Actual Enrollment Data Sample Spreadsheet.xlsx

Basic Health Program Report for Health Insurance Exchange Premium (CMS-10510)

Actual Enrollment Data Sample Spreadsheet.xlsx

OMB: 0938-1218

Document [xlsx]
Download: xlsx | pdf

Overview

Enrollee Information
Data Dictionary


Sheet 1: Enrollee Information

BHP Enrollment Data














































Enrollee Information Coverage Information Plan Information
Personal Identifier Date of Birth County Name County FIPS Code American Indian or Alaska Native Household Size Household Annual Income Number of BHP Enrollees in Household Family Identifier Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Plan Name Plan Issuer Plan ID
111111111 1/1/1970 AAA 01001 N 3 $35,000 1 111111111 1 1 1








XXX XXX 111
222222222 1/1/1966 BBB 01003 N 1 $20,000 1 222222222 0 0 1








YYY YYY 222
333333333 1/1/1975 CCC 01005 N 2 $25,000 2 333333333 1 1 1








ZZZ ZZZ 333
444444444 1/1/1976 CCC 01005 N 2 $25,000 2 333333333 1 1 1








ZZZ ZZZ 333
555555555 1/1/1980 DDD 01007 Y 1 $20,000 1 555555555 1 1 1








XXX XXX 111

Sheet 2: Data Dictionary

Data Element Required Specification State Specificiation
Personal identifier SSN, unique Marketplace identification number, or unique Medicaid identification number
Date of Birth mm/dd/yyyy
County Name county name as text
County FIPS Code numeric FIPS code
American Indian or Alaska Native Y=Yes, N=No
Household Size number of people in household
Household Annual Income annual MAGI household income
Number of BHP Enrollees in Household number of BHP enrollees
Family Identifier personal identifier of head of household
Coverage Month 1=enrolled, 0=not enrolled
Plan Name plan name as text
Plan Issuer plan issuer as text
Plan ID HIOS ID or NAIC-issued Payer ID
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

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