State Based Marketplace Data Collection Templates for Bi-Annual Reporting

Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges (CMS-10371)

CMS-10371 - Cooperative Agreement Bi-Annual Metrics 30-day Final

State Based Marketplace Data Collection Templates for Bi-Annual Reporting

OMB: 0938-1119

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Expiration date: XX/XX/XXXX

OMB control number: 0938-1119

State Based Marketplace Data Collection Template: Bi-Annual Reporting

Cancellations/Terminations

1

Cancelled or Terminated for Non-Payment (gross)

Number of individuals who had their (PY) 20XX Exchange medical plan cancelled or terminated by an issuer (or Exchange, if applicable) for non-payment of premium. This includes cancellations due to nonpayment of the first premium and terminations due to nonpayment of the premium after the policy has been effectuated. This is a gross measure. For example, if an individual has a plan selection canceled in January, makes a new plan selection, and then has that plan selection cancelled in March, this measure would be incremented by 2.

2

Cancelled or Terminated for Other Reason (gross)

Number of individuals who had their (PY) 20XX Exchange medical plan cancelled or terminated for any reason other than non-payment. This includes cancellations/terminations by the issuer or by the consumer. This is a gross measure. For example, if an individual has a plan selection cancelled in January, makes a new plan selection, and then has that plan selection cancelled in March, this measure would be incremented by 2.

Appeals and Complaints

3

Appeals- Upheld (gross)

Count of appeals that were upheld (i.e. unfavorable outcome for consumer). This is a gross measure. For example, if two appeals are entered on a similar issue and both are upheld, this metric should be incremented by 2.

4

Appeals- Reversed (gross)

Count of appeals that were reversed (i.e. favorable outcome for consumer). This is a gross measure. For example, if two appeals are entered on a similar issue and both are reversed, this metric should be incremented by 2.

5

Appeals- Withdrawn, Dismissed, or Halted (gross)

Count of appeals that were withdrawn, dismissed, or otherwise halted. This is a gross measure. For example, if two appeals are entered on a similar issue and both are withdrawn/dismissed/otherwise halted, this metric should be incremented by 2. If those appeals are re-opened within the same reference period, these appeals should still be counted against withdrawn/dismissed/halted regardless of whether they are also counted against appeals upheld or appeals reversed.

6

Appeals- Unresolved (net)

Count of unique appeals that were unresolved but still active (i.e. not withdrawn or dismissed).

7

Median age for completed appeals

Median age (in days) of appeals that were resolved. Only include appeals that were upheld or reversed (no decimals; round to nearest day).

8

Average age for completed appeals

Average age (in days) of appeals that were resolved. Only include appeals that were upheld or reversed.

9

Number of Complaints (gross)

Count of complaints that were received by the Exchange. This is a gross measure. For example, if a complaint is made, goes unresolved for a few days, and is made again by the same complainant, this metric should be incremented by 2.

Data Matching Issues (DMIs)

10

DMIs Generated - Annual Income (gross)

Count of households that were subjected to a data matching inconsistency based on Annual Household Income. This is a gross measure. For example, if a household receives an Annual Household Income DMI, resolves it, and later receives another Annual Income DMI, this metric should be incremented by 2.

11

DMIs Generated - Citizen/Immigration (gross)

Count of individuals who were subjected to a data matching inconsistency based on Citizen/Immigration status. This is a gross measure. For example, if an individual receives a Citizen/Immigration status DMI, resolves it, and later receives another Citizen/Immigration status DMI, this metric should be incremented by 2.

12

DMIs Generated - Incarceration (gross)

Count of individuals who were subjected to a data matching inconsistency based on Incarceration. This is a gross measure. For example, if an individual receives an Incarceration DMI, resolves it, and later receives another Incarceration DMI, this metric should be incremented by 2.

13

DMIs Generated - American Indian/Alaskan Native (gross)

Count of individuals who were subjected to a data matching inconsistency based on American Indian/Alaskan Native status. This is a gross measure. For example, if an individual receives an American Indian/Alaska Native status DMI, resolves it, and later receives another American Indian/Alaska Native status DMI, this metric should be incremented by 2.

14

DMIs Generated - Non ESC MEC (gross)

Count of individuals who were subjected to a data matching inconsistency based on Non Employer Sponsored Minimum Essential Coverage (Non ESC MEC) status. This is a gross measure. For example, if an individual receives a Non ESC MEC DMI, resolves it, and later receives another Non ESC MEC DMI, this metric should be incremented by 2

15

DMIs Generated - ESC MEC (gross)

Count of individuals who were subjected to a data matching inconsistency based on Employer Sponsored Minimum Essential Coverage (ESC MEC) status. This is a gross measure. For example, if an individual receives an ESC MEC DMI, resolves it, and later receives another ESC MEC DMI, this metric should be incremented by 2.

16

DMIs Generated - Total (gross)

Sum of households that were subjected to Annual Household Income data matching inconsistency and individuals who were subjected to any data matching inconsistency of all other DMI types. Note this metric should be the sum of the number of annual income DMIs at the household level and the number of individuals with DMIs of all other types. This is a gross measure. For example, if an individual receives a DMI, resolves it, and later receives another DMI, this metric should be incremented by 2.

17

DMIs Resolved - Annual Income (gross)

Count of households whose data matching inconsistency based on Annual Household Income was resolved. This is a gross measure. For example, if a household receives an Annual Income DMI, resolves it, and later receives another Annual Income DMI and resolves that, this metric should be incremented by 2.

18

DMIs Resolved - Citizen/Immigration (gross)

Count of individuals whose data matching inconsistency based on Citizen/Immigration status was resolved. This is a gross measure. For example, if an individual receives a Citizen/Immigration status DMI, resolves it, and later receives another Citizen/Immigration status DMI and resolves that, this metric should be incremented by 2.

19

DMIs Resolved - Incarceration (gross)

Count of individuals whose data matching inconsistency based on Incarceration was resolved. This is a gross measure. For example, if an individual receives an Incarceration DMI, resolves it, and later receives another Incarceration DMI and resolves that, this metric should be incremented by 2.

20

DMIs Resolved - American Indian/Alaskan Native (gross)

Count of individuals whose data matching inconsistency based on American Indian/Alaskan Native status was resolved. This is a gross measure. For example, if an individual receives an American Indian/Alaskan Native status DMI, resolves it, and later receives another American Indian/Alaskan Native status DMI and resolves that, this metric should be incremented by 2.

21

DMIs Resolved - Non ESC MEC (gross)

Count of individuals who were subjected to a data matching inconsistency based on Non-employer Sponsored Minimum Essential Coverage. This is a gross measure. For example, if an individual receives a DMI for something other than eligibility for non- employer sponsored minimum essential coverage, resolves it, and later receives another of the same DMI, this metric should be incremented by 2.

22

DMIs Resolved - ESC MEC (gross)

Count of individuals who were subjected to a data matching inconsistency based on employer sponsored minimum essential coverage was resolved. This is a gross measure. For example, if an individual receives a DMI based on eligibility for employer sponsored minimum essential coverage, resolves it, and later receives another of the same DMI, this metric should be incremented by 2.

23

DMIs Resolved - Total (gross)

Sum of households whose Annual Household Income data matching inconsistencies were resolved and individuals whose data matching inconsistencies of all other DMI types were resolved. Note this metric should be the sum of the number of Annual Household Income DMIs at the household level and the number of individuals with DMIs of all other types that were resolved. This is a gross measure. For example, if an individual receives a DMI, resolves it, and later receives another DMI, this metric should be incremented by 2.

24

DMIs Resulted in Change in Coverage/APTC - Annual Income (gross)

Count of households whose APTC was removed or adjusted due to Annual Income DMIs. This is a gross measure. For example, if a household's APTC is adjusted/removed once for an Annual Income DMI, reinstated, and then adjusted/removed a month later for an Annual Income DMI, this metric should be incremented by 2.

25

DMIs Resulted in Change in Coverage/APTC - Citizen/Immigration (gross)

Count of individuals whose APTC was removed and/or Exchange medical coverage was terminated due to Citizen/Immigration status DMI. This is a gross measure. For example, if an individual's APTC is removed and Exchange medical coverage is terminated for a Citizen/Immigration status DMI, reinstated, and then APTC is removed and Exchange medical coverage terminated a month later for a Citizen/Immigration status DMI, this metric should be incremented by 2.

26

DMIs Resulted in Change in Coverage/APTC - Incarceration (gross)

Count of individuals whose APTC was removed and/or Exchange medical coverage was terminated due to Incarceration DMI. This is a gross measure. For example, if an individual's APTC is removed and Exchange medical coverage terminated for an Incarnation DMI, reinstated, and then APTC is removed and Exchange medical coverage terminated a month later for an Incarnation DMI, this metric should be incremented by 2.

27

DMIs Resulted in Change in Coverage/APTC - American Indian/Alaskan Native (gross)

Count of individuals whose financial assistance was removed or adjusted due to American Indian/Alaskan Native status DMIs. This is a gross measure. For example, if an individual's financial assistance is adjusted/removed for an American Indian/Alaskan Native DMI, reinstated, and then financial assistance is adjusted/removed a month later for an American Indian/Alaskan Native DMI, this metric should be incremented by 2.

28

DMIs Resulted in Change in Coverage/APTC - Non-ESC MEC (gross)

Count of individuals whose APTC was removed due to a Non-employer Sponsored Minimum Essential Coverage (Non-ESC MEC) status DMI. This is a gross measure. For example, if an individual’s APTC is removed for a Non-ESC MEC status DMI, reinstated, and then APTC is removed a month later for a Non-ESC MEC status DMI, this metric should be incremented by 2.

29

DMIs Resulted in Change in Coverage/APTC - ESC MEC (gross)

Count of individuals whose APTC was removed due to an Employer Sponsored Minimum Essential Coverage (ESC MEC) status DMI. This is a gross measure. For example, if an individual’s APTC is removed for an ESC MEC status DMI, reinstated, and then APTC is removed a month later for an ESC MEC status DMI, this metric should be incremented by 2.

30

DMIs Resulted in Change in Coverage/APTC - Total (gross)

Sum of households whose APTC was removed or adjusted due to Annual Household Income data matching inconsistency and individuals whose APTC was removed/adjusted and/or Exchange medical coverage was terminated due to any data matching inconsistency of all other DMI types. Note this metric should be the sum of the number of annual income DMIs at the household level and the number of individuals with DMIs of all other types. This is a gross measure. For example, if an individual receives a DMI, resolves it, and later receives another DMI, this metric should be incremented by 2.

31

Open DMIs - Annual Income (net)

Count of unique households with at least one unresolved Annual Household Income data matching inconsistency. This count does not include data matching issues that have expired or are for canceled or terminated coverage.

32

Open DMIs - Citizen/Immigration (net)

Count of unique individuals with at least one unresolved Citizen/Immigration status data matching inconsistency. This count does not include data matching issues that have expired or are for canceled or terminated coverage.

33

Open DMIs - Incarceration (net)

Count of unique individuals with at least one unresolved Incarceration data matching inconsistency. This count does not include data matching issues that have expired or are for canceled or terminated coverage.

34

Open DMIs - American Indian/Alaska Native (net)

Count of unique individuals with at least one unresolved American Indian/Alaska Native data matching inconsistency. This count does not include data matching issues that have expired or are for canceled or terminated coverage.

35

Open DMIs - Non ESC MEC (net)

Count of unique individuals with at least one unresolved Non Employer Sponsored Minimum Essential Coverage data matching inconsistency. This count does not include data matching issues that have expired or are for canceled or terminated coverage.

36

Open DMIs - ESC MEC (net)

Count of unique individuals with at least one unresolved Employer Sponsored Minimum Essential Coverage data matching inconsistency. This count does not include data matching issues that have expired or are for canceled or terminated coverage.

37

Open DMIs - Total (net)

Sum of unique households with at least one unresolved annual household income data matching inconsistency and unique individuals with at least one unresolved data matching inconsistency of all other DMI types. This count does not include data matching issues that have expired or are for canceled or terminated coverage. Note this metric should be the sum of the number of unique annual income DMIs at the household level and the number of unique individuals with DMIs of all other types.

Special Enrollment Periods (SEP) Plan Selection Type

38

SEP Plan Selections - Loss of qualifying health coverage (gross)

The number of individuals with (PY) 20XX plan selections that were granted an SEP on the basis of loss of qualifying health coverage. This is a gross measure. For example, if an individual makes two (PY) 20XX SEP plan selections over the course of the plan year on the basis of loss of qualifying health coverage, this metric should be incremented by 2. If an individual is being added to an existing plan selection on an SEP basis (e.g. birth or marriage), only count the individuals being added rather than all individuals on that plan selection.

39

SEP Plan Selections - Change in household size (gross)

The number of individuals with (PY) 20XX plan selections that were granted an SEP on the basis of change in household size. This is a gross measure. For example, if an individual makes two (PY) 20XX SEP plan selections over the course of the plan year on the basis of change in household size, this metric should be incremented by 2. If an individual is being added to an existing plan selection on an SEP basis (e.g. birth or marriage), only count the individuals being added rather than all individuals on that plan selection.

40

SEP Plan Selections - Change in primary place of living (gross)

The number of individuals with (PY) 20XX plan selections that were granted an SEP on the basis of change in primary place of living. This is a gross measure. For example, if an individual makes two (PY) 20XX SEP plan selections over the course of the plan year on the basis of change in primary place of living, this metric should be incremented by 2. If an individual is being added to an existing plan selection on an SEP basis (e.g. birth or marriage), only count the individuals being added rather than all individuals on that plan selection.

41

SEP Plan Selections - Change in eligibility for Exchange coverage or financial assistance (gross)

The number of individuals with (PY) 20XX medical plan selections that were granted an SEP on the basis of change in eligibility for Exchange medical coverage or financial assistance. This is a gross measure. For example, if an individual makes two (PY) 20XX SEP plan selections over the course of the plan year on the basis of change in eligibility for Exchange coverage or financial assistance, this metric should be incremented by 2. If an individual is being added to an existing plan selection on an SEP basis (e.g. birth or marriage), only count the individuals being added rather than all individuals on that plan selection.

42

SEP Plan Selections - Enrollment or plan error (gross)

The number of individuals with (PY) 20XX medical plan selections that were granted an SEP on the basis of enrollment or plan error. This is a gross measure. For example, if an individual makes two (PY) 20XX SEP plan selections over the course of the plan year on the basis of enrollment or plan error, this metric should be incremented by 2. If an individual is being added to an existing plan selection on an SEP basis (e.g. birth or marriage), only count the individuals being added rather than all individuals on that plan selection.

43

SEP Plan Selections - Other qualifying changes (gross)

The number of individuals with (PY) 20XX plan selections that were granted an SEP on the basis of other qualifying changes. This is a gross measure. For example, if an individual makes two (PY) 20XX SEP plan selections over the course of the plan year on the basis of other qualifying changes, this metric should be incremented by 2. If an individual is being added to an existing plan selection on an SEP basis (e.g. birth or marriage), only count the individuals being added rather than all individuals on that plan selection.

44

SEP Plan Selections - Total (gross)

The number of individuals with PY) 20XX plan selections that were granted an SEP on any basis. This is a gross measure. For example, if an individual makes two (PY) 20XX SEP plan selections over the course of the plan year on any basis this metric should be incremented by 2. If an individual is being added to an existing plan selection on an SEP basis (e.g. birth or marriage), only count the individuals being added rather than all individuals on that plan selection.

Small Business Health Options (SHOP)

45

Consumers with a Plan Selection (net)

Count of unique individuals (employees & dependents) who have selected a (PY) 20XX Marketplace SHOP plan, and who have non-canceled coverage.

46

Active Employers (net)

Count of unique employers who have selected a (PY) 20XX Marketplace SHOP plan, and who have non-canceled coverage.

47

Active Employees (net)

Count of unique employees active in the SHOP market.

48

Plan Selection by Issuer: Issuer 1

No additional definition provided.

49

Plan Selection by Issuer: Issuer 2

No additional definition provided.

50

Plan Selection by Issuer: Issuer 3

No additional definition provided.

51

Plan Selection by Issuer: Issuer 4

No additional definition provided.

52

Plan Selection by Issuer: Issuer 5

No additional definition provided.

53

Plan Selection by Issuer: Issuer 6

No additional definition provided.

54

Plan Selection by Issuer: Issuer 7

No additional definition provided.

55

Plan Selection by Issuer: Issuer 8

No additional definition provided.

56

Plan Selection by Issuer: Issuer 9

No additional definition provided.

57

Plan Selection by Issuer: Issuer 10

No additional definition provided.

58

Plan Selection by Issuer: Issuer 11

No additional definition provided.

59

Plan Selection by Issuer: Issuer 12

No additional definition provided.

60

Plan Selection by Issuer: Issuer 13

No additional definition provided.

61

Plan Selection by Issuer: Issuer 14

No additional definition provided.

62

Plan Selection by Issuer: Issuer 15

No additional definition provided.

63

Name Issuer 1

No additional definition provided.

64

Name Issuer 2

No additional definition provided.

65

Name Issuer 3

No additional definition provided.

66

Name Issuer 4

No additional definition provided.

67

Name Issuer 5

No additional definition provided.

68

Name Issuer 6

No additional definition provided.

69

Name Issuer 7

No additional definition provided.

70

Name Issuer 8

No additional definition provided.

71

Name Issuer 9

No additional definition provided.

72

Name Issuer 10

No additional definition provided.

73

Name Issuer 11

No additional definition provided.

73

Name Issuer 12

No additional definition provided.

75

Name Issuer 13

No additional definition provided.

76

Name Issuer 14

No additional definition provided.

77

Name Issuer 15

No additional definition provided.

General Enrollment Metrics (Priority/Expanded Metrics)

78

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.


Same as Indicator 1 in priority and expanded metrics.

79

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.


Same as Indicator 6 in priority and expanded metrics.

80

Consumers on Applications Submitted

Total count of individuals requesting coverage on submitted applications. Both new consumers and consumers re-enrolling (automatic and active) in coverage should be counted.


Same as Indicator 7 in priority and expanded metrics.

81

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 non-financial QHP should be counted but should not be counted in Indicator 9.


Same as Indicator 8 in priority and expanded metrics.

82

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.



Same as Indicator 9 in priority and expanded metrics.

82.1

Consumers Not Found Eligible for QHP, with Financial Assistance (gross)

Count of individuals on submitted applications who were determined ineligible for enrollment in a (PY) 20XX Marketplace medical plan and eligible to receive APTC and/or CSRs. Both new consumers and consumers re-enrolling (automatic and active) in coverage should be counted. This count is a subset of Consumers Determined Eligible for Medicaid/CHIP (Indicator 8).



Same as Indicator 9.1 in priority and expanded metrics.

84

Number of Plan Selections with Financial Assistance (net)

Count of unique individuals with a (PY) 20XX Marketplace medical plan selection, where the consumer has elected to receive APTC in an amount greater than $0 and/or receives CSR. This includes consumers with APTC and CSRs (priority and expanded metric 22; bi-annual metric 85), consumers with only APTC (priority and expanded metric 23; bi-annual metric 86), and consumers with only CSRs (priority and expanded metric 24; bi-annual metric 87).



Same as Indicator 21 in priority and expanded metrics.

85

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 receives CSR. Count includes consumers with APTC and CSRs. Consumers with only APTC or with only CSRs should not be counted.


Same as Indicator 22 in priority and expanded metrics.

86

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.


Same as Indicator 23 in priority and expanded metrics.

87

Number of Plan Selections with CSR only (net)

The number 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.


Same as Indicator 24 in priority and expanded metrics.

88

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 CSR.


Same as Indicator 25 in priority and expanded metrics.

89

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 metal level is Platinum.


Same as Indicator 46 in priority and expanded metrics.

90

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 metal level is Gold.


Same as Indicator 47 in priority and expanded metrics.

91

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 metal level is Silver.


Same as Indicator 48 in priority and expanded metrics.

92

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 metal level is Bronze.


Same as Indicator 49 in priority and expanded metrics.

93

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 metal level is Catastrophic.


Same as Indicator 50 in priority and expanded metrics.

93.1

Consumers with a Plan Selection and Income < 100% (net)

Count of unique individuals in households with income less than 100% of FPL who have selected a non-canceled (PY) 20XX Marketplace medical plan.

Same as Indicator 51 in priority and expanded metrics.

94

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.


Same as Indicator 52 in priority and expanded metrics.

95

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.



Same as Indicator 53 in priority and expanded metrics.

96

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 3250% of FPL who have selected a non-canceled (PY) 2020 Marketplace medical plan.


Same as Indicator 54 in priority and expanded metrics.

97

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) 2020X Marketplace medical plan.

98

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.


Same as Indicator 54.2 in priority and expanded metrics.

99

Consumers with a Plan Selections 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) 20XXMarketplace medical plan.


Same as Indicator 54.3 in priority and expanded metrics.

100

Consumers with a Plan Selections and Income > 400% FPL (net)

Count of unique individuals in households with income greater than 400% of FPL who have selected a non-canceled (PY) 20XX Marketplace medical plan.



Same as Indicator 55 in priority and expanded metrics.

101

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.



Same as Indicator 56 in priority and expanded metrics.

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 29.4 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.



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