CMS-10398 (GenIC#7 CMS-10398_GenIC_7-CycleVbMonthlyReportwTarget

CKC Monthly Data Report

This form is for monthly reporting to CMS by Connecting Kids to Coverage grantees.
Grantee: Select your organization
Reporting Month: Reporting Month
Date of Submission:

Instructions

These instructions provide guidance on how to complete each section of this reporting template. A
data dictionary, including official definitions for terms included in this form, is included at the end.

Data confirmations
This section asks you to confirm that the data you are submitting are consistent with reporting
requirements.

Child data
You should report:
a) The number of children for whom applications were submitted in the current reporting month
b) The number of children verified as newly enrolled or renewed in the current reporting month,
according to the data definitions provided below
If you can identify which children were already covered by Medicaid or CHIP when you provided
substantial interactive assistance, data should be entered in columns 1, 2, 6, and 7; column 3 and 8 will
calculate automatically. Only if you cannot identify which children were already covered, should you
enter data in columns 3 and 8 and leave columns 1, 2, 6, and 7 blank. Similarly, if you can identify which
children were targeted children, data should be entered in columns 4, 5, 9, and 10; if not, columns 4, 5,
9, and 10 should be left blank.
In the first months of the grant when no enrollments or renewals have been verified, and/ or when no
applications are completed during the current reporting month, you should enter a zero in the relevant
columns.

Parent data
This section is similar to the Child data section. You are only required to complete this section if your
grant application included goals for enrolling or renewing parents. Still, you may choose to enter data in
this section if you collect data consistent with the data definitions below.

Main activities
This section is allows you to provide narrative updates on your activities during the reporting month,
and to report any areas in which you would like help that CMS may be able to provide. Each table cell is
limited to 1,000 characters; you are encouraged to be more concise than this, as these tables are only
intended as a starting point for monthly conversations with your CMS project officer.

Data confirmations
☐ Check this box if all applications, enrollments, and renewals counted in this report resulted from
assistance by staff 100% funded by your CKC HEALTHY KIDS grant. If they did not, please
estimate the share of applications, enrollments and renewals reported that are attributable to
CKC funding (and explain how you arrived at this estimate) in the ‘data limitations’ field in the
following child and parent data sections.
☐ Check this box if all applications, enrollments, and renewals counted in this report are reported
consistently with the data definitions provided in the data dictionary at the end of this reporting
template. If they are not, please explain how they differ in the ‘data limitations’ field in the
following child and parent data sections.
☐ Check this box if all enrollments and renewals counted in this report were verified.

Child data
Application data
Enter the number of children for whom a Medicaid/CHIP application was submitted during the current reporting month as a direct result of your CKC HEALTHY KIDS grant activities. If you can
identify which children were already covered by Medicaid/CHIP when you provided them with substantial interactive assistance, enter data in columns 1 and 2 of row A; column 3 will calculate
automatically. If you cannot identify which children were already covered, leave row A blank and enter the total number of children assisted in column 3 of row B. If you can identify which children
were in your target population, enter data in columns 4 and 5 of row A; if you cannot, leave these columns 4 and 5 blank. The sum of columns 4 and 5 must equal the total number of children in
column 3; an error will appear in the DATA CHECK box if they do not match. If you completed no applications this month, enter 0s in columns 1, 2, 4, and 5.

#

1
Number of children for whom a new
application was submitted during the
current reporting month

2
Number of children for whom a
renewal application was submitted
during the current reporting month

Unavailable

Unavailable

3
Total number of children applying
during the current reporting month

4
Number of targeted children for whom
an application was submitted during
the current reporting month

5
Number of other children for whom an
application was submitted during the
current reporting month

Unavailable

Unavailable

A
B

DATA CHECK

TOTALS MATCH

Verified enrollment data
Enter the number of children for whom a Medicaid/CHIP new enrollment or renewal was verified during the current reporting month as a direct result of your CKC HEALTHY KIDS grant activities.
If you can identify which children were already covered by Medicaid/CHIP when you provided them with substantial interactive assistance, enter data in columns 6 and 7 of row A; column 8 will
calculate automatically. If you cannot identify which children were already covered, leave row A blank and enter the total number of children enrolled or renewed in column 8 of row B. If you can
identify which children were in your target population, enter data in columns 9 and 10 of row A; if you cannot, leave columns 9 and 10 blank. The sum of columns 9 and 10 must equal the total
number of children in column 8; an error will appear in the DATA CHECK box if they do not match. If you verified no new enrollments or renewals this month, enter 0s in columns 6, 7, 9, and 10.
#

6

7

Number of children newly enrolled
during the current reporting month

Number of children renewed during the
current reporting month

8
Total number of children enrolled or
renewed during the current reporting
month

9
Number of targeted children enrolled
or renewed during the current
reporting month

10
Number of other children enrolled or
renewed during the current reporting
month

Unavailable

Unavailable

A
B

Unavailable

Unavailable
DATA CHECK

TOTALS MATCH

Data limitations
Explain any limitations that may help us understand these data, such as reasons the data reported do not reflect the true number of applications submitted, or enrollments or renewals completed,
that were funded by this grant

Parent data
Application data
Enter the number of parents for whom an insurance affordability application was submitted during the current reporting month, as a direct result of your CKC HEALHTY KIDS grant activities. If you
can identify which parents were already covered by an insurance affordability program when you provided them with substantial interactive assistance, enter data in columns 1 and 2 of row A;
column 3 will calculate automatically. If you cannot identify which parents were already covered, leave row A blank and enter the total number of parents assisted in column 3 of row B. If you can
identify which parents were parents of children in your target population, enter data in columns 4 and 5 of row A; if you cannot, leave columns 4 and 5 blank. The sum of columns 4 and 5 must equal
the total number of parents in column 3; an error will appear in the DATA CHECK box if they do not match. If you completed no applications this month, enter 0s in columns 1, 2, 4, and 5.

#

1
Number of parents for whom a new
application was submitted during the
current reporting month

2
Number of parents for whom a renewal
application was submitted during the
current reporting month

Unavailable

Unavailable

3
Total number of parents applying
during the current reporting month

4
Number of targeted parents for whom
an application was submitted during
the current reporting month

5
Number of other parents for whom an
application was submitted during the
current reporting month

Unavailable

Unavailable

A
B

DATA CHECK

TOTALS MATCH

Verified enrollment data
Enter the number of parents for whom an insurance affordability new enrollment or renewal was verified during the current reporting month, as a direct result of your CKC HEALTHY KIDS grant
activities. If you can identify which parents were already covered by an insurance affordability program when you provided them with substantial interactive assistance, enter data in columns 6 and 7
and row A; column 8 will calculate automatically. If you cannot identify which parents were already covered, leave row A blank and enter the total number of parents enrolled or renewed in column
8 of row B. If you can identify which parents were parents of children in your target population, enter data in columns 9 and 10 of row A; if you cannot, leave columns 9 and 10 blank. The sum of
columns 9 and 10 must equal the total number of parents in column 8; an error will appear in the DATA CHECK box if they do not match. If you verified no new enrollments or renewals this month,
enter 0s in columns 6, 7, 9, and 10.

#

6

7

Number of parents newly enrolled
during the current reporting month

Number of parents renewed during the
current reporting month

Unavailable

Unavailable

8
Total number of parents enrolled or
renewed during the current reporting
month

9
Number of targeted parents enrolled or
renewed during the current reporting
month

10
Number of other parents enrolled or
renewed during the current reporting
month

Unavailable

Unavailable

A
B

DATA CHECK

TOTALS MATCH

Data limitations
Explain any limitations that may help us understand these data, such as reasons the data reported do not reflect the true number of applications submitted, or enrollments or renewals completed,
that were funded by this grant.

Main activities
Major activities, achievements, and challenges
Describe 1 to 6 major activities, achievements, and challenges that you experienced on this grant project
during the current reporting period. Each cell is limited to 1,000 characters.
Major activities, achievements, and challenges

Description/details

Technical assistance
Enter up to 6 topics that you would like help with. Each cell is limited to 1,000 characters.
I need help with…

Description/details

Reset Form

Data dictionary
Term
Child

Definition
Individuals who were age-eligible to be enrolled in Medicaid or Children’s Health Insurance
Program (CHIP) children’s coverage when your organization assisted them. Upper age limits
vary by state and range from 18 to 21 years.
Include pregnant women if they are age-eligible for Medicaid or CHIP children’s health
coverage. Only include children who are not yet born if the state provides coverage to
unborn children under CHIP.

Targeted
children
Other children

Parent

Children who are part of the population you were targeting. For example, if you were
targeting Latino teenagers and you assisted 100 teenagers identifying as Latino, you should
report 100 targeted children.
Children who are not part of the population you were targeting. For example, if you were
targeting Latino teenagers and you assisted 20 teenagers identifying as non-Latino, you
should report 20 other children.
Individuals who:
Were above the age limit for children’s Medicaid or CHIP in your state when your
organization assisted them (age limits vary by state and range from 18 to 21 years)
AND
Were a parent or caretaker relative of a child who was within your state’s age limit for
Medicaid or CHIP children’s coverage when your organization assisted them.
Include pregnant women who already have other children as parents. Do not count pregnant
women who are pregnant with their first child as parents.

Parents of
targeted
children

Parents of children who were part of the population you were targeting. For example, if you
were targeting Latino teenagers and you assisted 100 parents of teenagers identifying as
Latino, you should report 100 parents of targeted children.

Other parents

Parents of children who are not part of the population you were targeting. For example, if
you were targeting Latino teenagers and you assisted 20 parents of teenagers identifying as
non-Latino, you should report 20 parents of other children.

Insurance
affordability
program
Applied as a
direct result of
project
activities

CHIP, Medicaid, Qualified Health Plans with Premium Tax Credits sold via state-based or
federally facilitated marketplaces, or a Basic Health Program (MinnesotaCare in Minnesota or
the Essential Plan in New York).
Individuals who meet the following criteria:
They, or someone acting on their behalf, received substantial interactive assistance on or
after January 1, 2019,
AND
They submitted (or someone submitted on their behalf) an application for health coverage to
the state Medicaid or CHIP agency, to a state-based marketplace, or to the federally
facilitated Marketplace between the first and last days of the current reporting month, after
receiving substantial interactive assistance
Do not count individuals in these data if you have reported or will be reporting them as
applicants assisted under another funding source.

Term
New
applications

Definition
Applications submitted by individuals who:
Applied for CHIP/Medicaid (for children) or for any insurance affordability program
(for parents) as a result of your CKC HEALTHY KIDS project activities
AND
Were not enrolled in Medicaid or CHIP (for children) or in any insurance affordability
program (for parents) when they applied.

Renewal
applications

Applications submitted by individuals who:
Applied for CHIP/Medicaid (for children) or for any insurance affordability program (for
parents) as a result of your CKC HEALTHY KIDS project activities
AND
Were already enrolled in Medicaid or CHIP (for children) or in any insurance affordability
program (for parents) when they applied for coverage
AND
They did not benefit from an Ex Parte or automatic renewal.

Substantial
interactive
assistance

Enrolled as a
direct result of
project
activities

Person-to-person assistance provided in person, by phone, or online, by a member of your
organization or project partner, resulting from funding from the Centers for Medicare and
Medicaid Services (CMS) CKC HEALTHY KIDS grants. This does not include sending mailings or
emails or calling people with pre-recorded messages.
This definition of substantial interactive assistance is relevant to the definitions of applied as
a direct result of project activities, enrolled as a direct result of project activities, and
renewed as a direct result of project activities.
Individuals who meet the following criteria:
They, or someone acting on their behalf, received substantial interactive assistance on or
after January 1, 2019,
AND
They were not already enrolled in Medicaid or CHIP (for children) or in any insurance
affordability program (for parents) when they received substantial interactive assistance
AND
They were newly enrolled in Medicaid or CHIP (for children) or in any insurance affordability
program (for parents) between January 1, 2019 and the last day of the current reporting
month, after receiving substantial interactive assistance.
Only count full eligibility determinations: do not count individuals benefitting from
‘presumptive eligibility’ unless a full determination has subsequently been made.
Enrollment data should be verified by state or county enrollment records. If you are unable
to verify, explain in the data limitations note how you calculated new enrollments.
Do not count individuals in these data if you have reported or will be reporting them as
applicants enrolled under another funding source.

Term
Renewed as a
direct result of
project
activities

Definition
Individuals who meet the following criteria:
They, or someone acting on their behalf, received substantial interactive assistance on or
after January 1, 2019,
AND
They were already enrolled in Medicaid or CHIP (for children) or in any insurance
affordability program (for parents) when they received substantial interactive assistance
AND
They were renewed in Medicaid or CHIP (for children) or in any insurance affordability
program (for parents) between January 1, 2019 and the last day of the current reporting
month, after receiving substantial interactive assistance
AND
They did not benefit from an Ex Parte or automatic renewal.
Renewals data should be verified by state or county enrollment records. If you are unable to
verify, explain in the data limitations note how you calculated renewals.
Do not count individuals in these data if you have reported or will be reporting them as
renewed under another funding source.