| State-based Exchange Budget |
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| FY 2022 - 2023 |
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| FY 2023 - 2024 |
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| CCIIO/SMIPG |
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| A. |
General Information |
Details |
Notes (if needed) |
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State: |
Select Your State |
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State Budget Year (indicate if Calendar or Fiscal): |
Fiscal |
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e.g.:
Oct 1- Sep 30
If State Budget Year is Fiscal, indicate the date range: |
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Note:
Total Full Time Equivalents engaged in the Individual Marketplace activities.
Total Current Individual FTEs: |
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Note:
Total Full Time Equivalents engaged in the SHOP Marketplace activities (if applicable) .
Total Current SHOP FTEs: |
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Note:
Total Full Time Equivalents engaged in the Individual Marketplace activities.
Total Marketplace FTE |
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Does the state require issuers to pay a carrier assessment (user fee)? If yes, is it a broad or market wide assessment? |
Yes |
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Carrier Assessment (User fees) This is carrier assessment for the individual Marketplace and should not include outside of Marketplace values. If a flat dollar amount, please estimate in the notes how it might translate to a percentage of premiums |
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General Notes/Comments (if needed): |
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| B. |
Marketplace Effectuated Enrollment |
2023 Actual |
2024 Projected |
Notes (if needed) |
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Total QHP Enrollment for Plan Year |
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Note:
The count of accumulated members over the 12 month period for Individual Marketplace enrollment.
Member Months |
0 |
0 |
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| B.1 |
Individual Marketplace Effectuated Enrollment |
2022 Actual |
2023 Projected |
Notes (if needed) |
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QHP Enrollment for Plan Year |
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Note:
The count of accumulated members over the 12 month period for Individual Marketplace enrollment.
Member Months |
0 |
0 |
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| B.2 |
SHOP Marketplace Effectuated Enrollment (if applicable) |
2022 Actual |
2023 Projected |
Notes (if needed) |
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SHOP QHP Enrollment for Plan Year |
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Note:
The count of accumulated members over the 12 month period for SHOP Marketplace enrollment.
Member Months |
0 |
0 |
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| C. |
Revenue |
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2022 Actual $ |
2022 Actual $ Revenue Allocated to Individual Expenditures |
2022 Actual $ Revenue Allocated to SHOP Expenditures |
2023 Projected $ |
2023 Projected $ Revenue Allocated to Individual Expenditures |
2023 Projected $ Revenue Allocated to SHOP Expenditures |
Notes (if needed/as requested) |
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Carrier Assessment (User fees) |
Separate between Inside or Outside Marketplace and between Individual and SHOP plans, if applicable. |
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Total Marketplace Carrier Assessment Collected |
Indicate sources in the Notes column. |
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Total Carrier Assessment Inside Individual Marketplace |
Indicate sources in the Notes column. |
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Total Carrier Assessment Inside Small Group Marketplace |
Indicate sources in the Notes column. |
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Total Carrier Assessment Outside Marketplace Individual Plans |
Indicate sources in the Notes column. |
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Total Carrier Assessment Outside Marketplace Small Group Plans |
Indicate sources in the Notes column. |
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Other Tax Assessments |
Indicate sources in the Notes column. |
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Includes American Rescue Plan (State Modernization Grant)
Other Grant Funding |
Indicate sources in the Notes column. |
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Revenue or Reimbursement from Medicaid/CHIP |
Include Federal and state together. |
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State Revenue/Reimbursement (list sources below) |
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Other State Revenue Sources (list sources below) |
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e.g.:
interest, revenue carried forward from the previous year, one time transfers.
Other Revenue |
Indicate sources in the Notes column. |
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Total $ Revenue |
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$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
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| D. |
Marketplace Expenditures (total revenue and expenditures should balance out) |
Definition/Details |
2022 Actual $ |
2022 Actual $ Budget Allocated to Individual Expenditures |
2022 Actual $ Budget Allocated to SHOP Expenditures |
2023 Projected $ |
2023 Projected $ Budget Allocated to Individual Expenditures |
2023 Projected $ Budget Allocated to SHOP Expenditures |
Notes (if needed/as requested) |
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General Totals |
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$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
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Personnel and Fringe |
Officer and director salaries, temporary help, etc. |
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Indirect Costs |
Travel, supplies, etc. |
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Facility and Other Non-IT Administrative |
Rent, utilities, repairs, printing, etc. |
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Other (list items in Notes column) |
Vendor costs should be in other sections. |
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External Marketing & Outreach Totals |
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$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
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Navigators/IPAs |
Grants or fees. |
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Direct Marketing & Outreach to Consumers |
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Education & Outreach to Consumers
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Consumer facing education, training, outreach activities, and materials. |
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Education & Outreach to Agents/Brokers and Issuers |
Agent/broker and issuer facing education, training, outreach activities, and materials . |
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Paid Media |
Paid media. |
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Advertising & Marketing |
e.g.:
Development of outreach materials, graphic design, marketing content on websites, campaigns
Efforts dedicated to engaging consumers, alliances, etc. |
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Other (list items in Notes column) |
Training Support Materials, Communications, Research, Website, Event Management. |
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Note:
Percent should be entered as number between 1 and 100.
% of Total External Marketing & Outreach Allocated to Contractors |
Contractor allocation. |
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Call Center Totals |
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$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
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Maintenance and Operations |
Note:
Include fixed and variable cost in the total.
Labor, back office labor, technology, operations, etc. |
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DDI |
Efforts associated with development and enhancements. |
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Other (list items in Notes column) |
Other. |
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Note:
Percent should be entered as a number between 1 and 100.
% of Total Call Center Allocated to Contractors |
Contractor allocation. |
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IT Platform Totals |
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$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
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Maintenance and Operations |
Note:
Include fixed and variable cost in the total.
Labor, back office labor, technology, operations, etc. |
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DDI |
Efforts associated with development and enhancements. |
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Other (list items in Notes column) |
Other. |
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Note:
Percent should be entered as number between 1 and 100.
% of Total IT Platform Efforts Allocated to Contractors |
Contractor allocation. |
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Total $ Expenditures |
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$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
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| E. |
Net Gain/(Loss) |
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2022 Actual |
2023 Projected |
Notes (if needed) |
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Legislative Authority to have a reserve (Select Yes/No from drop-down choices) |
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Yes |
Yes |
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Total Reserve |
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Number of Months of Reserve |
Number of Months currently available for reserve. |
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Number of Months of Allowable Reserve |
Number of Months allowed to have reserve available for. |
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Total $ Net Gain/(Loss) |
Indicate in Notes if reserves/other funding source covers any loss |
$0 |
$0 |
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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
FORM PENDING APPROVAL
PRA Disclosure 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 OMB control number. The valid OMB control number for this information collection is 0938-1119 (05/31/2025). This is mandatory information collection. The time required to complete this information collection is estimated to average 16 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Tiffany Animashaun. |
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Note: Information Collection is estimated at 16hrs but may be less with recent streamlining and changes. |
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