result in corroborating the consumer’s attestation. | Reasons for the verification result can vary depending on the verification logic used by the Exchange. For example, the reason could be ‘Inconsistent with External Data Source’ if the verification logic is simply using a basic comparison of the consumer’s attestation with those observed from the external data source. If the consumer does not exactly match the external data source, then the consumer receives a Verification Result of ‘Inconsistent’. | Alphanumeric | 1000 | "External data source not reasonably compatible with attestation", "Applicant did not give sufficient information", "Applicant attestation was over set thresholds" |
| Citizenship Verification Result | The final determination on whether the Exchange was able to verify the consumer’s attestation. | The verification result should clearly indicate if the verification was successful in verifying the attestation, or if inconsistency was found. | Alphanumeric | 100 | "Yes", "No", "Success", "Failure", "Verified", "Inconsistency Found" |
| Citizenship/Lawful Presence Inconsistency Indicator | Indicator as to whether the application has a Citizenship/LP inconsistency triggered. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Citizenship/LP Status Verification Event ID | The event ID of the citizenship/lawful presence status verification event. | This field may not be applicable to all Exchanges. |
Alphanumeric | 100 | "12345678" |
| Consumer Documents Expiration Date | Date of expiry of the consumer submitted document. | N/A | Date | 8 | "12JAN2021" |
| Consumer Documents Issue Date | Date of issuance of the consumer submitted document. | N/A | Date | 8 | "12JAN2021" |
| Consumer Documents Received Date | Date(s) of receipt of the consumer submitted document. | Dates of receipt of the consumer submitted documents for manual verification. This information could be provided together with the list of consumer documents in a text field or could be provided for each separately listed documents. | Date | 8 | "12JAN2021" |
| Consumer Documents Reflected in Manual Income Verification Result | Consumer documents reflected in standard or custom tool / method / process for manual verification. | This may not be applicable to Exchanges. |
Alphanumeric | 1000 | "1040" |
| Consumer Income Document Effective End Date | The effective start date of the income document as submitted by the consumer. | This field could be used to understand the effective date range of the income document. This field may not be applicable to all Exchanges. | Date | 8 | "12JAN2021" |
| Consumer Income Document Effective Start Date | The effective start date of the income document as submitted by the consumer. | This field could be used to understand the effective date range of the income document. This field may not be applicable to all Exchanges. | Date | 8 | "12JAN2021" |
| Consumer Income Documented Amount | The amount of total annual tax income of the tax household calculated by the inconsistency verification worker based on documentation the applicant provided. | Examples of income sources could be from an employer pay stub, 1040, etc. | Decimal | 10 | "60000" |
| Coverage 60 Days Before Marriage Indicator | Indicates whether the application member attested to having MEC within 60 days before the attested marriage date. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Coverage 60 Days Before Move Indicator | Indicates whether the application member attested to having MEC within 60 days before the attested move date | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Coverage Year | Indicates the year the applicant applies for coverage. | N/A | Integer | 10 | "2021", "2022", "2023" |
| Death Data Present | SSA indicated that applicant is associated with death data. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Death Date | Death date of applicant. | N/A | Date | 8 | "12JAN2021" |
| Death PDM Actual Run Date | Date when Death PDM was executed for application member. | N/A | Date | 8 | "12JAN2021" |
| Death PDM Scheduled Date | The date during the benefit year when the Death PDM is scheduled to occur. | There should be at least one date scheduled for Death PDM. | Date | 8 | "12JAN2021" |
| Death Resolution Status | Status used to indicate whether or not an applicant has resolved death-related issues with application. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| DHS SAVE Manual Verification Indicator | An indicator that reflects whether DHS SAVE (Systematic Alien Verification for Entitlements) was used to manually verify an applicant's attestation of lawful presence status. - N/A – The inconsistency was not related immigration status. - Yes Successful – Alien ID was provided by consumer and lawful presence was determined = Yes using DHS SAVE. - Not Successful – Alien ID was provided but lawful presence could not be verified. - Not Attempted – Alien ID was either: - Not provided and not used - Provided but not used for resolution |
DHS SAVE is a Third Party Data Source that is used when performing electronic verification (Step 1). Steps 2 and 3 may be used during the manual verification process to verify applicants' lawful presence status. - N/A – The inconsistency was not related immigration status. - Yes Successful – Alien ID was provided by consumer and lawful presence was determined = Yes using DHS SAVE. - Not Successful – Alien ID was provided but lawful presence could not be verified. - Not Attempted – Alien ID was either: - Not provided and not used - Provided but not used for resolution |
Alphanumeric | 100 | "N/A", "Yes Successful", "Not Successful", "Not Attempted" |
| Eligible for ESC Sampling | The applicant is eligible to be added to the ESC sampling frame. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Enrollee Tax Return Access Authorization | An indication of whether the tax data used in the application can be used at the time of renewal. True or false. | XML Data | Character | 5 | "True", "False", "Yes", "No", "Y", "N" |
| ESC Data Found | Indicates whether or not ESC verification data was found in the data source. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| ESC Data Source | The external data source that is used to verify the ESC attestation. | N/A | Alphanumeric | 100 | "Office of Personnel Management", "Employer Sampled Information" |
| ESC Inconsistency Manual Adjudication Conducted | Indicates whether an ESC verification inconsistency was manually adjudicated. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| ESC MEC Inconsistency | The number of ESC MEC verification inconsistencies that were associated to a tax household for a given plan year. Note: if SE cannot provide a specific count, then a "Y/N" value is acceptable to indicate that an inconsistency type exists for the tax household | N/A | Numeric | 3 | "1", "8", "Y", "N" |
| ESC Meets MEC and Affordability Standards | Indicates whether consumers ESC meets Minimum Essential Coverage (MEC) and Affordability standards | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| ESC Verification Determination Date | The date that the application ESC verification was determined. | N/A | Date | 8 | "12JAN2021" |
| ESC Verification Reason | The findings used to set the final verification result in corroborating or disagreeing with the consumer’s attestation. | Reasons for the verification result can vary depending on the verification logic used by the Exchange. For example, the reason could be ‘Inconsistent with External Data Source’ if the verification logic is simply using a basic comparison of the consumer’s attestation with those observed from the external data source. If the consumer does not exactly match the external data source, then the consumer receives a Verification Result of ‘Inconsistent’. | Alphanumeric | 1000 | "External data source not reasonably compatible with attestation", "Applicant did not give sufficient information", "Applicant attestation was over set thresholds" |
| ESC Verification Result | Indicator denoting the verification result of an ESC verification. | N/A | Alphanumeric | 10 | "Yes", "No", "Success", "Failure", "Verified", "Inconsistency Found", "Hold" |
| Escalation Guidance | Indicates whether an application was escalated to proper authorities for review and guidance. | This may not apply to all Exchanges. | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Essential Health Benefits Policy Premium Amount | Essential Health Benefits (EHB) policy premium amount in a given month. | N/A | Decimal | 10 | "2000" |
| Exchange Applied SEP Determination Date | The date that the exchange applied SEP was determined for the application version. | N/A | Date | 8 | "12JAN2021" |
| Exchange Applied SEP End Date | The date that the exchange applied SEP ended or will end. | N/A | Date | 8 | "12JAN2021" |
| Exchange Applied SEP Indicator | Indicator that marks the SEP that was applied by the exchange. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Exchange Applied SEP Start Date | The date that the exchange applied SEP started or will start. | N/A | Date | 8 | "12JAN2021" |
| Exchange Assigned Policy ID | A unique identifier assigned by the exchange to the insurance policy. | N/A | Alphanumeric | 100 | "12345678" |
| Exchange Assigned Policy ID (Filled Out By CMS) | A unique identifier assigned by the exchange to the insurance policy. | N/A | Alphanumeric | 100 | "12345678" |
| Exchange Benefit End Date | Benefit end date for the QHP coverage period as reflected by Exchange records. | N/A | Date | 8 | "12JAN2021" |
| Exchange Benefit Start Date | Benefit start date for the QHP coverage period as reflected by Exchange records. | N/A | Date | 8 | "12JAN2021" |
| Exchange Certified Plan Identifier | Insurance plan identifier for plans that have been listed as certified by Exchange. | This indicator is made of a code, 2 sets of numbers identifying the plan selected, with the state abbreviation in between them. | Alphanumeric | 100 | "99969OH100010" |
| Exchange Effectuation Status | Indicates whether the applicant paid their initial premium for a given policy as indicated by Exchange. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Exchange Policy Applied APTC Amount | The policy applied APTC the Exchange reported in their reconciliation output (RCNO) file that was sent to the issuer. | N/A | Decimal | 10 | "2000" |
| Failure to Reconcile Indicator | Indicates whether the tax household anchor attested that the tax household reconciled to premium tax credits on last year's tax return. | XML Data | Character | 5 | "True", "False", "Yes", "No", "Y", "N" |
| Federal Poverty Level Amount | This is the Federal Poverty Level (FPL), as published on the first day of the regular enrollment period for coverage by a qualified health plan (QHP) through an Exchange for a calendar year, for a family size equal to tax household size without regard to lawful presence status. | FPL guidelines can be found at https://aspe.hhs.gov/poverty-guidelines. | Decimal | 10 | "60000" |
| First Name | First name of application member | N/A | Alphanumeric | 100 | "Sherwin" |
| FPL Percentage Per Attested Income | Income as a percentage of the Federal Poverty Level (FPL) amount, calculated per advanced payment tax credit rules published by the treasury based on information provided by the consumer. | APTC eligible range is 100.00% to 400.00%. | Decimal | 10 | "60000" |
| FTR PDM Actual Run Date | Date when FTR PDM was executed for application member. | N/A | Date | 8 | "12JAN2021" |
| FTR PDM Confirmed Expiration | The applicant has failed to resolve the FTR issue within the given resolution period. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| FTR PDM Confirmed Expiration Date | The date when applicant failed to resolve their FTR issue within the allotted resolution period. | N/A | Date | 8 | "12JAN2021" |
| FTR PDM Scheduled Date | The date during the benefit year when the FTR PDM is scheduled to occur. | There should be at least one date scheduled for Death PDM. | Date | 8 | "12JAN2021" |
| Good Faith Extension | Indicator that reflects whether a good faith extension has been applied to the inconsistency clock end date. | The field could be populated with the following: - The date and time that a Clock End Date was extended, by applying GFE, the reason for the extension. - What the clock End Date was before the GFE was applied and after. - Blank: No GFE |
Alphanumeric | 1000 | "Yes (with original clock end date, extended clock end date, and reason)", "No" |
| Home City | Applicant home city. | N/A | Alphanumeric | 100 | "McLean" |
| Home State Code | Applicant home state code. | N/A | Alphanumeric | 10 | "VA" |
| Home Street Address | Applicant home street address. | N/A | Alphanumeric | 100 | "123 Forrest Street" |
| Home Zip Code | Applicant home zip code. | N/A | Alphanumeric | 10 | "22102" |
| I-94 Number Indicator | Indicates whether the consumer provided an I-94 number. | Indicator of whether the DMI was adjudicated using the consumer I-94 number. Values for this field are: - Yes – I-94 number was used to resolve the issue. - No – I-94 number was not used to resolve the issue. |
Alphanumeric | 100 | "Yes – I-94 number was used to resolve the issue", "No – I-94 number was not used to resolve the issue" |
| Immigration Status Expiration Date | Date when consumer's immigration status expires and needs to be redetermined. | N/A | Date | 8 | "12JAN2021" |
| Incarceration Inconsistency Manual Adjudication Conducted | Indicates whether an Incarceration verification inconsistency was manually adjudicated. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Incarceration Verification Date | Date when verification of incarceration attestation was conducted. | This date associates to each unique member on the application. | Date | 8 | "12JAN2021" |
| Incarceration Verification Reason | The findings used to set the final verification result in corroborating the consumer’s attestation. | Reasons for the verification result can vary depending on the verification logic used by the Exchange. For example, the reason could be ‘Inconsistent with External Data Source’ if the verification logic is simply using a basic comparison of the consumer’s attestation with those observed from the external data source. If the consumer is not found within the external data source, then the consumer's attestation value is used. | Alphanumeric | 1000 | "External data source not reasonably compatible with attestation", "Applicant did not give sufficient information" |
| Incarceration Verification Result | The final determination on whether the Exchange was able to verify the consumer’s attestation. | The verification result should clearly indicate if the verification was successful in verifying the attestation, or if inconsistency was found. | Alphanumeric | 100 | "Yes", "No", "Success", "Failure", "Verified", "Inconsistency Found" |
| Income Inconsistency Manual Adjudication Conducted | Indicates whether an Income verification inconsistency was manually adjudicated. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Income Inconsistency Raised for Manual Verification | An indicator that an inconsistency for income was triggered for manual verification. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Income Verification Date | Date when verification of income attestation was conducted. | This date associates to the tax household on the application. | Date | 8 | "12JAN2021" |
| Income Verification Reason | The findings used to set the final verification result in corroborating the consumer’s attestation. | Reasons for the verification result can vary depending on the verification logic used by the Exchange. For example, the reason could be ‘Inconsistent with External Data Source’ if the verification logic is simply using a basic comparison of the consumer’s attestation with those observed from the external data source. If the consumer does not exactly match the external data source, then the consumer receives a Verification Result of ‘Inconsistent’. | Alphanumeric | 1000 | "External data source not reasonably compatible with attestation", "Applicant did not give sufficient information", "Applicant attestation was over set thresholds" |
| Income Verification Result | Indicator denoting the verification result of an income verification. | N/A | Alphanumeric | 100 | "Yes", "No", "Success", "Failure", "Verified", "Inconsistency Found" |
| Inconsistency Adjudication Date | Date that the manual verification of an inconsistency was concluded. | This field may not be applicable to all Exchanges. | Date | 8 | "12JAN2021" |
| Inconsistency Adjudication Date (Alternative) | An alternative date that the manual verification of an inconsistency was concluded, per a system different from the original source. Such a system could be a data warehouse. | This field may not be applicable to all Exchanges. | Date | 8 | "12JAN2021" |
| Inconsistency Clock End Date | The clock end date set by the Exchange based on the date the inconsistency was triggered. | N/A | Date | 8 | "12JAN2021" |
| Inconsistency Clock End Date (Alternative) | The clock end date set by the Exchange based on the date the inconsistency was triggered, per alternative source, for example a data warehouse. | N/A | Date | 8 | "12JAN2021" |
| Inconsistency Expiration Date | The date of expiration for an inconsistency, set by the manual verification. | This data is after the consumer submitted the requested documents per the clock end, and indicates a deadline for completing the manual verification. | Date | 8 | "12JAN2021" |
| Inconsistency Identifier | A unique identifier for an inconsistency generated as a result of unsuccessful electronic verifications performed by the Exchange. |
An inconsistency is triggered by the Exchange when the outcome of a verification indicates a discrepancy between the applicant's attestation and the information available from a Trusted Data Source. An inconsistency identifier would be assigned for each event where an inconsistency is triggered by the Exchange. The inconsistency identifier would be specific to each type of inconsistency triggered by the Exchange pertaining to any application member. In the event that an Exchange does not have dedicated inconsistency identifiers to identify unique inconsistencies, the Exchange could create such an identifier as long as it is unique within the sample. |
Alphanumeric | 100 | "123456789" |
| Inconsistency Status | An indicator that reflects the current status. | Statuses include: - Successful manual verification: Inconsistency was resolved and consumer attestation verified. - Unsuccessful manual verification: Inconsistency was not resolved and consumer attestation not verified. - Other: This category could include various statuses used by an Exchange. |
Alphanumeric | 1000 | "Successful manual verification", "Unsuccessful manual verification", "Other - Insufficient document. The consumer was asked to submit additional document(s) to confirm their attested information, and the inconsistency was not successfully resolved" |
| Inconsistency Sub-Type | A field that describes the sub type of inconsistency that was generated by the Exchange. | The Exchange may trigger several sub types of inconsistencies based on which consumer attestation(s) are found to be inconsistent with Trusted Data Sources. Inconsistency Subtype is associated with unique verification issue within the application. It further classifies the inconsistency type. This field may or may not be applicable for all Exchanges. |
Alphanumeric | 100 | "citizenship_born_qhp" |
| Inconsistency Type | The eligibility criterion where an inconsistency was found. | Possible types are annual income, citizenship, etc. | Alphanumeric | 100 | "Annual Income", "Citizenship", "ESC MEC" |
| Insurance Policy End Date | The end date of the Policy which the applicants are enrolled in. | N/A | Date | 8 | "12JAN2021" |
| Insurance Policy Identifier | A unique identifier assigned by the exchange to the insurance policy. | N/A | Alphanumeric | 100 | "12345678" |
| Insurance Policy Selected Date | Date when the insurance policy was selected. | N/A | Date | 8 | "12JAN2021" |
| Insurance Policy Start Date | The start date of the Policy which the applicants are enrolled in. | N/A | Date | 8 | "12JAN2021" |
| Insurance Policy Status | The status of the Policy which the applicants are enrolled in. | Possible values are: - Initial enrollment - Effectuated - Canceled - Terminated |
Alphanumeric | 100 | "Initial enrollment" |
| IRS Annual Tax Household Income Amount | The Annual Tax Household Income amount returned from IRS. | XML Data | Numeric | 8 | |
| IRS Income Data Available | Indicates whether or not Income verification data was found in the IRS. | XML Data | Character | 5 | |
| IRS Tax Form Receipt | Indicates whether the tax household anchor attested that the tax household reconciled to premium tax credits on last year's tax return. | XML Data | Character | 5 | |
| Issuer Benefit End Date | Benefit end date for the QHP coverage period as reflected by Issuer records. | N/A | Date | 8 | "12JAN2021" |
| Issuer Benefit Start Date | Benefit start date for the QHP coverage period as reflected by Issuer records. | N/A | Date | 8 | "12JAN2021" |
| Issuer Effectuation Status | Indicates whether the applicant paid their initial premium for a given policy as indicated by issuer. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Issuer Policy Applied APTC Amount | The amount of APTC that has been applied to the policy as reflected by Issuer records. | N/A | Decimal | 10 | "2000" |
| Issuer Reconciliation Coverage Start Date | The date an applicant's qualified health plan starts as indicated by the issuer. | N/A | Date | 8 | "12JAN2021" |
| Issuer Reconciliation Data Matching Issue Indicator For Applied APTC Amount | Indicates whether Issuer and Exchange had data matching issues during reconciliation for applied APTC amount. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Issuer Reconciliation Data Matching Issue Indicator For Benefit End Date | Indicates whether Issuer and Exchange had data matching issues during reconciliation for benefit end date. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Issuer Reconciliation Data Matching Issue Indicator For Benefit Start Date | Indicates whether Issuer and Exchange had data matching issues during reconciliation for benefit start date. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Issuer Reconciliation Data Matching Issue Indicator For Effectuation Status | Indicates whether the issuer and Exchange had data matching issues during reconciliation for effectuation status. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Issuer Reconciliation Data Matching Issue Resolution For Applied APTC Amount | Indicates the action taken to resolve data discrepancies between the issuer and Exchange for applied APTC amount. | N/A | Alphanumeric | 1000 | "Exchange keeps data value and tells issuer to update their data records", "Exchange adopts issuer data values" |
| Issuer Reconciliation Data Matching Issue Resolution For Benefit End Date | Indicates the action taken to resolve data discrepancies between the issuer and Exchange for benefit end date. | N/A | Alphanumeric | 1000 | "Exchange keeps data value and tells issuer to update their data records", "Exchange adopts issuer data values" |
| Issuer Reconciliation Data Matching Issue Resolution For Benefit Start Date | Indicates the action taken to resolve data discrepancies between the issuer and Exchange for benefit start date. | N/A | Alphanumeric | 1000 | "Exchange keeps data value and tells issuer to update their data records", "Exchange adopts issuer data values" |
| Issuer Reconciliation Data Matching Issue Resolution For Effectuation Status | Indicates the action taken to resolve data discrepancies between the issuer and Exchange for effectuation status. | N/A | Alphanumeric | 1000 | "Exchange keeps data value and tells issuer to update their data records", "Exchange adopts issuer data values" |
| Issuer Total Premium Amount | Issuer total premium amount provided during the reconciliation process. | N/A | Decimal | 10 | "2000" |
| Last Name | Last name of application member | N/A | Alphanumeric | 100 | "Brown" |
| Latest Policy Record | For a specific policy, if multiple versions exist, this indicator will represent the latest version for that policy. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Lawful Presence Inconsistency | The number of lawful presence verification inconsistencies that were associated to a tax household for a given plan year. Note: if SE cannot provide a specific count, then a "Y/N" value is acceptable to indicate that an inconsistency type exists for the tax household | N/A | Numeric | 3 | "1", "8", "Y", "N" |
| Lawful Presence Inconsistency Manual Adjudication Conducted | Indicates whether a Lawful Presence verification inconsistency was manually adjudicated. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Lawful Presence Verification Date | Date when verification of lawful presence attestation was conducted. | This date associates to each unique member on the application. | Date | 8 | "12JAN2021" |
| Lawful Presence Verification Reason | The findings used to set the final verification result in corroborating the consumer’s attestation. | Reasons for the verification result can vary depending on the verification logic used by the Exchange. For example, the reason could be ‘Inconsistent with External Data Source’ if the verification logic is simply using a basic comparison of the consumer’s attestation with those observed from the external data source. If the consumer does not exactly match the external data source, then the consumer receives a Verification Result of ‘Inconsistent’. | Alphanumeric | 1000 | "External data source not reasonably compatible with attestation", "Applicant did not give sufficient information", "Applicant attestation was over set thresholds" |
| Lawful Presence Verification Result | The final determination on whether the Exchange was able to verify the consumer’s attestation. | The verification result should clearly indicate if the verification was successful in verifying the attestation, or if inconsistency was found. | Alphanumeric | 100 | "Yes", "No", "Success", "Failure", "Verified", "Inconsistency Found" |
| Level of Assurance 2 Verified | Boolean indicator of whether application was verified for level of assurance 2. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Lived In Foreign Country 60 Days Before Marriage Indicator | Indicates whether the applicant or the spouse attested to living in a foreign country or U.S. territory within 60 days before the marriage. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Lived In No QHP Zone Within 60 Days Before Marriage Indicator | Indicates whether the applicant or the spouse attested to living in a service area where no QHP was available through the Exchange within 60 days before the marriage. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Lived In No QHP Zone Within 60 Days Before Move Indicator | Indicates whether the applicant attested to moving from a service area where no QHP was available through the Exchange within the last 60 days. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Lived in US 5 Years Indicator | Indicates whether an applicant attested to living in the US for at least 5 years. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Mailing City | Applicant mailing city. | N/A | Alphanumeric | 100 | "McLean" |
| Mailing State Code | Applicant mailing state code. | N/A | Alphanumeric | 10 | "VA" |
| Mailing Street Address | Applicant mailing street address. | N/A | Alphanumeric | 100 | "123 Forrest Street" |
| Mailing Zip Code | Applicant mailing zip code. | N/A | Alphanumeric | 10 | "22102" |
| Manual Income Verification Result | Outcome of income verification performed by manual reviewers to assess compatibility between attested and documented income. | The values for this field should clearly indicate if the manual income verification was successful or not. | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Maximum APTC Amount | The maximum advanced payment tax credit amount for which the tax household is eligible for. | N/A | Decimal | 10 | "2000" |
| Medicaid Denied Date | Date that an applicant was denied eligibility for Medicaid. | N/A | Date | 8 | "12JAN2021" |
| Medicaid Denied Indicator | Indicates whether an applicant has been denied eligibility for Medicaid in the last 60 days. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Medicaid Eligibility End Date | The date that the application exchange Medicaid MAGI eligibility ended or will end. | N/A | Date | 8 | "12JAN2021" |
| Medicaid/CHIP Confirmed Dual Enrollment | Medicaid CHIP was confirmed to be dually enrolled and applicant has not resolved issue within the allotted resolution period. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Medicaid/CHIP Confirmed Expiration Date | The date when applicant failed to resolve their Medicaid/CHIP dual enrollment issue within the allotted resolution period. | N/A | Date | 8 | "12JAN2021" |
| Medicaid/CHIP PDM Actual Run Date | Date when Medicaid/CHIP PDM was executed for application member. | N/A | Date | 8 | "12JAN2021" |
| Medicaid/CHIP PDM Scheduled Date | The date during the benefit year when the Medicaid/CHIP PDM is scheduled to occur. | There should be at least two dates scheduled for Medicaid/CHIP PDM. | Date | 8 | "12JAN2021" |
| Medicare Dual Enrollment Status | Indicates whether an applicant is dually enrolled in Medicare and Non ESC MEC. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Medicare PDM Actual Run Date | Date when Medicare PDM was executed for application member. | N/A | Date | 8 | "12JAN2021" |
| Medicare PDM Scheduled Date | The date during the benefit year when the Medicare PDM is scheduled to occur. | There should be at least two dates scheduled for Medicare PDM. | Date | 8 | "12JAN2021" |
| Medicare Resolution Status | Status used to indicate whether or not an applicant has resolved Medicare dual-enrollment issues with application. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Member Association Role Type | The relationship the member has to the tax filer. | N/A | Alphanumeric | 10 | "spouse", "daughter", "son" |
| Member-Level Allocated APTC Amount | Allocated APTC Amount is the amount that is allocated to the policy based on the amount the tax household has elected without consideration for amounts that are reallocated from other policies. The final amount of APTC that is applied takes into consideration the amounts that are leftover from policies. | This is a numeric text value. | Decimal | 10 | "2000" |
| Middle Name | Middle name of application member | N/A | Alphanumeric | 100 | "David" |
| Monthly EHB Premium Amount for the Policy | The Monthly EHB Premium amount of the policy | N/A | Decimal | 10 | "2000" |
| Moved From Foreign Country Within Last 60 Days Indicator | Indicates whether the applicant attested to moving from a foreign country to the USA within the last 60 days. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Multiple Tax Household Indicator | Indicates whether the insurance application contains multiple tax households. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| No IRS data for past 3 Benefit Years | Indicator that the Exchange has not received updated IRS data fro the applicant for the past three years. | Derived by RC examining the auto re-enrolled applications from the past three years and determining whether IRS data was found (reviewing data source and data found indicators). | Character | 5 | "True", "False", "Yes", "No", "Y", "N" |
| No updates to application for past 2 Benefit Years | Indicator that applicant has not update their application in the past two benefit years. | Derived by RC examining the past two applications and determining whether the applicant submitted an application where the interface mode is other than Batch Offline Update and origin type is other than auto re-enrollment. | Character | 5 | "True", "False", "Yes", "No", "Y", "N" |
| Non-ESC MEC Coverage End Date | The date that the applicants Non-ESC MEC coverage ended or will end. | N/A | Date | 8 | "12JAN2021" |
| Non-ESC MEC EDS Data Found | Hub returned data for any Non-ESC MEC coverage | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Non-ESC MEC Inconsistency | The number of Non-ESC MEC verification inconsistencies that were associated to a tax household for a given plan year. Note: if SE cannot provide a specific count, then a "Y/N" value is acceptable to indicate that an inconsistency type exists for the tax household | N/A | Numeric | 3 | "1", "8", "Y", "N" |
| Non-ESC MEC Inconsistency Identifier | A unique identifier for an inconsistency generated as a result of unsuccessful electronic verifications of Non-ESC MEC coverage performed by the Exchange. | An inconsistency is triggered by the Exchange when the outcome of a verification indicates a discrepancy between the applicant's attestation and the information available from a Trusted Data Source. An inconsistency identifier would be assigned for each event where an inconsistency is triggered by the Exchange. The inconsistency identifier would be specific to each type of inconsistency triggered by the Exchange pertaining to any application member. In the event that an Exchange does not have dedicated inconsistency identifiers to identify unique inconsistencies, the Exchange could create such an identifier as long as it is unique within the sample. |
Alphanumeric | 10 | "123456789" |
| Non-ESC MEC Inconsistency Manual Adjudication Conducted | Indicates whether a Non-ESC MEC verification inconsistency was manually adjudicated. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Non-ESC MEC Verification Determination Date | The date that the application Non-ESC MEC verification was determined. | N/A | Date | 8 | "12JAN2021" |
| Non-ESC MEC Verification Reason | The findings used to set the final verification result in corroborating the consumer’s attestation. | Reasons for the verification result can vary depending on the verification logic used by the Exchange. For example, the reason could be ‘Inconsistent with External Data Source’ if the verification logic is simply using a basic comparison of the consumer’s attestation with those observed from the external data source. If the consumer does not exactly match the external data source, then the consumer receives a Verification Result of ‘Inconsistent’. | Alphanumeric | 1000 | "External data source not reasonably compatible with attestation", "Applicant did not give sufficient information", "Applicant attestation was over set thresholds" |
| Non-ESC MEC Verification Result | Indicator denoting the verification result of a Non-ESC MEC verification. | N/A | Alphanumeric | 100 | "Yes", "No", "Success", "Failure", "Verified", "Inconsistency Found" |
| Number of Applicants Applying for Coverage | Total number of applicants applying for coverage within the application. | N/A | Integer | 10 | "1" |
| Number of Tax Household Members | Total number of individuals considered to be part of a tax household | N/A | Integer | 10 | "1" |
| Person Tracking Number | A unique identification number that is used to identify a person across benefit years. | N/A | Alphanumeric | 10 | "12345678" |
| Physical Document Type | The type of document that would be supplied by the consumer to validate or verify certain eligibility status (e.g. citizenship, lawful presence). Specific physical document types would require manual adjudication. | N/A | Alphanumeric | 100 | |
| Plan Certified Indicator | Indicates whether the selected QHP by the consumer has been certified | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Plan Year | Year for which this plan has been created. | N/A | Integer | 10 | "2021", "2022", "2023" |
| Policy Applied APTC Amount | The amount of APTC that has been applied to the policy. | N/A | Decimal | 10 | "2000" |
| Policy Creation Date | The date when the policy was created. | N/A | Date | 8 | "12JAN2021" |
| QHP Eligibility Determination Date | Date when the application member's QHP eligibility was determined. | N/A | Date | 8 | "12JAN2021" |
| QHP Eligibility Indicator | Indicates if the Exchange determines an applicant is eligible for QHP. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| QHP Eligibility Indicator for Current Version used use AR_RU3 | QHP Eligibility Indicator for Current Version used use AR_RU3. | The indication whether the applicant QHP eligibility was successful. | Character | 5 | "True", "False", "Yes", "No", "Y", "N" |
| QHP Eligibility Indicator for Prior Version used use AR_RU3 | QHP Eligibility Indicator for Prior Version used for AR_RU3. | The indication whether the applicant QHP eligibility was successful. | Character | 5 | "True", "False", "Yes", "No", "Y", "N" |
| QHP Eligibility Reason | Reason for the given determination for QHP eligibility. | N/A | Alphanumeric | 100 | "Applicant is incarcerated", "Applicant is neither a citizen or has lawful presence", "Applicant meets all QHP eligibility criteria" |
| QHP Residency Eligibility Determination Date | Date when the application member QHP Residency date was determined. | N/A | Date | 8 | "12JAN2021" |
| QHP Residency Eligibility Indicator | Indicates whether the applicant was determined to be QHP Residency eligible. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| QHP Residency Eligibility Reason | Reason for the given determination for QHP Residency eligibility. | N/A | Alphanumeric | 100 | "Applicant residency is out of state" |
| QHP State Code | State code indicating where the QHP has been certified for use. | N/A | Alphanumeric | 10 | "VA", "MA", "NY" |
| QHP Suppression Date | Date of QHP suppression. | N/A | Date | 8 | "12JAN2021" |
| QHP Suppression Reason | Reason for the suppression of a QHP. | N/A | Alphanumeric | 100 | "Exchange freezes new enrollments" |
| QHP Unsuppression Date | Date of QHP unsuppression. | N/A | Date | 8 | "12JAN2021" |
| Relevant Consumer Documents | A list of documents provided by the consumer to adjudicate a specific inconsistency, including name, date received, and any other relevant information. If providing multiple documents, please separate document by semi-colon |
Not all documents from the consumer may be used to adjudicate an inconsistency. | Alphanumeric | 1000 | "I-551 Card (Received on 01-01-2020) via Mailroom" |
| Residency Inconsistency Manual Adjudication Conducted | Indicates whether a Residency verification inconsistency was manually adjudicated. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Residency Verification Date | Date when verification of residency attestation was conducted. | This date associates to each unique member on the application. | Date | 8 | "12JAN2021" |
| Residency Verification Reason | The findings used to set the final verification result in corroborating the consumer’s attestation. | Reasons for the verification result can vary depending on the verification logic used by the Exchange. For example, the reason could be ‘Inconsistent with External Data Source’ if the verification logic is simply using a basic comparison of the consumer’s attestation with those observed from the external data source. If the consumer is not found within the external data source, then the consumer's attestation value is used. | Alphanumeric | 1000 | "External data source not reasonably compatible with attestation", "Applicant did not give sufficient information" |
| Residency Verification Result | The final determination on whether the Exchange was able to verify the consumer’s attestation. | The verification result should clearly indicate if the verification was successful in verifying the attestation, or if inconsistency was found. | Alphanumeric | 100 | "Yes", "No", "Success", "Failure", "Verified", "Inconsistency Found" |
| Second Lowest Cost Silver Plan Premium Amount | This is the adjusted monthly premium of the Second Lowest Cost Silver Plan (SLCSP) (or sum of SLCSPs) that cover the primary taxpayer, his or her spouse, and their tax dependents for use in computing max advance payments of the premium tax credit. | N/A | Decimal | 10 | "2000" |
| Selected For Sample (Filled Out By CMS) | Indicator that flags whether a tax household was selected as part of the sample for review | N/A | Alphanumeric | 3 | "Yes", "No" |
| Selected Insurance Plan Identifier | Insurance plan identifier for the policy selected by the applicant. | This indicator is made of a code, 2 sets of numbers identifying the plan selected, with the state abbreviation in between them. | Alphanumeric | 100 | "99969OH100010" |
| SEP Eligibility Determination Date | The date when the application members SEP eligibility was determined. | N/A | Date | 8 | "12JAN2021" |
| SEP Eligibility End Date | The date that the application SEP eligibility ended or will end. | N/A | Date | 8 | "12JAN2021" |
| SEP Eligibility Indicator | Indicator that marks which SEP the application is eligible for based on the applicant's attestation. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| SEP Eligibility Start Date | The date that the application SEP eligibility started or will start. | N/A | Date | 8 | "12JAN2021" |
| SEP Manual Adjudication Clock End Date | Date when the SEP manual adjudication ends. | N/A | Date | 8 | "12JAN2021" |
| SEP Manual Adjudication Date | Date when the SEP was manually adjudicated. | N/A | Date | 8 | "12JAN2021" |
| SEP Manual Adjudication Identifier | A unique identifier for a SEP manual review performed by the Exchange. | N/A | Alphanumeric | 10 | "123456789" |
| SEP Manual Adjudication Indicator | Indicates if the SEP application was manually adjudicated by the exchange. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| SEP Manual Adjudication Status | Outcome of the manual SEP verification adjudication. | N/A | Alphanumeric | 100 | "Expired", "Obsolete", "Resolved", "Running" |
| SEP Type | The type of SEP. | N/A | Alphanumeric | 100 | "Adoption", "Newborn", "Marriage", "Relocation", "Loss of MEC" |
| Special Rule For Non-Citizens Override Indicator | Indicates whether an applicant who is lawfully present, with income below the 100% FPL, but is ineligible for Medicaid by reason of immigration status, making them eligible for APTC. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| SSN Inconsistency Manual Adjudication Conducted | Indicates whether a SSN verification inconsistency was manually adjudicated. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| SSN Provided by Applicant | Social Security Number provided by applicant. | This field is only used for applicants who attest to citizenship, applicants who are lawfully present may or may not have an SSN. | Alphanumeric | 100 | "123-45-6789" |
| SSN Verification Date | Date when SSN attestation verification was conducted. | This date associates to each unique member on the application. | Date | 8 | "12JAN2021" |
| SSN Verification Event ID | The event ID of the SSN verification event. | This field may not be applicable to all Exchanges. |
Alphanumeric | 100 | "12345678" |
| SSN Verification Reason | The findings used to set the final verification result in corroborating the consumer’s attestation. | Reasons for the verification result can vary depending on the verification logic used by the Exchange. For example, the reason could be ‘Inconsistent with External Data Source’ if the verification logic is simply using a basic comparison of the consumer’s attestation with those observed from the external data source. If the consumer does not exactly match the external data source, then the consumer receives a Verification Result of ‘Inconsistent’. |
Alphanumeric | 1000 | "External data source not reasonably compatible with attestation", "Applicant did not give sufficient information", "Applicant attestation was over set thresholds" |
| SSN Verification Result | The final determination on whether the Exchange was able to verify the consumer’s attestation. | The verification result should clearly indicate if the verification was successful in verifying the attestation, or if inconsistency was found. |
Alphanumeric | 100 | "Yes", "No", "Success", "Failure", "Verified", "Inconsistency Found" |
| Tax Dependent Indicator | Applicant attesting to being a dependent within a tax household. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Tax Filer Indicator | Applicant attesting to being a tax filer within a tax household. | N/A | Alphanumeric | 10 | "True", "False", "Yes", "No", "Y", "N" |
| Tax Filing Status | Tax filing status of an applicant. | N/A | Alphanumeric | 100 | "Single", "Married", "Married Filing Separately" |
| Tax Household Grouping Identifier | Identifier that groups application members within a single tax household. | N/A | Alphanumeric | 10 | "0123456789" |
| Tax Household Size in Manual Income Verification | Tax household size reflected any standard or custom tool / method / process for manual verification. | This may not be applicable to Exchanges. |
Integer | 10 | "2" |
| Total APTC Distributed Payments | Sum of all payments distributed to members of a tax household. | N/A | Decimal | 10 | "2000" |
| Transient City | Applicant intended future home city. | N/A | Alphanumeric | 100 | "McLean" |
| Transient State Code | Applicant intended future home state code. | N/A | Alphanumeric | 10 | "VA" |
| Transient Street Address | Applicant intended future home street address. | N/A | Alphanumeric | 100 | "123 Forrest Street" |
| Transient Zip Code | Applicant intended future mailing zip code. | N/A | Alphanumeric | 10 | "22102" |
| Version Number of Application Version of Interest | The version number of insurance application document. | N/A | Numeric | 8 | "1", "2" |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |