GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports

Medicaid and Children’s Health Insurance
Program Eligibility and Enrollment Data
Specifications for Reporting During Unwinding
February 23, 2022

PRA Disclosure Statement: The Centers for Medicare & Medicaid Services (CMS) is collecting this mandatory report under the authority in
sections 1902(a)(4)(A), 1902(a)(6) and 1902(a)(75) of the Act and at 42 CFR § 431.16 to ensure proper and efficient administration of the
Medicaid program and section 2101(a) of the Act to promote the administration of the Children's Health Insurance Program (CHIP) in an
effective and efficient manner. This reported information will be used to assess the state's plans for processing renewals when states begin
restoring routine Medicaid and CHIP operations after the COVID-19 public health emergency ends. Under the Privacy Act of 1974 any
personally identifying information obtained will be kept private to the extent of the law. 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 0938-1148 (CMS-10398 #66). The time required to complete this information collection is estimated to average 817 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.

Contents
Medicaid and Children’s Health Insurance Program Eligibility and Enrollment Data
Specifications for Reporting During Unwinding ...................................................................... 1
I.

Introduction ..................................................................................................................... 1
A.

Background .............................................................................................................. 1

B.

About the submission .............................................................................................. 1

1. What types of data are being reported?...................................................................... 1
2. How frequently and when will the data be reported? .................................................. 1
3. How will the data be submitted? ................................................................................. 1
4. What if the state is unable to submit data as defined in this specification document? 2
5. Can the data reported be changed after it has been submitted? ................................ 2
6. How can questions about data be answered? ............................................................ 2
II.

Data Specifications: Unwinding Baseline Report ............................................................ 3
A.

Baseline Report Metric Specifications ..................................................................... 3

1.

Baseline Report Metric 1: Application Processing ................................................... 3

2.

Baseline Report Metric 2: Renewals ........................................................................ 4

3.

Baseline Report Metric 3: State’s Policy for Completing Renewals ......................... 5

4.

Baseline Report Metric 4: Medicaid Fair Hearings .................................................. 5

III. Data Specifications: Unwinding Monthly Report ............................................................. 6
A.

Monthly Report Metric Specifications ...................................................................... 6

1.

Monthly Report Metrics 1-3: Application Processing ............................................... 6

2.

Monthly Report Metric 4: Renewals Initiated ........................................................... 9

3.

Monthly Report Metrics 5-7: Renewals and Outcomes............................................ 9

4.

Monthly Report Metric 8: Medicaid Fair Hearings .................................................. 11

I. Introduction
A. Background
The ongoing COVID-19 outbreak and implementation of federal policies to address the public health
emergency (PHE) have disrupted routine Medicaid, Children's Health Insurance Program (CHIP), and
Basic Health Program (BHP) eligibility and enrollment operations. Medicaid and CHIP enrollment has
grown to historic levels due in large part to the continuous enrollment requirements that states
implemented as a condition of receiving a temporary 6.2 percentage point federal medical assistance
percentage increase under section 6008 of the Families First Coronavirus Response Act (P.L. 116-127).
States will have a large volume of eligibility and enrollment actions to complete when the PHE ends, and
the Centers for Medicare & Medicaid Services (CMS) released State Health Official letter #22-00X,
“Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid,
the Children's Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon Conclusion of
the COVID-19 Public Health Emergency,” which outlines timelines and guidance for states to restore
routine operations in a manner that promotes continuity of coverage for eligible individuals and facilitates
seamless coverage transitions for those who become eligible for other insurance affordability programs
(e.g., Marketplace).

B. About the submission
1. What types of data are being reported?
CMS will require states 1 to report on specific metrics described in the “Unwinding Eligibility and
Enrollment Data Reporting Template” (Unwinding Data Report). These metrics are designed to
demonstrate a state’s progress towards restoring timely application processing and initiating and
completing renewals of eligibility for all Medicaid and CHIP enrollees, consistent with the guidance
outlined in SHO #22-00X. The remainder of this document specifies the metrics and their definitions.
2. How frequently and when will the data be reported?
States will complete a one-time baseline report and subsequent monthly reports.
•

The baseline report is due at the end of the month prior to the month in which the state’s
unwinding period begins.

•

The monthly report will be due on the 8th calendar day of each month. The first monthly
report will be due on the 8th of the month following the month in which the state begins its
unwinding period.

3. How will the data be submitted?
These reports will be submitted to CMS using the same portal in which states enter their Performance
Indicator (PI) data (https://sdis.medicaid.gov/user/login). This portal is set up to accept submissions from
those with PI submission credentials. States may use the Unwinding Data Report excel workbook as a
planning tool to review the metrics before submitting their baseline and monthly reports through the PI
portal.

1

Throughout this document, “states” refers to states, the District of Columbia, and the U.S. Territories.
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4. What if the state is unable to submit data as defined in this specification document?
There is a check box under the majority of metrics on both report forms labeled, “Unable to Report.” If a
state is unable to report a metric as defined, please check this box and include in the notes section for that
metric an explanation of why the state cannot report the metric. CMS may follow up to further discuss.
5. Can the data reported be changed after it has been submitted?
If states later discover they made a mistake or if they have additional data to report, states will be able to
update either report (baseline or monthly report) using the same link at which the data was originally
submitted.
6. How can questions about data be answered?
We realize that states may have questions or need help as they review the metrics in the reports and
reporting specifications.
•

States can access help at anytime by emailing [email protected].

•

CMS will also be hosting an all-state webinar in which they will review the metrics and how to
submit their Unwinding Data Report; the webinar will be recorded and posted on Medicaid.gov
so that states can access it at any time.

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II. Data Specifications: Unwinding Baseline Report
This chapter provides detailed instructions on how to complete the Unwinding Baseline Report. Table 1
summarizes key details about baseline reporting. Step-by-step descriptions of each of the metrics, and
how to compute them, are found below.
Table 1. Summary of Unwinding Baseline Period Reporting Specifications
What is the baseline report?

The baseline report is meant to serve as a starting point to track a state’s pending
eligibility and enrollment actions that the state will need to address when the state
begins its unwinding period. States will be required to report summary data on
pending applications, renewals, and fair hearings.
States will report Medicaid and CHIP data in this report. 2 Data will not be
reported separately by program.

How do I submit it?

States will log on to https://sdis.medicaid.gov/user/login to submit their data.

When is it due?

At the end of the month prior to the month in which the state’s unwinding period
begins

What if, after submission, I
States will be able to update the baseline report at the same link,
need to change or update data https://sdis.medicaid.gov/user/login, if they later discover they made a mistake, or
if they did not have all of the data they needed to complete the form when it was
previously reported?
initially submitted.
What if I have questions not
answered in these
instructions?

If the state has questions while completing the baseline report, please email the
technical assistance help desk at [email protected].

A. Baseline Report Metric Specifications
The baseline report begins with asking states to submit two key pieces of information:
•

Submission Date. This field will be auto populated with the current date, in the format
MM/DD/YYYY. It is due no later than the end of the month prior to the month in which the state’s
unwinding period begins.

•

Unwinding Period Start Date. States will enter the month in which their unwinding period begins in
the format MM/YYYY.

1.

Baseline Report Metric 1: Application Processing

States must report the total number of pending applications that the state received between March 1, 2020,
and the end of the month prior to the state’s unwinding period. This information will be broken out by (1)
pending MAGI and other non-disability related applications (e.g., individuals determined on the basis of
being age 65 or older), and (2) pending disability-related applications (e.g., individuals who apply for
Medicaid on the basis of a disability). Table 2 provides instructions for how to report these metrics.
Table 2: Baseline Metrics 1, 1a, and 1b

Metric 1: Total pending applications received between March 1, 2020 and the end of the month prior to the
state’s unwinding period
• This metric includes:
How is the metric
• All applications received by the Medicaid and CHIP state agency between March 1,
defined?
2020 and the end of the month prior to the state’s unwinding period for which a final
eligibility determination has not been made. This includes applications received

Note that Baseline Metric 4, Medicaid Fair Hearings, will only include data on Medicaid fair hearings and not
separate CHIP reviews.

2

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directly by the state and accounts transferred from the Federally Facilitated
Marketplace or a State-Based Marketplace.
• All applications received during the timeframe outlined above should be counted,
regardless of the modality used for submission as described at 42 C.F.R. §435.907
(e.g., online, by phone, by mail, or in person).
• This metric is the sum of metrics 1a and 1b.
• Applications that were received and completed (i.e., a final eligibility determination was
What is excluded
made) before the state begins its unwinding period.
from this metric?
• Applications received during the unwinding period.
• If a state deviates from the specifications above or has any additional context that
What is included in
impacts the data they feel CMS should be aware of, they should use the free text field to
the Metric 1 Notes
report that information in narrative format for metrics 1, 1a, or 1b.
field?
• This field should be left blank if the state has nothing additional to report.
Metric 1a: Pending MAGI and other non-disability applications
• This metric includes:
• All MAGI and other non-disability related applications (e.g., individuals determined on
the basis of being age 65 or older) received by the Medicaid and CHIP state agency
between March 1, 2020 and the end of the month prior to the state’s unwinding
period for which a final eligibility determination has not been made. This includes
How is the metric
applications received directly by the state and accounts transferred from the
defined?
Federally Facilitated Marketplace or a State-Based Marketplace.
• All MAGI and other non-disability related applications received during the timeframe
outlined above should be counted, regardless of the modality used for submission as
described at 42 C.F.R. §435.907 (e.g., online, by phone, by mail, or in person).
• This metric is a subset of metric 1.
• Applications for individuals seeking coverage on a MAGI or other non-disability related
What is excluded
basis that were received and completed (i.e., a final eligibility determination was made)
from this metric?
before the state begins its unwinding period.
• Applications received during the unwinding period.
Metric 1b: Pending disability-related applications
• This metric includes:
• All disability-related applications received by the Medicaid and CHIP state agency
between March 1, 2020 and the end of the month prior to the state’s unwinding
period for which a final eligibility determination has not been made. This includes
How is the metric
applications received directly by the state and accounts transferred from the
defined?
Federally Facilitated Marketplace or a State-Based Marketplace.
• All disability-related applications received during the timeframe outlined above should
be counted, regardless of the modality used for submission as described at 42 C.F.R.
§435.907 (e.g., online, by phone, by mail, or in person).
• This metric is a subset of metric 1.
• Applications for individuals seeking coverage on a disability related basis that were
What is excluded
received and completed (i.e., a final eligibility determination was made) before the state
from this metric?
begins its unwinding period.
• Applications received during the unwinding period.

2.

Baseline Report Metric 2: Renewals

States must report the total number of beneficiaries enrolled as of the end of the month prior to the state’s
unwinding period. Table 3 provides instructions for how to report this metric.
Table 3: Baseline Metric 2
Metric 2: Total beneficiaries enrolled as of the end of the month prior to the state's unwinding period
How is the metric
defined?
What is excluded
from this metric?

This metric includes a count of all beneficiaries or “total caseload,” including those
receiving full and limited benefits, enrolled in Medicaid or CHIP as of the end of the month
prior to the state’s unwinding period.
Individuals who applied for Medicaid but have not had an eligibility determination
completed because they were granted a reasonable opportunity period consistent with
435.956(b) because their citizenship or immigration status was not verified and who

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What is included in
the Metric 2 Notes
field?

3.

remained enrolled as authorized by section 6008 of the FFCRA in order to claim enhanced
temporary FMAP.
• If a state deviates from the specifications above or has any additional context that
impacts the data they feel CMS should be aware of, they should use the free text field
to report that information in narrative format.
• This field should be left blank if the state has nothing additional to report.

Baseline Report Metric 3: State’s Policy for Completing Renewals

States must report their policy for completing renewals. Table 4 provides instructions for how to report
this metric.
Table 4: Baseline Metric 3
Metric 3: State’s timeline for the renewal process
How is the metric
defined?

4.

This metric includes the number of days in the state’s renewal processing period, which is
the time from the day a renewal process is initiated to when a final eligibility determination
is expected.

Baseline Report Metric 4: Medicaid Fair Hearings

States must report Medicaid fair hearings that have been pending more than 90 days as of the end of the
month prior to the state’s unwinding period. Table 5 provides instructions for how to report this metric.
Table 5: Baseline Metric 4
Metric 4: Total number of Medicaid fair hearings pending more than 90 days at the end of the month prior
to the state’s unwinding period

How is the metric
defined?

What is excluded
from this metric?

What is included in
the Metric 4 Notes
field?

• This metric includes:
• All pending fair hearings, including those meeting the criteria for an expedited
resolution in accordance with 42 C.F.R. § 431.224(a), for which the state has not taken
final administrative action within 90 days of the date the agency received a request for
a fair hearing in accordance with 42 C.F.R. § 431.221(a)(1) as of the end of the month
prior to the state’s unwinding period.
• All pending fair hearings for which the state has not taken action within 90 days from
the date the enrollee filed a managed care organization (MCO), prepaid inpatient
health plan (PIHP), or prepaid ambulatory health plan (PAHP) appeal, not including
the number of days the enrollee took to subsequently file for a Medicaid fair hearing.
• For states utilizing Medicaid expansion CHIP, all pending fair hearings, including those
meeting the criteria for an expedited resolution in accordance with 42 C.F.R. §
457.1160(a) or 42 C.F.R. § 457.1260(f), for which the state has not taken final
administrative action within 90 days of the date the agency received a request for a fair
hearing in accordance with 42 C.F.R. § 457.1130(a) as of the end of the month prior to
the state’s unwinding period.
• Fair hearings for which a final fair hearing decision was issued and a state has taken
final administrative action in accordance with 42 CFR 431.244(f). A final fair hearing
decision may include a dismissal of the fair hearing request.
• States should exclude separate CHIP review data from this metric.
•
If a state deviates from the specifications above or has any additional context that
impacts the data they feel CMS should be aware of, they should use the free text field
to report that information in narrative format. For example, please specify if the state is
not able to report solely Medicaid fair hearings data and has included separate CHIP
reviews in the reported information.
•
This field should be left blank if the state has nothing additional to report.

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III.

Data Specifications: Unwinding Monthly Report

This chapter provides detailed instructions on how to complete the Unwinding Monthly Report. Table 6
summarizes key details about monthly reporting. Step-by-step descriptions of each of the metrics, and
how to compute them, are found below.
Table 6: Summary of Unwinding Monthly Period Reporting Specifications
What is the
monthly report?

How do I submit it?
When is it due?
What if, after
submission, I need
to change or
update data
previously
reported?
What if I have
questions not
answered in these
instructions?

The monthly report is designed to support CMS in tracking the state’s progress in
addressing pending eligibility and enrollment actions when the state’s unwinding period
begins. States will be required to report summary data on pending and completed
applications and renewals and pending fair hearings.
States will report Medicaid and CHIP data in this report. 3 Data will not be reported
separately by program.
States will log on to https://sdis.medicaid.gov/user/login.
The 8th calendar day of the month following the report month
States will be able to update the monthly report at the same link,
https://sdis.medicaid.gov/user/login, if they later discover they made a mistake, or if they
did not have all of the data they needed to complete the form when it was initially
submitted.
If the state has questions while completing the monthly report, please email the technical
assistance help desk at [email protected].

A. Monthly Report Metric Specifications
The monthly report begins with asking states to submit one key piece of information:
Submission Date. This field will be auto populated with the current date, in the format
MM/DD/YYYY. It is due no later than by the 8th day of the month following the reporting period.

•
1.

Monthly Report Metrics 1-3: Application Processing

Metric 1 and its sub-metrics are the same metrics reported on the baseline report. States must report the
total number of pending applications that the state received between March 1, 2020, and the end of the
month prior to the state’s unwinding period; if these metrics have not changed, they will be the same as
the data the state reported in the baseline report. Additionally, in the monthly reports, states will report on
number of applications completed and those that remain pending as of the last day in the reporting period
covered by the report. Tables 7-9 provide instructions for how to report these metrics.
Table 7: Monthly Metrics 1, 1a, and 1b

Metric 1: Total pending applications received between March 1, 2020 and the end of the month prior to the
state’s unwinding period
• This metric includes:
• All applications received by the Medicaid and CHIP state agency between March 1,
How is the metric
2020 and the end of the month prior to the state’s unwinding period for which a final
defined?
eligibility determination has not been made. This includes applications received
directly by the state and accounts transferred from the Federally-Facilitated
Marketplace or a State-Based Marketplace.

Note that Monthly Metric 8, Medicaid Fair Hearings, will only include data on Medicaid fair hearings and not
separate CHIP reviews.

3

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• All applications received during the timeframe outlined above should be counted,
regardless of the modality used for submission as described at 42 C.F.R. §435.907
(e.g., online, by phone, by mail, or in person).
• This metric is the sum of metrics 1a and 1b.
• Applications that were received and completed (i.e., a final eligibility determination was
What is excluded
made) before the state begins its unwinding period.
from this metric?
• Applications received during the unwinding period.
• If a state deviates from the specifications above or has any additional context that
What is included in
impacts the data they feel CMS should be aware of, they should use the free text field to
the Metric 1 Notes
report that information in narrative format for metrics 1, 1a, or 1b.
field?
• This field should be left blank if the state has nothing additional to report.
Metric 1a: Total MAGI and other non-disability applications
• This metric includes:
• All MAGI and other non-disability related applications (e.g., individuals determined on
the basis of being age 65 or older) received by the Medicaid and CHIP state agency
between March 1, 2020 and the end of the month prior to the state’s unwinding
period for which a final eligibility determination has not been made. This includes
How is the metric
applications received directly by the state and accounts transferred from the
defined?
Federally Facilitated Marketplace or a State-Based Marketplace.
• All MAGI and other non-disability related applications received during the timeframe
outlined above should be counted, regardless of the modality used for submission as
described at 42 C.F.R. §435.907 (e.g., online, by phone, by mail, or in person).
• This metric is a subset of metric 1.
• Applications for individuals seeking coverage on a MAGI or other non-disability related
What is excluded
basis that were received and completed (i.e., a final eligibility determination was made)
from this metric?
before the state begins its unwinding period.
• Applications received during the unwinding period.
Metric 1b: Total disability-related applications
• This metric includes:
• All disability-related applications received by the Medicaid and CHIP state agency
between March 1, 2020 and the end of the month prior to the state’s unwinding
period for which a final eligibility determination has not been made. This includes
How is the metric
applications received directly by the state and accounts transferred from the
defined?
Federally Facilitated Marketplace or a State-Based Marketplace.
• All disability-related applications received during the timeframe outlined above should
be counted, regardless of the modality used for submission as described at 42 C.F.R.
§435.907 (e.g., online, by phone, by mail, or in person).
• This metric is a subset of metric 1.
• Applications for individuals seeking coverage on a disability related basis that were
What is excluded
received and completed (i.e., a final eligibility determination was made) before the state
from this metric?
begins its unwinding period.
• Applications received during the unwinding period.

Table 8: Monthly Metrics 2, 2a, and 2b

Metric 2: Of those applications included in Monthly Metric 1, the total number of applications completed as
of the last day of the reporting period
• This is defined as the cumulative number of applications counted in Monthly Metric 1
that have been completed as of the last day in the reporting period covered by this
How is the metric
report.
defined?
• A completed application is one in which a final eligibility determination has been made.
• This metric is the sum of metrics 2a and 2b.
What is excluded
from this metric?
What is included in
the Metric 2 Notes
field?

Applications that have not been completed by the last day of the reporting period covered
by this report.
• If a state deviates from the specifications above or has any additional context that
impacts the data they feel CMS should be aware of, they should use the free text field to
report that information in narrative format for metrics 2, 2a, or 2b.
• This field should be left blank if the state has nothing additional to report.

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Metric 2a: Completed MAGI and other non-disability related applications as of the last day of the reporting
period
• This is defined as the cumulative number of MAGI and other non-disability related
applications (e.g., individuals determined on the basis of being age 65 or older) counted
in Monthly Metric 1a that have been completed as of the last day in the reporting period
covered by this report.
How is the metric
• A completed application is one in which a final eligibility determination has been made
defined?
and the state has either enrolled an eligible applicant or denied coverage for an
individual the agency could not determine to be eligible as of the last day of the reporting
period.
• This metric is a subset of metric 2.
What is excluded
Applications that have not been completed by the last day of the reporting period covered
from this metric?
by this report.
Metric 2b: Completed disability-related applications as of the last day of the reporting period
• This is defined as the cumulative number of disability-related applications counted in
Monthly Metric 1b that have been completed as of the last day in the reporting period
covered by this report.
How is the metric
• A completed application is one in which a final eligibility determination has been made
defined?
and the state has either enrolled an eligible applicant or denied coverage for an
individual the agency could not determine to be eligible as of the last day of the reporting
period.
• This metric is a subset of metric 2.
What is excluded
Applications that have not been completed by the last day of the reporting period covered
from this metric?
by this report.

Table 9: Monthly Metrics 3, 3a, and 3b

Metric 3: Of those applications included in Monthly Metric 1, the total number of applications that remain
pending as of the last day of the reporting period
How is the metric
• This is defined as the cumulative number of applications included in Monthly Metric 1
defined?
for which a final eligibility determination has not been made as of the last day of the
reporting period. It represents the remaining balance of applications that remain pending
at the end of the reporting period.
• This metric is the sum of metrics 3a and 3b.
What is excluded
Applications completed as of the last day of the reporting period.
from this metric?
What do states
• If a state deviates from the specifications above or has any additional context that
include in the
impacts the data they feel CMS should be aware of, they should use the free text field to
Metric 3 Notes
report that information in narrative format for metrics 3, 3a, or 3b.
field?
• This field should be left blank if the state has nothing additional to report.
Metric 3a: Pending MAGI and other non-disability applications as of the last day of the reporting period
• This is defined as the cumulative number of MAGI and non-disability related
applications (e.g., individuals determined on the basis of being age 65 or older) included
How is the metric
in Monthly Metric 1a for which a final eligibility determination has not been made as of
defined?
the last day of the reporting period. It represents the remaining balance of MAGI and
non-disability related applications that remain pending at the end of the reporting period.
• This metric is a subset of metric 3.
What is excluded
MAGI and non-disability related applications completed as of the last day of the reporting
from this metric?
period.
Metric 3b: Pending disability-related applications as of the last day of the reporting period
• This is defined as the cumulative number of disability-related applications counted in
Monthly Metric 1b for which a final eligibility determination has not been made as of the
How is the metric
last day of the reporting period. It represents the remaining balance of disability-related
defined?
applications that remain pending at the end of the reporting period.
• This metric is a subset of metric 3.
What is excluded
Disability-related applications completed as of the last day of the reporting period.
from this metric?

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2.

Monthly Report Metric 4: Renewals Initiated

States must report on the number of renewals initiated in the monthly reports. Table 10 provides
instructions for how to report this metric.
Table 10: Monthly Metric 4

Metric 4: Total beneficiaries for whom a renewal was initiated in the reporting period
How is the metric
• This is defined as the total number of beneficiaries, including those receiving full or
defined?
limited benefits, with an annual renewal that was initiated between the first and last day
of the reporting period.
• An annual renewal is considered “initiated” when a state first begins the ex parte
process.
• This metric is not cumulative and should only include data on renewals initiated in the
reporting period.
What is excluded
Annual renewals that were initiated in prior reporting periods as well as those that have not
from this metric?
been initiated yet.
What do states
• If a state deviates from the specifications above or has any additional context that
include in the
impacts the data they feel CMS should be aware of, they should use the free text field to
Metric 4 Notes
report that information in narrative format.
field?
• This field should be left blank if the state has nothing additional to report.

3.

Monthly Report Metrics 5-7: Renewals and Outcomes

States must report on the number of beneficiaries due for renewal and the final disposition of renewals in
the monthly reports. Tables 11-13 provide instructions for how to report these metrics.
Table 11: Monthly Metrics 5, 5a, 5a(1), 5a(2), 5b, 5c, and 5d

Metric 5: Total beneficiaries due for a renewal in the reporting period
How is the metric
• This is defined as the total number of beneficiaries, including those receiving full or
defined?
limited benefits, with an annual renewal due in the reporting period.
• This metric is not cumulative and should only include data on renewals due in the
reporting period, representing beneficiaries whose annual renewal processes were
initiated in a prior month, based on the state’s renewal policy. In this context, which
renewals are “due” relate to what the state reported in baseline metric 3 (state's timeline
for the renewal process). For example, if a state initiated a batch of renewals on March
15th and noted a timeline of 75 days for the renewal process, CMS would consider that
batch of renewals “due” at the end of May.
•
Note: depending on what the state reported in baseline metric 3 (state’s timeline
for the renewal process), it may report 0 for the first two to three months of
monthly reporting because renewals that have been initiated are not yet due.
• This metric is the sum of metrics 5a, 5b, 5c, and 5d.
What is excluded
Annual renewals not due in the reporting period.
from this metric?
What do states
• If a state deviates from the specifications above or has any additional context that
include in the
impacts the data they feel CMS should be aware of, they should use the free text field to
Metric 5 Notes
report that information in narrative format.
field?
• This field should be left blank if the state has nothing additional to report.
Metric 5a: Of the beneficiaries included in Metric 5, the number renewed and retained in Medicaid or CHIP
(those who remained enrolled)
• This is defined as the total number of beneficiaries, including those receiving full or
limited benefits, whose annual renewal was due in the reporting period who were
renewed and retained in Medicaid or CHIP at the end of the reporting period.
How is the metric
• This metric is not cumulative and should only include those beneficiaries renewed and
defined?
retained in the reporting period.
• This metric is a subset of metric 5.
• This metric is the sum of metrics 5a(1) and 5a(2).
What is excluded
Any beneficiary not retained in Medicaid or CHIP at the end of the reporting period.
from this metric?

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What do states
• If a state deviates from the specifications above or has any additional context that
include in the
impacts the data they feel CMS should be aware of, they should use the free text field to
Metric 5a Notes
report that information in narrative format for metrics 5a, 5a(1), or 5a(2).
free text field?
• This field should be left blank if the state has nothing additional to report.
Metric 5a(1): Number of beneficiaries renewed on an ex parte 4 basis
• This is defined as the total number of beneficiaries, including those receiving full or
limited benefits, whose annual renewal was due in the reporting period who were
renewed and retained in Medicaid or CHIP in the reporting period on an ex parte basis,
meaning eligibility was redetermined based on information available to the agency
How is the metric
without requiring additional information from the individual.
defined?
• This metric is not cumulative; states will only report on those beneficiaries that were
renewed on an ex parte basis in the reporting period.
• This metric is a subset of metric 5a.
What is excluded
Any beneficiary not renewed through ex parte processes in the reporting period.
from this metric?
Metric 5a(2): Number of beneficiaries renewed using a pre-populated renewal form
• This is defined as the total number of beneficiaries, including those receiving full or
limited benefits, whose annual renewal was due in the reporting period who were
renewed and retained in Medicaid or CHIP in the reporting period using a pre-populated
How is the metric
form.
defined?
• This metric is not cumulative; states will only report on those beneficiaries that were
renewed using a pre-populated renewal form in the reporting period.
• This metric is a subset of metric 5a.
What is excluded
Any beneficiary not renewed through use of a pre-populated form in the reporting period.
from this metric?
Metric 5b: Of the beneficiaries included in Metric 5, the number determined ineligible for Medicaid or CHIP
(and transferred to the Marketplace)
• This is defined as the total number of beneficiaries, including those receiving full or
limited benefits, whose annual renewal was due in the reporting period who were
determined ineligible for Medicaid or CHIP and were transferred to the Marketplace in
How is the metric
the reporting period.
defined?
• This metric is not cumulative and should only include data on beneficiaries determined
ineligible for Medicaid or CHIP and transferred to the Marketplace in the reporting period.
• This metric is a subset of metric 5.
What is excluded
Any beneficiary who remained eligible for Medicaid or CHIP coverage or who was not
from this metric?
transferred to the Marketplace.
What do states
• If a state deviates from the specifications above or has any additional context that
include in the
impacts the data they feel CMS should be aware of, they should use the free text field to
Metric 5b Notes
report that information in narrative format.
field?
• This field should be left blank if the state has nothing additional to report.
Metric 5c: Of the beneficiaries included in Metric 5, the number terminated for procedural reasons (i.e.,
failure to respond)
• This is defined as the total number of beneficiaries, including those receiving full or
limited benefits, whose annual renewal was due in the reporting period that were
determined ineligible for Medicaid or CHIP for procedural reasons in the reporting period.
How is the metric
• Procedural reasons include instances where a beneficiary fails to provide information
defined?
necessary to complete a Medicaid or CHIP redetermination.
• This metric is not cumulative and should only include data on beneficiaries that were
determined ineligible for Medicaid or CHIP for procedural reasons in the reporting period.
• This metric is a subset of metric 5.
What is excluded
Any beneficiary who was not terminated for procedural reasons in the reporting period.
from this metric?
What do states
• If a state deviates from the specifications above or has any additional context that
include in the
impacts the data they feel CMS should be aware of, they should use the free text field to
Metric 5c Notes
report that information in narrative format.
field?
• This field should be left blank if the state has nothing additional to report.

An ex parte renewal is sometimes referred to as auto renewal, passive renewal, or administrative renewal and is
described at 42 CFR 435.916(a)(2).

4

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Metric 5d: Of the beneficiaries included in Metric 5, the number whose renewal was not completed
• This is defined as the total number of annual renewals for beneficiaries, including those
receiving full or limited benefits, that were due in the reporting period that were not
completed or a final eligibility determination had not been made as of the end of the
How is the metric
reporting period.
defined?
• This metric is not cumulative and should only include data on renewals due in the
reporting period.
• This metric is a subset of metric 5.
What is excluded
Any beneficiary whose renewal was completed.
from this metric?
• If a state deviates from the specifications above or has any additional context that
What do states
impacts the data they feel CMS should be aware of, they should use the free text field to
include in the
report that information in narrative format.
Metric 5d Notes?
• This field should be left blank if the state has nothing additional to report.

Table 12: Monthly Metric 6

Metric 6: Month in which renewals due in the reporting period were initiated
How is the metric
• States will expand a drop-down menu and select the month in which the renewals that
defined?
were due in the reporting period covered by the report were initiated; this should be
based off of the state’s timeline for the renewal process reported in Baseline Metric 3.
What do states
• If a state deviates from the specifications above or has any additional context that
include in the
impacts the data they feel CMS should be aware of, they should use the free text field to
Metric 6 Notes?
report that information in narrative format.
• This field should be left blank if the state has nothing additional to report.

Table 13: Monthly Metric 7

Metric 7: Number of beneficiaries due for a renewal since the beginning of the state’s unwinding period
whose renewal has not yet been completed
How is the metric
• This is defined as the total number of beneficiaries, including those receiving full or
defined?
limited benefits, due for renewal whose renewal has been initiated but not been fully
processed.
• This metric is cumulative; it counts all renewals that have been initiated since the
beginning of the state’s unwinding period and were due prior to or as of the last day of
the reporting period covered by this report (per the state’s timeline for the renewal
process), but whose renewals were not fully processed as of the last day in the reporting
period.
• States should be cautious of simply adding the numbers previously reported in 5d, as
doing so would not reflect renewals that may have been completed after the month in
which it was due.
What is excluded
All renewals that have been completed.
from this metric?
What do states
• If a state deviates from the specifications above or has any additional context that
include in the
impacts the data they feel CMS should be aware of, they should use the free text field to
Metric 7 Notes
report that information in narrative format.
field?
• This field should be left blank if the state has nothing additional to report.

4.

Monthly Report Metric 8: Medicaid Fair Hearings

States must report Medicaid fair hearings that have been pending more than 90 days at the end of the
reporting period. Table 14 provides instructions for how to report this metric.
Table 14: Monthly Metric 8

Metric 8: Total number of Medicaid fair hearings pending more than 90 days at the end of the reporting
period
How is the metric
• This metric includes:
defined?
• All pending fair hearings, including those meeting the criteria for an expedited
resolution in accordance with 42 C.F.R. § 431.224(a), for which the state has not taken
final administrative action within 90 days of the date the agency received a request for

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What is excluded
from this metric?
What do states
include in the
Metric 8 Notes
field?

•
•
•

•

a fair hearing in accordance with 42 C.F.R. § 431.221(a)(1) as of the end of the
reporting period.
• All pending fair hearings for which the state has not taken action within 90 days from
the date the enrollee filed a managed care organization (MCO), prepaid inpatient
health plan (PIHP), or prepaid ambulatory health plan (PAHP) appeal, not including
the number of days the enrollee took to subsequently file for a State fair hearing.
• This includes Medicaid fair hearing requests received both before and after the end of
the continuous enrollment requirement.
• For states utilizing Medicaid expansion CHIP, all pending fair hearings, including those
meeting the criteria for an expedited resolution in accordance with 42 C.F.R. §
457.1160(a) or 42 C.F.R. § 457.1260(f), for which the state has not taken final
administrative action within 90 days of the date the agency received a request for a fair
hearing in accordance with 42 C.F.R. § 457.1130(a) as of the end of the reporting
period.
This metric excludes fair hearings for which a final fair hearing decision was issued and a
state has taken final administrative action in accordance with 42 CFR 431.244(f). A final
fair hearing decision may include a dismissal of the fair hearing request.
States should exclude separate CHIP review data from this metric.
If a state deviates from the specifications above or has any additional context that
impacts the data they feel CMS should be aware of, they should use the free text field to
report that information in narrative format. For example, please specify if the state is not
able to report solely Medicaid fair hearings data and has included separate CHIP reviews
in the reported information.
This field should be left blank if the state has nothing additional to report.

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