Form CMS-10371 SBM Three-Year Budget Template

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Overview

Instructions for SBMs
Updated Budget Template 4-10-17

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Sheet 1: Instructions for SBMs

INSTRUCTIONS FOR COMPLETING THE BUDGET TEMPLATE

1. Only place content in cells with a white background (e.g. do not place content in cells with grey or blue background)

2. Do not insert additional rows/columns

3. Indicate NA in a cell if the metric is not applicable to the state

4. Highlight cell yellow if metric is drawing confusion for the state

5.  If 0% is allocated to a percent allocation metric, please indicate 0% in the relevant cell

6. When providing actual or projected $ for 2016, 2017, or 2018 in Table B or C, only provide $ for shared services if you cannot provide a direct dollar amount for Individual Marketplace, and do so consistently across tables B and C.

7. Provide data in tables A-C consistently in calendar year or fiscal year

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Sheet 2: Updated Budget Template 4-10-17

FY 2016 - FY 2018 STATE-BASED MARKETPLACE BUDGET

Form Approved- exp. 3/31/2018

OMB No: 0938-1119

State:

State Fiscal Year:

Data provided in Table A, B, and C by Calendar Year or Fiscal Year:

Total Current Individual FTEs:

Total Current SHOP FTEs:

A.1

INDIVIDUAL MARKETPLACE EFFECTUATED ENROLLMENT

2016 Actual

2017 Projected

2018 Projected

QHP Enrollment for Plan Year

Member Months

A.1

SHOP MARKETPLACE EFFECTUATED ENROLLMENT

2016 Actual

2017 Projected

2018 Projected

SHOP QHP Enrollment for Plan Year

Member Months

B.

REVENUE

Notes (if needed or as requested

2016 Actual $

2016 Actual % Revenue Allocated to Individual Expenditures

2016 Actual % Revenue Allocated to SHOP Expenditures

2017 Projected $

2017 Projected % Revenue Allocated to Individual Expenditures

2017 Projected % Revenue Allocated to SHOP Expenditures

2018 Projected $

2018 Projected % Revenue Allocated to Individual Expenditures

2018 Projected % Revenue Allocated to SHOP Expenditures

Total Carrier Assessment Inside Individual Marketplace (indicate fee breakdown in notes cell to right (ex. $5.00 PMPM, and show fee breakdown for both medical and dental if different)

Total Carrier Assessment Inside Small Group Marketplace (indicate fee breakdown in notes cell to right (ex. $5.00 PMPM, and show fee breakdown for both medical and dental if different)

Total Carrier Assessment Outside Marketplace Individual Plans (indicate fee breakdown in notes cell to right (ex. $5.00 PMPM, and show fee breakdown for both medical and dental if different)

Total Carrier Assessment Outside Marketplace Small Group Plans (indicate fee breakdown in notes cell to right (ex. $5.00 PMPM, and show fee breakdown for both medical and dental if different)

Other Tax Assessments (indicate sources in notes cell to right)

1311 Grant Funding

Other Grant Funding (indicate sources in notes cell to right)

Revenue or Reimbursement from Medicaid/CHIP (include federal and state together)

State Revenue/Reimbursement (list sources below)

Other Revenue (indicate sources in notes cell to right)

TOTAL $ REVENUE

$-

$-

$-

C.

MARKETPLACE EXPENDITURES (total revenue and expenditures should balance out).

Definition

Notes (if needed or as requested

2016 Actual $

2016 Actual % Budget Allocated to Individual

2016 Actual % Budget Allocated to SHOP

2017 Projected $

2017 Projected % Budget Allocated to Individual

2017 Projected % Budget Allocated to SHOP

2018 Projected $

2018 Projected % Budget Allocated to Individual

2018 Projected % Budget Allocated to SHOP

General

$-

$-

$-

Personnel and Fringe

Officer and director salaries, temporary help, etc.

Indirect Costs

Travel, supplies, etc.

Facility and Other Non-IT Administrative

Rent, utilities, repairs, printing, etc.

Other (List items in notes cell to right)

Other

External Marketing & Outreach Total

$-

$-

$-

Navigators/IPAs

Grants or fees

Education & Outreach to Consumers

Consumer facing education, training, outreach activities and materials

Education & Outreach to Agents/Brokers and Issuers

Agent/broker and issuer facing education, training, outreach activities and materials

Paid Media

Paid Media

Advertising & Marketing

Efforts dedicated to engaging consumers, alliances, etc., including development of outreach materials, graphic design, marketing content on websites, campaigns

Other (list items in notes cell to right)

Other

% of Total External Marketing & Outreach Allocated to Contractors

Contractor allocation

Call Center Totals

$-

$-

$-

Maintenance and Operations

Labor (fixed and variable), back office labor, technology (fixed and variable), operations (fixed and variable), etc.

DDI

Efforts associated with development and enhancements, etc.

Other (list items in notes cell to right)

Other

% of Total Call Center Allocated to Contractors

Contractor allocation

IT Platform

$-

$-

0.0

Maintenance and Operations

Labor (fixed and variable), back office labor, technology (fixed and variable), operations (fixed and variable), etc.

DDI

Efforts associated with development and enhancements, etc.

Other (list items in notes cell to right)

Other

% of Total IT Platform Efforts Allocated to Contractors

Contractor allocation

TOTAL $ EXPENDITURES

$-

$-

$-

D.

NET Gain/(Loss)

2016 Actual

2017 Projected

2018 Projected

$-

$-

$-

Legislative Authority to have a reserve (Indicate Yes/No)

Total Reserve

Number of Months of Reserve

PRA 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 0938-1119.