Form CMS-10371 SBM Individual Market Reporting

Expiration date. XX/XX/XXXX

OMB control number 0938-1119

	State Based Marketplace Data Collection Template: Open Enrollment Period Weekly and Expanded End of Open Enrollment Reporting
General
1		Total Plan Selections (net)	Count of unique individuals who have selected a Plan Year (PY) 20XX Marketplace medical plan. Count includes all new and re-enrolling consumers (defined in indicators 2 and 3), regardless of whether the consumer has paid the first month premium. Count does not include plans that were canceled or terminated. Instant check: This metric should total the sum of new consumers (2) and total re-enrollees (3).
2		New Consumers (net)	Count of unique individuals who have selected a (PY) 20XX Marketplace medical plan, where the consumer had non-canceled (PY) 20XX Marketplace medical coverage on or after 11/1/20XX. Count includes consumers who either returned to the Marketplace and actively selected a (PY) 20XX Marketplace medical coverage or were automatically enrolled into a (PY) 20XX Marketplace medical coverage. Count does not include plans that were canceled or terminated.
3		Total Re-enrollees (net)	Count of unique individuals who have selected a (PY) 20XX Marketplace medical plan, where the consumer had non-canceled (PY) 20XX Marketplace medical coverage on 11/1/20XX. Count includes consumers who either returned to the Marketplace and actively selected a (PY) 20XX Marketplace medical coverage or were automatically enrolled into a (PY) 20XX Marketplace medical coverage. Count does not include plans that were canceled or terminated. Instant check: This metric should total the sum of active re-enrollees (4) and automatic re-enrollees (5).
4		Active Re-enrollees (net)	Count of unique individuals who returned to the Marketplace to actively select a (PY) 20XX Marketplace medical plan, where the consumer had non-canceled (PY) 20XX Marketplace medical coverage on or after 11/1/20XX. Count does not include plans that were canceled or terminated.
5		Automatic Re-enrollees (net)	Count of unique individuals who were automatically re-enrolled into a (PY) 20XX Marketplace medical plan, where the consumer had non-canceled (PY) 20XX Marketplace medical coverage on or after 11/1/20XX. Count does not include plans that were canceled or terminated.
6		Number of Submitted Applications (gross)	Total count of submitted electronic and paper applications. When a consumer is renewed into a plan, whether automatic or active, that should be counted as an application submission. Updated applications should not be counted as an additional application.
7		Consumers on Applications Submitted (gross)	Total count of individuals requesting coverage on submitted applications. Both new consumers and consumers re-enrolling (automatic and active) in coverage should be counted.
8		Consumers Determined Eligible for Medicaid/CHIP (gross)	Count of individuals on submitted applications who are determined or assessed eligible for enrollment in Medicaid or CHIP. Both new consumers and consumers re-enrolling (automatic and active) in coverage should be counted. This count is a subset of Consumers on Applications Submitted (Indicator 7). Eligibility for Medicaid/CHIP takes precedence over eligibility for a QHP without financial assistance. Individuals determined eligible for both Medicaid/CHIP and a non-financial QHP should be counted, but should not be counted in Indicator 9.
9		Consumers Eligible for QHP (gross)	Count of individuals on submitted applications who were determined eligible for enrollment in a (PY) 20XX Marketplace medical plan, regardless of whether they applied for or are eligible for financial assistance. Both new consumers and consumers re-enrolling (automatic and active) in coverage should be counted. This count is a subset of Consumers on Applications Submitted (Indicator 7). Eligibility for Medicaid/CHIP takes precedence over eligibility for a QHP without financial assistance. Individuals determined eligible for both Medicaid/CHIP and a non-financial QHP should not be counted.
11		Consumers with a 20XX Plan Selection as of 11/1/20XX (ONE TIME)	Count of unique individuals with non-canceled (PY) 20XX coverage ending on or after November 1, 20XX.
12		New Consumers without a Previous Marketplace Application (net)	Count of unique individuals with a non-canceled (PY) 20XX Marketplace medical plan selection, where the consumer did not submit a (PY) 20XX Marketplace application.
13		New Consumers with a Prior Application but No Plan Selection (net)	Count of unique individuals with a non-canceled (PY) 20XX Marketplace medical plan selection, where the consumer submitted a (PY) 20XX Marketplace but did not make a plan selection for (PY) 20XX Marketplace medical coverage.
14		New Consumers with a Prior Plan Selection but No Coverage on November 1, 20XX (net)	Count of unique individual with a non-canceled (PY) 20XX Marketplace medical plan selection, where the consumer made a (PY) 20XX Marketplace medical plan selection but did not have (PY) 20XX Marketplace medical coverage on or after 11/1/20XX.
20		Cancellations and Terminations (gross)	Count of individuals who have canceled their (PY) 20XX Marketplace medical plan or had their (PY) 20XX Marketplace medical plan terminated by the issuer or Exchange during Open Enrollment. All cancellations and terminations should be counted. For example, if an individual selects a plan in November and immediately cancels it, then selects another plan in December and again immediately cancels it, both cancellations should be counted.
Financial Assistance/Premiums
21		Number of Plan Selections with Financial Assistance (net)	Count of unique individuals with a non-canceled (PY) 20XX Marketplace medical plan selection, where the consumer has elected to receive APTC in an amount greater than $0 and/or receives CSRs. This count includes consumers with APTC and CSRs (22) , consumers with only APTC (23), and consumers with only CSRs (24).
22		Number of Plan Selections with both CSR and APTC (net)	Count of unique individuals with a non-canceled (PY) 20XX Marketplace medical plan selection, where the consumer has elected to receive APTC in an amount greater than $0 and/or receives CSRs. Count includes consumers with APTC and CSRs. Consumers with only APTC or with only CSRs should not be counted.
23		Number of Plan Selections with APTC only (net)	Count of unique individuals with a non-canceled (PY) 20XX Marketplace medical plan selection, where the consumer has elected to receive APTC in an amount greater than $0. Consumers with CSRs should not be counted.
24		Number of Plan Selections with CSR only (net)	Count of unique individuals with a non-canceled (PY) 20XX Marketplace medical plan selection, where the consumer receives CSR in an amount greater than $0. Count may include consumers who are eligible to receive APTC but have elected not to receive APTC.
25		Number of Plan Selections without Financial Assistance (net)	Count of unique individuals with a non-canceled (PY) 20XX Marketplace medical plan selection, where the consumer is not eligible to receive APTC, is eligible but elects not to receive APTC, and/or does not receive CSRs.
26		Average Premium for All Consumers with a Plan Selection (net)	The average per person monthly premium for all consumers with a non-canceled (PY) 20XX Marketplace medical plan selection, before the application of any APTC.
27		Average Premium for all Consumers with a Plan Selection after APTC (net)	The average per person monthly premium for all consumers with a non-canceled (PY) 20XX Marketplace medical plan selection, after the application of APTC. That is, where the consumer receives APTC, the policy premium should be reduced by the APTC amount before being included in the numerator. The denominator should be the total covered lives.
28		Average APTC Amount for All Consumers with a Plan Selection Receiving APTC (net)	The average per person monthly APTC for all consumers with a non-canceled (PY) 20XX Marketplace medical plan selection, who have elected to receive an APTC amount greater than $0.
29		Average Premium after APTC for All Consumers with a Plan Selection Receiving APTC (net)	The average per person monthly premium for all consumers with a non-canceled (PY) 20XX Marketplace medical plan selection, who have elected to receive an APTC amount greater than $0, after the application of APTC.
Demographics
30		Number of Plan Selections where age is 0 - 17 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who are age of 0 - 17. Age represents the recorded age as of the policy effective coverage date.
31		Number of Plan Selections where age is 18 - 25 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who age of 18 - 25. Age represents the recorded age as of the policy effective coverage date.
31.1		Number of Plan Selections where age is 26 - 34 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who are age 26 - 34. Age represents the recorded age as of the policy effective coverage date.
32		Number of Plan Selections where age is 35 - 44 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who are age of 35 - 44. Age represents the recorded age as of the policy effective coverage date.
32.1		Number of Plan Selections where age is 45 - 54 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who are age 45 - 54. Age represents the recorded age as of the policy effective coverage date.
33		Number of Plan Selections where age is 55 - 64 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who are age of 55 - 64. Age represents the recorded age as of the policy effective coverage date.
33.1		Number of Plan Selections where age is ≥ 65 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who are age ≥ 65. Age represents the recorded age as of the policy effective coverage date.
34		Number of Plan Selections where age is unknown (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and whose age is unknown. Age represents the recorded age as of the policy effective coverage date.
35		Number of Plan Selections where gender is Female (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and whose gender is Female, according to the selected policy.
36		Number of Plan Selections where gender is Male (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and whose gender is Male, according to the selected policy.
37		Number of Plan Selections where gender is Unknown (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and whose gender is unknown, according to the selected policy.
38		Number of Plan Selections where Race/Ethnicity is Hispanic or Latino (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who have indicated they were Mexican, Mexican American or Chicano/a, Puerto Rican, Cuban, or “other ethnicity” on their application.
39		Number of Plan Selections where Race/Ethnicity is White (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who have indicated they were white on their application.
40		Number of Plan Selections where Race/Ethnicity is African American (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace Medical plan and who have indicated they were black or African American on their application.
41		Number of Plan Selections where Race/Ethnicity is Asian (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace Medical plan and who have indicated they were Asian Indian, Chinese, Filipino, Korean, Vietnamese, Japanese, or “other Asian” on their application.
42		Number of Plan Selections where Race/Ethnicity is Native Hawaiian/Pacific Islander (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace Medical plan and who have indicated they were Guamanian or Chamorro, Native Hawaiian, Samoan, or Other Pacific Islander on their application.
43		Number of Plan Selections where Race/Ethnicity is American Indian/Alaska Native (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace Medical plan and who have indicated they were American Indian or Alaska Native on their application.
44		Number of Plan Selections where Race/Ethnicity is Multi-Racial (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace Medical plan and who have indicated more than one distinct racial: American Indian / Alaska Native, Asian, Native Hawaiian / Pacific Islander, African-American, and White on their application.
45		Number of Plan Selections where Race/Ethnicity is Unknown (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace Medical plan and who did not indicate a race on their application.
46		Number of Plan Selections where Metal Level is Platinum (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan where the metal level is Platinum.
47		Number of Plan Selections where Metal Level is Gold (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan where the metal level is Gold.
48		Number of Plan Selections where Metal Level is Silver (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan where the metal level is Silver.
49		Number of Plan Selections where Metal Level is Bronze (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan where the metal level is Bronze.
50		Number of Plan Selections where Metal Level is Catastrophic (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan where the metal level is Catastrophic.
51		Consumers with a Plan Selection and Income < 100%	Count of unique individuals in households with income less than 100% of FPL who have selected a non-canceled (PY) 20XX Marketplace medical plan.
52		Consumers with a Plan Selection and Income ≥ 100% FPL and ≤ 150% FPL (net)	Count of unique individuals in households with income greater than or equal to 100% and less than or equal to 150% of FPL who have selected a non-canceled (PY) 20XX Marketplace medical plan.
53		Consumers with a Plan Selection and Income > 150% FPL and ≤ 200% FPL (net)	Count of unique individuals in households with income greater than 150% and less than or equal to 200% of FPL who have selected a non-canceled (PY) 20XX Marketplace medical plan.
54		Consumers with a Plan Selection and Income > 200% FPL and ≤ 250% FPL (net)	Count of unique individuals in households with income greater than 200% and less than or equal to 250% of FPL who have selected a non-canceled (PY) 20XX Marketplace medical plan.
54.1		Consumers with a Plan Selection and Income > 250% FPL and ≤ 300% FPL (net)	Count of unique individuals in households with income greater than 250% and less than or equal to 300% of FPL who have selected a non-canceled (PY) 20XX Marketplace medical plan.
54.2		Consumers with a Plan Selection and Income > 300% FPL and ≤ 350% FPL (net)	Count of unique individuals in households with income greater than 300% and less than or equal to 350% of FPL who have selected a non-canceled (PY) 20XX Marketplace medical plan.
54.3		Consumers with a Plan Selection and Income > 350% FPL and ≤ 400% FPL (net)	Count of unique individuals in households with income greater than 350% and less than or equal to 400% of FPL who have selected a non-canceled (PY) 20XX Marketplace medical plan.
55		Consumers with a Plan Selections and Income > 400% FPL (net)	Count of unique individuals in households with income greater than 400% who have selected a non-canceled (PY) 20XX Marketplace medical plan.
56		Number of Plan Selections where Income as a Percent of FPL is Unknown (net)	Count of unique individuals in households with non-reported income and who have selected a non-canceled (PY) 20XX Marketplace medical plan. Count should include individuals who do not report income because they are not requesting financial assistance.
Operations
5759		Call Center Volume	The total number of incoming calls received by the call center. Repeat calls from the same number should be counted separately.
58		Call Center Wait Time (in seconds)	The average wait time, rounded to the nearest second, for each incoming call to the call center.
59		Calls Abandoned	The number of incoming calls terminated while waiting to speak to a call center representative.
60		Average Call Handle Time (in seconds)	The average amount of time, rounded to the nearest second, spent by call center representatives on each individual call.
61		Number of Website Visits	The count of webpage and mobile application visits of each IP address that has not made a webpage or mobile application visit within the last 30 minutes. For example, if IP address 147.194.0.3 requests the webpage at 12:30 PM and 1:01 PM, that gets counted as 2 visits. If IP address 147.194.0.3 requests the webpage at 1:24, 1:54, and 1:56, this counts as 1 visit. At 1:24, there was no previous request within 30 minutes; at 1:54, there was a previous request exactly 30 minutes prior, and at 1:56 there was a previous request at 1:54. A subsequent request by that same IP address at 3:00 PM would be a new visit.
62		Number of Website Unique Visitors	The count of the unique IP addresses requesting the webpage or mobile application (e.g. IP 147.194.0.3 requests, gets counted as 1 unique visitor). A single person using dynamic IP address assignment (identified by login to the same Exchange account or some other method) should still be counted as two unique visitors if the IP addresses differ at the time of login.
63		Planned Website Downtime (gross)	The amount of planned downtime for the Exchange website, rounded to the nearest second.
64		Unplanned Website Downtime (gross)	The amount of unplanned downtime for the Exchange website, rounded to the nearest second.
65		Plan Selections with Any Assistance (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who received any form of personal assistance with enrollment. Assistance may have been provided by a navigator, certified application counselor (CAC), the call center, in-person assister, agent, or broker.
66		Plan Selections with Agent/Broker Assistance (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who received personal assistance with enrollment from an agent or broker. This count should only include individuals who received assistance from an agent or broker.
67		Plan Selections with Other Assistance (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who received personal assistance with enrollment from someone other than an agent or broker. This count should only include individuals who received assistance from a source other than an agent or broker. Such assistance may have been provided by a navigator, certified application counselor (CAC), the call center, or in-person assister.
68		Plan Selections with No Assistance (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX Marketplace medical plan and who received no personal assistance with enrollment.
Issuers
69		Plan Selection by Issuer: Issuer 1
70		Plan Selection by Issuer: Issuer 2
71		Plan Selection by Issuer: Issuer 3
72		Plan Selection by Issuer: Issuer 4
73		Plan Selection by Issuer: Issuer 5
74		Plan Selection by Issuer: Issuer 6
75		Plan Selection by Issuer: Issuer 7
76		Plan Selection by Issuer: Issuer 8
77		Plan Selection by Issuer: Issuer 9
78		Plan Selection by Issuer: Issuer 10
79		Plan Selection by Issuer: Issuer 11
80		Plan Selection by Issuer: Issuer 12
81		Plan Selection by Issuer: Issuer 13
82		Plan Selection by Issuer: Issuer 14
83		Plan Selection by Issuer: Issuer 15
83.1		Plan Selection by Issuer: Issuer 16
83.2		Plan Selection by Issuer: Issuer 17
83.3		Plan Selection by Issuer: Issuer 18
83.4		Plan Selection by Issuer: Issuer 19
83.5		Plan Selection by Issuer: Issuer 20
84		Name Issuer 1
85		Name Issuer 2
86		Name Issuer 3
87		Name Issuer 4
88		Name Issuer 5
89		Name Issuer 6
90		Name Issuer 7
91		Name Issuer 8
92		Name Issuer 9
93		Name Issuer 10
94		Name Issuer 11
95		Name Issuer 12
96		Name Issuer 13
97		Name Issuer 14
98		Name Issuer 15
98.1		Name Issuer 16
98.2		Name Issuer 17
98.3		Name Issuer 18
98.4		Name Issuer 19
98.5		Name Issuer 20
Stand-alone Dental Plans
99		Total SADP Plan Selections (net)	Count of unique individuals who have selected a (PY) 20XX SADP. Count does not include plans that were canceled or terminated.
100		Number of SADP Plan Selections where age is 0 - 17 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX SADP and who are age 0 - 17. Age represents the recorded age as of the policy effective coverage date.
101		Number of SADP Plan Selections where age 18 - 25 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX SADP and who are age 18 - 25. Age represents the recorded age as of the policy effective coverage date.
101.1		Number of SADP Plan Selections where age is 26 - 34 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX SADP and who are age 26 - 34. Age represents the recorded age as of the policy effective coverage date.
102		Number of SADP Plan Selections where age 35 - 44 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX SADP and who are age 35 - 44. Age represents the recorded age as of the policy effective coverage date.
102.1		Number of SADP Plan Selections where age is 45 - 54 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX SADP and who are age 45 - 54. Age represents the recorded age as of the policy effective coverage date.
102.2		Number of SADP Plan Selections where age is 55 - 64 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX SADP and who are age 55 - 64. Age represents the recorded age as of the policy effective coverage date.
103		Number of SADP Plan Selections where age ≥65 (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX SADP and who are age ≥65. Age represents the recorded age as of the policy effective coverage date.
104		Number of SADP Plan Selections where age is unknown (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX SADP and whose age is unknown. Age represents the recorded age as of the policy effective coverage date.
105		Number of SADP Plan Selections where gender is Female (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX SADP and whose gender is Female, according to the selected policy.
106		Number of SADP Plan Selections where gender is Male (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX SADP and whose gender is Male, according to the selected policy.
107		Number of SADP Plan Selections where gender is unknown (net)	Count of unique individuals who have selected a non-canceled (PY) 20XX SADP and whose gender is unknown, according to the selected policy.
Metal Level by Age and Income
108		Silver plans selected by consumers age 0 - 17 (net)
109		Silver plans selected by consumers age 18 - 25 (net)
109.1		Silver plans selected by consumers age 26 - 34 (net)
110		Silver plans selected by consumers age 35 - 44 (net)
110.1		Silver plans selected by consumers age 45 - 54 (net)
110.2		Silver plans selected by consumers age 55 - 64 (net)
111		Silver plans selected by consumers age ≥65 (net)
112		Silver plans selected by consumers age is unknown (net)
113		Bronze plans selected by consumers age 0 - 17 (net)
114		Bronze plans selected by consumers age 18 - 25 (net)
114.1		Bronze plans selected by consumers age 26 - 34 (net)
115		Bronze plans selected by consumers age 35 - 44 (net)
115.1		Bronze plans selected by consumers age 45 - 54 (net)
115.2		Bronze plans selected by consumers age 55 - 64 (net)
116		Bronze plans selected by consumers age ≥65 (net)
117		Bronze plans selected by consumers age is unknown (net)
117.1		Gold Plans selected by consumers ages 0-17 (net) [Optional]	N/A; This metric is optional
117.2		Gold Plans selected by consumers ages 18-25 (net) [Optional]	N/A; This metric is optional
117.3		Gold Plans selected by consumers ages 26-34 (net) [Optional]	N/A; This metric is optional
117.5		Gold Plans selected by consumers ages 45-54 (net) [Optional]	N/A; This metric is optional
117.6		Gold Plans selected by consumers ages 55-64 (net) [Optional]	N/A; This metric is optional
117.7		Gold Plans selected by consumers ages ≥ 65 (net) [Optional]	N/A; This metric is optional
117.8		Gold Plans selected by consumers whose age is unknown (net) [Optional]	N/A; This metric is optional
118		Silver plans selected by consumers with income < 100% FPL (net)
119		Silver plans selected by consumers with income ≥ 100% FPL and ≤ 150% FPL (net)
120		Silver plans selected by consumers with income > 150% FPL and ≤ 200% FPL (net)
121		Silver plans selected by consumers with income > 200% FPL and ≤ 250% FPL (net)
121.1		Silver plans selected by consumers with income > 250% PL and ≤ 300% FPL (net)
121.2		Silver plans selected by consumers with income > 300% FPL and ≤ 350% FPL (net)
121.3		Silver plans selected by consumers with income > 350% FPL and ≤ 400% FPL (net)
122		Silver plans selected by consumers with income > 400% (net)
123		Silver plans selected by consumers whose income is unknown (net)
124		Bronze plans selected by consumers with income < 100% FPL (net)
125		Bronze plans selected by consumers with income ≥ 100% FPL and ≤ 150% FPL (net)
126		Bronze plans selected by consumers with income > 150% FPL and ≤ 200% FPL (net)
127		Bronze plans selected by consumers with income > 200% FPL and ≤ 250% FPL (net)
127.1		Bronze plans selected by consumers with income > 250% FPL and ≤ 300% FPL (net)
127.2		Bronze plans selected by consumers with income > 300% FPL and ≤ 350% FPL (net)
127.3		Bronze plans selected by consumers with income > 350% FPL and ≤ 400% FPL (net)
128		Bronze plans selected by consumers with income > 400% (net)
129		Bronze plans selected by consumers whose income is unknown (net)
129.1		Gold plans selected by consumers with income < 100% FPL (net) [Optional]	N/A; This metric is optional.
129.2		Gold plans selected by consumers with income ≥ 100% FPL and ≤ 150% FPL (net) [Optional]	N/A; This metric is optional.
129.3		Gold plans selected by consumers with income > 150% FPL and ≤ 200% FPL (net) [Optional]	N/A; This metric is optional.
129.4		Gold plans selected by consumers with income > 200% FPL and ≤ 250% FPL (net) [Optional]	N/A; This metric is optional.
129.5		Gold plans selected by consumers with income > 250% FPL and ≤ 300% FPL (net) [Optional]	N/A; This metric is optional.
129.6		Gold plans selected by consumers with income > 300% FPL and ≤ 350% FPL (net) [Optional]	N/A; This metric is optional.
129.7		Gold plans selected by consumers with income > 350% FPL and ≤ 400% FPL (net) [Optional]	N/A; This metric is optional.
129.8		Gold plans selected by consumers with income > 400% FPL (net) [Optional]	N/A; This metric is optional.
129.9		Gold plans selected by consumers whose income is unknown (net) [Optional]	N/A; This metric is optional.
Consumer Type by Age, Metal Level, and Income
130		New consumers who are age 0 - 17(net)
131		Active re-enrollees who are age 0 - 17(net)
132		Automatic re-enrollees who are age 0 - 17(net)
133		New consumers who are age 18 - 25 (net)
134		Active re-enrollees who are age 18 - 25 (net)
135		Automatic re-enrollees who are age 18 – 25 (net)
136		New consumers who are age 26 - 34 (net)
137		Active re-enrollees who are age 26 - 34 (net)
138		Automatic re-enrollees who are age 26 - 34 (net)
138.1		New consumers who are age 35 - 44 (net)
138.2		Active re-enrollees who are age 35 - 44 (net)
138.3		Automatic re-enrollees who are age 35 - 44
138.4		New consumers who are age 45 - 54 (net)
138.5		Active re-enrollees who are age 45 - 54 (net)
138.6		Automatic re-enrollees who are age 45 - 54 (net)
138.7		New consumers who are age 55 - 64 (net)
138.8		Active re-enrollees who are age 55 - 64 (net)
138.9		Automatic re-enrollees who are age 55 - 64 (net)
139		New consumers who are age ≥65 (net)
140		Active re-enrollees who are age ≥65 (net)
141		Automatic re-enrollees who are age ≥65(net)
142		New consumers whose age is unknown (net)
143		Active re-enrollees whose age is unknown (net)
144		Automatic re-enrollees whose age is unknown (net)
145		New consumers who selected a silver plan (net)
146		Active re-enrollees who selected a silver plan (net)
147		Automatic re-enrollees who selected a silver plan (net)
148		New consumers who selected a bronze plan (net)
149		Active re-enrollees who selected a bronze plan (net)
150		Automatic re-enrollees who selected a bronze plan (net)
150.1		New consumers who selected a gold plan (net) [Optional]	N/A; This metric is optional.
150.2		Active re-enrollees who selected a gold plan (net) [Optional]	N/A; This metric is optional.
150.3		Automatic re-enrollees who selected a gold plan (net) [Optional]	N/A; This metric is optional.
151		New consumers whose income is < 100% FPL (net)
152		Active re-enrollees whose income is < 100% FPL (net)
153		Automatic Re-enrollees whose income is < 100% FPL (net)
154		New consumers whose income is ≥ 100% FPL and ≤ 150% FPL (net)
155		Active re-enrollees whose income is ≥ 100% FPL and ≤ 150% FPL (net)
156		Automatic Re-enrollees whose income is ≥ 100% FPL and ≤ 150% FPL (net)
157		New consumers whose income is > 150% FPL and ≤ 200% FPL (net)
158		Active re-enrollees whose income is 150% FPL and ≤ 200% FPL (net)
159		Automatic Re-enrollees whose income is > 150% FPL and ≤ 200% FPL (net)
159.1		New consumers whose income is > 200% FPL and ≤ 250% FPL (net)
159.2		Active re-enrollees whose income is > 200% FPL and ≤ 250% FPL (net)
159.3		Automatic Re-enrollees whose income is > 200% FPL and ≤ 250% FPL (net)
160		New consumers whose income is > 250% FPL and ≤ 300% FPL (net)
161		Active re-enrollees whose income is > 250% FPL and ≤ 300% FPL (net)
162		Automatic Re-enrollees whose income is > 250% FPL and ≤ 300% FPL (net)
162.1		New consumers whose income is > 300% FPL and ≤ 350% FPL (net)
162.2		Active re-enrollees whose income is . 300% FPL and ≤ 350% FPL (net)
162.3		Automatic Re-enrollees whose income is 300% FPL and ≤ 350% FPL (net)
162.4		New consumers whose income is > 350% FPL and ≤ 400% FPL
162.5		Active re-enrollees whose income is > 350% FPL and ≤ 400% FPL (net)
162.6		Automatic Re-enrollees whose income is > 350% FPL and ≤ 400% FPL (net)
163		New consumers whose income is > 400% FPL (net)
164		Active re-enrollees whose income is > 400% FPL (net)
165		Automatic Re-enrollees whose income is 400% FPL (net)
166		New consumers whose income is unknown (net)
167		Active re-enrollees whose income is unknown (net)
168		Automatic Re-enrollees whose income is unknown (net)
Basic Health Plan Program – only for states with BHP
169		Total BHP Enrollees (net)	Count of individuals who have enrolled in BHP. Count does not include enrollments that were canceled or terminated, or individuals enrolled in Medicaid/CHIP programs that are not BHP.
170		New BHP Enrollees (New Enrollees) (net)	Count of unique individuals who have enrolled in BHP who were not enrolled in an exchange-facilitated program (i.e. BHP, QHP, or any other integrated programs, like Medicaid) immediately prior to this BHP enrollment.
171		BHP Re-enrollees (net)	Count of unique individuals who have enrolled in BHP who were enrolled in an exchange-facilitated program (i.e. BHP, QHP, or any other integrated programs, like Medicaid) immediately prior to this BHP enrollment.
172		Consumers Eligible for BHP (gross)	Count of all individuals determined or assessed eligible for BHP. Only individuals on submitted applications and requesting coverage are included. Count all individuals determined/assessed eligible even if the individual does not subsequently enroll in coverage.
173		Consumers enrolled in BHP as of 11/1/20XX (ONE TIME)	Count of unique individuals with non-canceled BHP coverage ending as of 11/1/20XX .
174		Number of Plan Selections where age is 0 - 17 (net)	Count of unique individuals who have non-canceled BHP coverage and who are age 0 - 17. Age represents the recorded age as of the policy effective coverage date.
175		Number of BHP Enrollees where age 18 - 25 (net)	Count of unique individuals who have non-canceled BHP coverage and who are age 18 - 25. Age represents the recorded age as of the policy effective coverage date.
175.1		Number of BHP Enrollees where age is 26 - 34 (net)	Count of unique individuals who have non-canceled BHP coverage and who are age 26 - 34. Age represents the recorded age as of the policy effective coverage date.
176		Number BHP Enrollees where age 35 - 44 (net)	Count of unique individuals who have non-canceled BHP coverage and who are age 35 - 44. Age represents the recorded age as of the policy effective coverage date.
176.1		Number of BHP Enrollees where age is 45 - 54 (net)	Count of unique individuals who have non-canceled BHP coverage and who are age 45 - 54. Age represents the recorded age as of the policy effective coverage date.
177		Number of BHP Enrollees where age ≥55 (net)	Count of unique individuals who have non-canceled BHP coverage and who are age ≥55. Age represents the recorded age as of the policy effective coverage date.
178		Number of BHP Enrollees where age is unknown (net)	Count of unique individuals who have non-canceled BHP coverage and whose age is unknown. Age represents the recorded age as of the policy effective coverage date.
179		Number of BHP Enrollees where gender is Female (net)	Count of unique individuals who have non-canceled BHP coverage and whose gender is Female, according to the selected policy.
180		Number of BHP Enrollees where gender is Male (net)	Count of unique individuals who have non-canceled BHP coverage and whose gender is Male, according to the selected policy.
181		Number of BHP Enrollees where gender is unknown (net)	Count of unique individuals who have non-canceled BHP coverage and whose gender is unknown, according to the selected policy.
182		Number of BHP Enrollees where Race/Ethnicity is Hispanic or Latino (net)	Count of unique individuals who have non-canceled BHP coverage and who have indicated they are Mexican, Mexican American or Chicano/a, Puerto Rican, Cuban, or “other ethnicity” on their application.
183		Number of Plan Selections where Race/Ethnicity is White (net)	Count of unique individuals who have non-canceled BHP coverage and who have indicated they are white on their application.
184		Number of BHP Enrollees where Race/Ethnicity is African American (net)	Count of unique individuals who have non-canceled BHP coverage and who have indicated they are black or African American on their application.
185		Number of BHP Enrollees where Race/Ethnicity is Asian (net)	Count of unique individuals who have non-canceled BHP coverage and who have indicated they are Asian Indian, Chinese, Filipino, Korean, Vietnamese, Japanese, or "other Asian" on their application.
186		Number of BHP Enrollees where Race/Ethnicity is Native Hawaiian/Pacific Islander (net)	Count of unique individuals who have non-canceled BHP coverage and who have indicated they are Guamanian or Chamorro, Native Hawaiian, Samoan, or Other Pacific Islander on their application.
187		Number of BHP Enrollees where Race/Ethnicity is American Indian/Alaska Native (net)	Count of unique individuals who have non-canceled BHP coverage and who have indicated they are American Indian or Alaska Native on their application.
188		Number of BHP Enrollees where Race/Ethnicity is Multi-Racial (net)	Count of unique individuals who have non-canceled BHP coverage and who have indicated more than one distinct racial group as defined above: American Indian / Alaska Native, Asian, Native Hawaiian / Pacific Islander, African-American, and White, on their application.
189		Number of BHP Enrollees where Race/Ethnicity is Unknown (net)	Count of unique individuals who have non-canceled BHP coverage and who did not indicate a race on their application.

Paperwork Reduction Act 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 Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1119. The time required to complete this information collection is estimated to average 16 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.