State Children's Health Insurance Program and Supporting Regulations in 42 CFR 457.525, 457.740, and 457.1180

CENTERS FOR MEDICARE &
MEDICAID SERVICES (CMS)
CHILDREN’S HEALTH INSURANCE
PROGRAM (CHIP)
STATISTICAL ENROLLMENT DATA
SYSTEM (SEDS)
https://seds.medicaid.gov/

INSTRUCTIONS FOR DATA ENTRY

February 2015 Update

I. INTRODUCTION

The Children’s Health Insurance Program (CHIP) Statistical Enrollment Data System
(SEDS) is a web-based application maintained by the Centers for Medicare &
Medicaid Services (CMS) to collect enrollment data from states. The statistical
reporting forms posted on the web (Forms CMS-21E, CMS-21PW, CMS-64.21E,
CMS-64EC, CMS-21Waiver, and Race, Ethnicity, Gender) gather basic information
about participation in federally-funded children’s health insurance programs – CHIP
and Medicaid. Also included in the system are forms that gather further information
about the enrolled populations reported on the statistical forms. These informational
forms gather data on employer sponsored insurance (ESI), dental wrap-around
benefits and other optional benefits.

II. SUBMISSION OF DATA

States are required to submit quarterly enrollment data within thirty (30) days after the
end of the quarter and aggregate annual data within thirty (30) days after the end of
the fourth quarter. Federal fiscal year quarters and due dates are as follows:
•
•
•
•

First quarter, October 1st through December 31st, data due January 30th;
Second quarter, January 1st through March 31st, data due April 30th;
Third quarter, April 1st through June 30th data due July 30th; and
Fourth quarter, July 1st through September 30th, data due October 30th.

For states that allow retroactive eligibility, these initial enrollment reports will be
deemed preliminary; and these states will also submit final reports thirty (30) days
after the end of the next quarter. The final reports should include information about
children whose eligibility was retroactive to the earlier quarter. So, for example, a
state with retroactive eligibility would submit a preliminary report for the second
quarter of the federal fiscal year (January 1st through March 31st) by April 30th and a
final report for that quarter by July 30th. The final report for the second quarter would
include information about children who applied in the third quarter (April 1st through
June 30th) whose eligibility was retroactive to sometime in the second quarter.

1

III. REPORTING FORMS

The required reporting forms posted on the web collect information about children
with three (3) different types of federally-funded health care coverage and for lowincome pregnant women eligible for title XXI through the CHIP State Plan.
•

Form CMS-21E. This form collects data on children enrolled in separate child
health programs, or separate CHIP. Use one (1) copy of this form to report data
for each separate child health program and/or operational entity. If, for example, a
state operates one separate child health program that serves children with
disabilities and a second separate child health program that serves other children,
the state should submit two (2) Form CMS-21Es. The system will combine data
from all forms to create an aggregate separate child health program report. States
with a separate program for children eligible due to the loss of Medicaid based on
the loss of income disregards (the 2101(f) protection) should report those
enrollments on this form, but should not use an additional copy of the form.

•

Form CMS-64.21E. This form collects data on children enrolled in Medicaid
expansion CHIPs, that is, Title XXI-funded Medicaid coverage. Use one (1) copy
of this form to provide data on all children covered by the state’s Medicaid
expansion. This form includes enrollment of children under 133 percent of the
FPL transitioning from a separate CHIP to Medicaid.

•

Form CMS-64.EC. This form collects data on children enrolled in the Medical
Assistance Program—that is, Title XIX-funded Medicaid coverage, which we will
refer to throughout this manual as “traditional Medicaid”. Use one (1) copy of this
form to provide data on all children covered by traditional Medicaid.

•

Form CMS-21PW. This form collects data on low-income pregnant women
enrolled in CHIP through the state plan option.

All of the above forms collect enrollment data by age category, CMS-defined income
levels, and type of service delivery system. Each report consists of screens (pages),
one for each specified age group. Separate columns are designated for each income
group, and separate rows for each type of delivery system in which enrollees may
receive health program benefits.
The quarterly report for each program should present unduplicated counts of
enrollees (there should be no duplication between program types), disenrollees,
enrollment months, and enrollees in a program on the last day of the quarter, for each
program. A child who was enrolled in more than one program (e.g., separate child
health program and a CHIP Medicaid expansion, or Medicaid expansion and
traditional Medicaid) at different times during the quarter should be only counted in
the program in which he or she was last enrolled.

2

•

Form CMS-21 Waiver. This form collects data on adults enrolled in a CHIP
section 1115 waiver for whom the state receives the title XXI federal matching
rate for at least some of the expenditures.

•

Form Gender, Race, Ethnicity. This form collects gender, race, and ethnicity
data for all enrollees reported on the Forms CMS-21E, CMS-64.21E, and CMS64EC.

•

Form Waiver Gender, Race, Ethnicity. This form collects gender, race and
ethnicity data for all enrollees reported on the form CMS-21 Waiver.

•

Informational Forms 21E, 21PW, 64.21E, 64EC, 21 Waiver. These
forms currently collect employer sponsored insurance (ESI) or dental wrap-around
enrollment data for the applicable program. Other future categories of interest
may also be added as an informational form. The enrollment data is a subset of
the enrollment already reported on the program that the child or eligible adult is
enrolled. (Aggregate enrollment reports count only the program forms, not
informational forms.) For example: If the state reports 1,000 children on the CMS21E, and, of that total, 60 children are enrolled in an ESI program, then the state
would additionally report on a CMS-21EI form indicating the 60 children enrolled
in the ESI program.

Note on the “CHIPRA 214” lawfully residing option: Some states have elected the
option provided by section 214 of the Children’s Health Insurance Program
Reauthorization Act of 2009 to lift the 5-year bar on coverage in Medicaid or CHIP for
certain pregnant women and/or children who are lawfully residing in the United
States. For those states that cover such lawfully residing children in Medicaid or
CHIP, or pregnant women in CHIP (pregnant women in Medicaid are not captured in
SEDS), those enrolled individuals should be reported in the same categories as other
children and pregnant women. For children enrolled in a separate CHIP, it is not
necessary to use an additional copy of the form to report lawfully residing children’s
enrollment.

3

IV. REPORTING CHANGES ASSOCIATED
WITH THE AFFORDABLE CARE ACT

The Affordable Care Act (ACA) makes many changes to eligibility and enrollment that
affect both Medicaid and CHIP. Starting January 1, 2014, the law requires the
application of new, standardized income counting rules based on Modified Adjusted
Gross Income (MAGI), which may cause some shifts in eligibility; increases the
mandatory Medicaid upper income limit for children from ages 6 up to 19 years old,
which may cause some CHIP children to transition to Medicaid; protects certain
children who lose Medicaid as a result of the loss of income disregards (2101(f)
protection); and requires the use of a new, streamlined application for health benefits
that includes more granular racial and ethnic categories. These changes may affect
the way in which states currently report data into SEDS. The changes are
summarized in Table 1 below.
To align with MAGI-based eligibility methodologies, effective with the second fiscal
quarter of 2014, all SEDS forms that gather enrollment data based on income use the
MAGI income and household methodologies. Enrollments are to be grouped based
on the percent of FPL as determined using MAGI methods, rather than including the
previous income disregards. In addition, we understand that because MAGI rules
took effect during a fiscal year that the year 2014 will necessarily have inconsistent
enrollment data between first fiscal quarter and the three following quarters.
States that covered children with family income below 133 percent of the FPL in a
separate CHIP through calendar year 2013 must transition these children to Medicaid
in 2014. Because expenditures for these children are still funded through CHIP,
enrollment data must be entered on the CMS-64.21E for Medicaid Expansion. And a
few states that enroll children protected by 2101(f) in a separate CHIP but do not
otherwise use the CMS-21E form for separate child health program must enter
2101(f) children on this form.
States should begin to implement the changes in reporting to account for MAGIbased rules, transitioning children to Medicaid expansion and the 2101(f) protection
effective at the beginning of the second federal fiscal quarter of 2014 (January 1
through March 31, 2014), for which reporting was due April 30, 2014. We are
directing states that have already certified data for Quarter 2 and later to go back in
the forms to make any necessary revisions to enrollment data and then recertify the
data.
In addition, we are taking this opportunity to revise the income range groups on all of
the forms such that the first group is now 0-133 percent FPL and the second group is
now 134-200 percent FPL. The other income groups are unchanged. We have also
modified the Gender, Race, Ethnicity form to give states the opportunity to report
additional granularity for the Hispanic, Asian, and Native Hawaiian or Other Pacific

4

Islander categories. Please see Section V on Definitions and Rules below for more
detail on the reporting changes associated with the ACA.
Changes to the income range groups on all forms and the categories and definitions
for the Form Gender, Race, Ethnicity are effective as of a different date: the first fiscal
quarter of 2015 (October 1 through December 31, 2014), for which reporting is due
January 30, 2015.

5

Table 1.
ACA Policy
Considerations
for SEDS
Reporting
MAGI Eligibility &
Methods

Title XXI Medicaid
Expansion

Establish 2101(f)
Group

Application Approval
and Processing

Programmatic
Change

Reporting
Considerations

Set MAGI income
standards for all
covered groups;
MAGI Methodology
assurances and
election of household
composition and
income counting
options
Set MAGI income
standards for
Medicaid expansion
covered group;
Some states will
establish a new group
for children ages 6 to
19 up to 133% of the
FPL (MAGI)
Establish new
coverage group for
children who lose
Medicaid only as a
result of the loss of
income disregards

States will need to report
children in the
appropriate FPL income
categories, based on
MAGI income, on the
appropriate form.

Federal Fiscal
Quarter 2/2014
(January-March,
2014)

States should report all
Medicaid expansion
children on Form CMS64.21E.
CMS will make this form
available to states that
will need it and do not
currently use it.

Federal Fiscal
Quarter 2/2014
(January-March,
2014)

States that create a
separate CHIP to cover
these children should
report these enrollments
on Form CMS-21E.
CMS will make this form
available to states that
will need it and do not
currently use it.
SEDS has been modified
to give states the ability
to report additional
granularity for the
Hispanic, Asian, and
Native Hawaiian or Other
Pacific Islander
categories on Form
Gender, Race, Ethnicity.

Federal Fiscal
Quarter 2/2014
(January-March,
2014)

The single,
streamlined
application collects
demographic
information about
applicants for health
coverage

6

Effective Date

Federal Fiscal
Quarter 1/2015
(OctoberDecember, 2014)

V. DEFINITIONS AND RULES

This section defines the various reporting categories specified on the forms and
provides detailed reporting rules.
A. HEADER ITEMS

The following items appear in the header of all enrollment data forms, except for the
Gender, Race, Ethnicity forms which have a uniquely different header (see below).
Quarter and Year. Enter the quarter (1-4) and the Federal Fiscal Year (FFY) to
which the data pertain. The FFY runs from October 1 through September 30. For
example, the first quarter of FFY 2015 is October 1 through December 31, 2014; the
second quarter is January 1 through March 31, 2015; the third quarter is April 1
through June 30, 2015; and the fourth quarter is July 1 through September 30, 2015.
Program Code. (This item appears only on Form CMS-21E, the separate child
health program form.) States should report enrollment data for each separate child
health program and/or operational entity on a separate copy of Form CMS-21E. The
program code uniquely identifies the separate child health program to which the
report pertains. To create a program code, enter the two-letter state abbreviation
followed by a descriptive letter or number from 1 to 9. For example, the State of
Florida would enter FL1, for its first separate child health program, FL2 for its second
separate child health program, and so forth.
Type of Eligible. (This item appears only on Form CMS-64.21E, the Medicaid
expansion form.) This two-character code identifies the Medicaid expansion group or
groups to which the data pertain.
U2. Select “U2" if the state’s Medicaid expansion covers only the 1905(u)(2)
expansion group, optional targeted low income children. These are uninsured
children under age 19 who meet Title XXI eligibility requirements who would
not be eligible for traditional Medicaid under the state plan in effect on 3/31/97.
Note: U3 is no longer a valid selection.
Age of Children or Pregnant Women. Each reporting form has screens (pages) for
each age group of eligible individuals. The age groups are defined as follows:
•
•
•
•
•
•
•

“Under 0”: conception to birth (CMS-21E only);
“0-1”: infants from birth to under age one (up to the first birthday);
“1-5”: age one through age five;
“6-12”: age six through age 12;
“13-18”: age 13 through age 18 inclusive (up to but not including age 19);
“19-20”: age 19 through age 21 inclusive (up to but not including age 21)
(CMS-64EC only); and
“19-64”: age 19 through age 64 (CMS-21PW and 21 Waiver only).

7

Age is defined as the enrollee’s age on the last day of his or her enrollment during
the quarter.
Note that states electing the option to cover pregnant women in CHIP may enroll
some pregnant women under age 19. These enrollments should still be captured
on the CMS-21PW form.
Family Income. States report data separately for all income range groups, as
applicable. Each income range group is specified in relation to the federal poverty
level (FPL). Beginning in the second federal fiscal quarter of 2014, the FPL is
determined using MAGI-based income counting and household composition rules.
Each form provides five (5) columns, to allow states to report data in the five (5)
income range groups defined as a percent of the FPL using MAGI. For all quarters
through the fourth federal fiscal quarter of 2014 (July 1 through September 30, 2014),
the income groups are as follows:
•
•
•
•
•

0-100;
101-200;
201-250;
251-300;
301-state specified.

Beginning in the first federal fiscal quarter of 2015 (October 1 through December 31,
2014), for which reporting is due January 30, 2015, the 100 percent break point is
modified to 133 percent. Beginning in this quarter, the income groups appear on each
form as follows:
•
•
•
•
•

0-133;
134-200;
201-250;
251-300;
301-state specified.

Please note that the upper limit in income range group 5 is state-defined. Therefore,
each state with a maximum income level exceeding 300 percent of the FPL must
enter the maximum income level as approved in the state plan.
For example, if a state program has a MAGI upper income limit of 228 percent of the
FPL, then an enrollee with a MAGI family income at 220 percent of the FPL is
counted in the 201-250 FPL group and an enrollee with a MAGI family income at 182
percent of the FPL is counted in the 134-200 FPL group.
B. HEADER ITEMS for Gender, Race, Ethnicity forms.
The following items appear in the header of each of the three Gender, Race, Ethnicity
forms.

8

Quarter and Year. Enter the quarter (1-4) and the Federal Fiscal Year (FFY) to
which the data pertain. The FFY runs from October 1 through September 30. For
example, the first quarter of FFY 2015 is October 1 through December 31, 2014; the
second quarter is January 1 through March 31, 2015; the third quarter is April 1
through June 30, 2015; and the fourth quarter is July 1 through September 30, 2015.
Program Forms. States must report each enrollee’s gender, race, and ethnicity on
the Gender, Race, Ethnicity forms. Each of these forms have five (5) columns, the
first column “21E Enrolled”, the second column “64.21E Enrolled”, the third column
“Total CHIP Enrolled”, totals the first two columns, and the fourth column “64EC
Enrolled”, the fifth column “21PW Enrolled”.
However, the Gender, Race, Ethnicity form for waivers has only one (1) column,
“Waiver Adults.”
C. CATEGORIES OF SERVICE DELIVERY SYSTEM
States must report each descriptive statistic (e.g., unduplicated number of new
enrollees) by the type of delivery system in which the children were served: fee-forservice (FFS), a managed care arrangement, or primary care case management
(PCCM). Each child, pregnant woman, or waiver adult should be grouped in one of
these three categories based on the system in which he or she was last covered
during the quarter. This categorization should reflect the basic plan in which the
individual was enrolled. For example, an individual enrolled in a FFS plan who
receives mental health services through a “carve-out” to a prepaid health plan should
be counted in the FFS group. The three types of service delivery systems are defined
as follows.
Fee-for-service (FFS). FFS is defined in this context as a payment system in which
providers submit claims to the state (or a claims processing firm that contracts with
the state) and are paid a specific amount for each service performed. Enrollees are
free to visit any state-certified provider. Count an individual in the FFS category if
FFS was the last system in which he or she was covered for basic services during the
quarter.
Managed care arrangements. Managed care is defined in this context as a system
in which the state contracts with health maintenance organizations (HMOs) or health
insuring organizations (HIOs) to provide a comprehensive set of services on a
prepaid capitated risk basis. Enrollees choose a plan and a primary care provider
(PCP), who will be responsible for managing their care. Count an individual in the
managed care category if managed care was the last system in which he or she was
covered for basic services during the quarter.
Primary care case management. PCCM is defined in this context as a system in
which the state contracts directly with PCPs who are responsible for providing or
coordinating medical services to the CHIP or Medicaid enrollees under their care.
Most state PCCM programs reimburse PCPs on a FFS basis for medical services

9

and also pay them a monthly management fee; other programs operate on a partial
capitation basis. Count an individual in the PCCM category if PCCM was the last
system in which he or she was covered for basic services during the quarter.
D. ENROLLMENT MEASURES FOR FORMS CMS-21E, CMS-21PW, CMS-64.21E,
CMS-64EC, AND CMS-21 WAIVER.
This section defines each enrollment measure and outlines rules for counting
enrollees, new enrollees, disenrollees, and enrollment months. Some key rules are
highlighted in the Appendix.
Unduplicated Number of Children (Pregnant Women, or Waiver Adult) Ever
Enrolled During the Quarter. Report each child, pregnant woman, or waiver adult
enrolled in the program for any length of time during the quarter. Count each
individual only once on each quarterly report regardless of the number of times he or
she was enrolled or re-enrolled in the program during the quarter. However, if a child
was enrolled in multiple programs – e.g., separate child health program or CHIP
Medicaid expansion – at different times during the quarter, count the child on the
quarterly report in the program in which he or she was last enrolled.
Note that any child, pregnant woman, or waiver adult reported as a new enrollee or
disenrollee during the quarter must also be reported as ever enrolled. Report each
child under the service delivery system in which he or she was last covered for basic
services during the quarter.
Report individuals with retroactive eligibility as “ever enrolled” in the quarter in which
they applied, and if their coverage became effective in an earlier quarter, report them
as “ever enrolled” in that quarter as well (on the final report for that quarter, as
described in Section II).
Unduplicated Number of New Enrollees in the Quarter. Report as a new enrollee
any child, pregnant woman, or waiver adult enrolled in the program at any time during
the quarter who was not enrolled in the program as of the last day of the previous
quarter. Count each individual once on each quarterly report regardless of the
number of times he or she enrolled and re-enrolled in the program during the quarter.
If, for example, a child was enrolled for the first time in a state’s separate child health
program in the first month of a quarter, disenrolled in the second, and re-enrolled in
the third, he or she should be counted as one new enrollee on the report for that
quarter. Report each new enrollee under the service delivery system in which he or
she was last covered for basic services during the quarter. In the case of new
enrollments in multiple different programs during the quarter – e.g., separate child
health program or CHIP Medicaid expansion – count the child on the quarterly report
in the program in which he or she was newly enrolled last.
An individual with retroactive eligibility should be reported as a new enrollee in the
quarter in which his or her coverage became effective. If a child’s eligibility is
retroactive to an earlier quarter, the state should report him or her as a “new enrollee”

10

(as well as “ever enrolled”) in that earlier quarter when it submits its final (updated)
report for that quarter. (See Section II.)
Unduplicated Number of Disenrollees in the Quarter. Report as a disenrollee any
child, pregnant woman, or waiver adult who disenrolled from a program at any time
during the quarter and who was not re-enrolled as of the last day of the quarter.
Count each individual once on each quarterly report regardless of the number of
times he or she enrolled and disenrolled from the program during the quarter. Report
each disenrollee under the service delivery system in which he or she was last
covered for basic services during the quarter. In the case of disenrollments from
multiple different programs during the quarter – e.g., separate child health program or
CHIP Medicaid expansion – count the child on the quarterly report in the program
from which he or she was disenrolled last.
Two circumstances – “aging out” and disenrollment at the end of a quarter – warrant
particular attention. A child who “ages out” of a program during the quarter (for
example, a CHIP enrollee who turns 19) should be counted as a disenrollee during
that quarter. A child who is disenrolled at the end of the quarter should be reported as
a disenrollee in that quarter. That is, a child who is enrolled through the last day of
the quarter for which the state is reporting data but who is no longer enrolled as of the
first day of the next quarter should be counted as a disenrollee in the earlier quarter
(the quarter being reported).
This rule ensures that each individual is reported as a disenrollee only in a quarter in
which he or she is reported as ever enrolled.
Number of Member-Months of Enrollment in the Quarter. Tally member-months
for each child, pregnant woman, or waiver adult ever enrolled during the quarter.
Count one month for each month in which the individual was enrolled for at least one
day. Count all of an individual’s member-months for a quarter under the service
delivery system and program type in which he or she was last covered for basic
services during the quarter. In the case that a child has member months in multiple
different programs during the quarter – e.g., separate child health program or CHIP
Medicaid expansion – count the member months in the program in which he or she
was enrolled last.
Average Number of Months of Enrollment. The system automatically calculates
the average number of months of enrollment by dividing the figures entered in section
4 (member-months of enrollment) by the corresponding figures in section 1 (number
ever enrolled).
Number of Children (Pregnant Women, or Waiver Adults) Enrolled at Quarter’s
End. Report the number of children, pregnant women, or waiver adults enrolled in the
program on the last day of the quarter. Report each individual under the service
delivery system and program type (e.g., separate child health program or traditional
Medicaid) in which he or she was covered for basic services on that day. This point-

11

in-time number will always be less than or equal to the number ever enrolled during
the quarter.
Unduplicated Number of Children (Pregnant Women, or Waiver Adults) Ever
Enrolled in the Year. This item appears only on the report for the fourth quarter of
the FFY. Report each child enrolled in the program at any time during the FFY
(October 1 through September 30). Count each child, pregnant woman, or waiver
adult once, regardless of the number of times he or she was enrolled or re-enrolled in
the program during the year. As with quarterly enrollment, report each individual
under the service delivery system in which he or she was last covered for basic
services during the year. And if a child was enrolled in multiple programs – e.g.,
separate child health program or CHIP Medicaid expansion – at different times during
the year, count the child in the program in which he or she was last enrolled.
Unduplicated Number of New Enrollees in the Year. This item appears only on the
report for the fourth quarter of the FFY. Report each child, pregnant woman, or
waiver adult newly enrolled in the program at any time during the FFY (October 1
through September 30). Count each individual once, regardless of the number of
times he or she was enrolled or re-enrolled in the program during the year. Report
each individual under the service delivery system in which he or she was last covered
for basic services during the year. In the case of new enrollments in multiple different
programs during the year – e.g., separate child health program or CHIP Medicaid
expansion – count the child on the report in the program in which he or she was
newly enrolled last.
Unduplicated Number of Disenrollees in the Year. This item appears only on the
report for the fourth quarter of the FFY. Report each child, pregnant woman, or
waiver adult disenrolled from the program at any time during the FFY (October 1
through September 30). Count each individual once, regardless of the number of
times he or she enrolled and disenrolled from the program during the year. Report
each individual under the service delivery system in which he or she was last covered
for basic services during the year. In the case of disenrollments from multiple different
programs during the year – e.g., separate child health program or CHIP Medicaid
expansion – count the child on the report in the program from which he or she was
disenrolled last.
E. CATEGORIES AND DEFINITIONS FOR GENDER, RACE, ETHNICITY FORMS.
Each “Gender, Race, Ethnicity” form has three sections.
Gender. This section has three (3) categories, Female, Male, and Unspecified
Gender. States should submit the number of enrollees who self report that they are
Male or Female, and if Gender is not reported or is unknown, states should report
that the enrollee is an Unspecified Gender.
Race. This section has nineteen (19) categories: White, Black or African American,
American Indian or Alaska Native, Asian Indian, Chinese, Filipino, Japanese, Korean,

12

Vietnamese, Other Asian, Asian Unknown, Native Hawaiian, Guamanian or
Chamorro, Samoan, Other Pacific Islander, Native Hawaiian or Other Pacific Islander
Unknown, Some Other Race, Two or more races (regardless of ethnicity), and
Unspecified Race. States should submit the number of enrollees who self report that
they are any of the above. Respondents who self report that they are more than one
of the above racial categories should be counted only in the Two or more races
category. The definitions of each self-reported category are identified on the form as
follows:
•

White. A person having origins in any of the
original peoples of Europe, the Middle East,
or North Africa.

•

Black or African American. A person
having origins in any of the Black racial
groups of Africa. Terms such a “Haitian” or
“Negro” can be used in addition to “Black or
African American.”

•

These categories
are part of the
current OMB
standard

American Indian or Alaska Native. A
person having origins in any of the original
peoples of North and South America
(including Central America), and who
maintains tribal affiliation or community
attachment.

Asian. A person having origins in any of the original
peoples of the Far East, Southeast Asian, or the Indian
subcontinent, including, for example, Cambodia, China,
India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam. This includes people
who indicated their race(s) as “Asian” or reported entries
such as “Asian Indian,” “Chinese,” “Filipino,” “Korean,”
“Japanese,” “Vietnamese,” and “Other Asian” or
provided other detailed Asian responses:
•
•
•
•
•
•
•

Asian Indian.
Chinese.
Filipino.
Japanese.
Korean.
Vietnamese.
Other Asian. A person whose specific
Asian subgroup is not available in the list of
options above (e.g., Hmong, Laotian, etc.)

13

These categories
roll up to the
Asian category of
the OMB standard

•

Asian Unknown. A person whose specific
Asian subgroup is unknown. The person’s
race may be reported only as “Asian.”

Native Hawaiian or Other Pacific Islander. A person
having origins in any of the original peoples of Hawaii,
Guam, Samoan, or other Pacific Islands. This includes
people who indicated their race(s) as “Pacific Islander”
or reported entries such as “Native Hawaiian,”
“Guamanian or Chamorro,” “Samoan,” and “Other
Pacific Islander” or provided other detailed Pacific
Islander responses:
•
•
•
•

•

Native Hawaiian.
Guamanian or Chamorro.
Samoan.
Other Pacific Islander. A person whose
specific Pacific Islander subgroup is not
available in the list of options above (e.g.,
Fijian, Tongan, etc.)
Native Hawaiian or Other Pacific Islander
Unknown. A person whose specific Native
Hawaiian or Other Pacific Islander
subgroup is unknown. The person’s race
may be reported only as “Native Hawaiian
or Other Pacific Islander.”

These categories
roll up to the
Native Hawaiian
or Other Pacific
Islander category
of the OMB
standard

•

Some Other Race. All other responses not included in the White, Black or
African American, American Indian or Alaska Native, Asian, and Native
Hawaiian or Other Pacific Islander race categories described above.
Respondents reporting a Hispanic or Latino group (for example, Mexican,
Puerto Rican, Cuban or Spanish) in response to the race question are
included in this category.

•

Two or More Races (regardless of ethnicity). Respondents who self report
that they are more than one of the above racial categories, as well as those
reporting entries such as “multiracial,” “mixed,” or “interracial” should be
counted only in this category. States should offer respondents the option of
selecting one or more racial designations.

•

Unspecified Race. If Race is not reported or is unknown, states should
report that the enrollee is an Unspecified Race.

Ethnicity. This section has seven (7) categories, Not of Hispanic or Latino/a, or
Spanish origin; Mexican, Mexican American, Chicano/a; Puerto Rican; Cuban;

14

Another Hispanic or Latino origin; Hispanic or Latino Unknown; and Unspecified
Ethnicity.
•

•
•
•
•

•

•

Not of Hispanic, Latino/a or Spanish
origin. Respondents who self-report that they
are not of Hispanic or Latino cultural origin
should be counted in this category.
Mexican, Mexican American, Chicano/a. A
person of Mexican, Mexican American, or
Chicano/a cultural origin, regardless of race.
Puerto Rican. A person of Puerto Rican
cultural origin, regardless of race.
Cuban. A person of Cuban cultural origin,
regardless of race.
Another Hispanic, Latino/a or Spanish
Origin. A person of another Hispanic,
Latino/a or Spanish origin (e.g., Argentinian,
Colombian, Dominican, etc.), regardless of
race.
Hispanic or Latino Unknown. A person
whose specific Hispanic or Latino subgroup is
unknown, regardless of race. The person
may be reported only as “Hispanic or Latino.”

These categories
roll up to the
Hispanic or Latino
category of the
OMB standard

Unspecified Ethnicity. If Ethnicity is not reported or is unknown, states
should report that the enrollee is an Unspecified Ethnicity.

NOTE: Changes to the reporting of Asian subgroups, Native Hawaiian and Other
Pacific Islander subgroups, and Hispanic or Latino subgroups, are effective for data
reported for Quarter 1 FFY 2015.

15

APPENDIX

KEY RULES FOR REPORTING
ENROLLMENT DATA
•

Effective January 1, 2014, each form that gathers enrollment data based on income
uses MAGI-based methodologies for income counting and household composition.
States must report enrollments in the income groups based on income as a percent
of FPL determined using MAGI methods. Effective October 1, 2014, the income
range groups on all of these forms are revised such that the first group is now 0-133
percent FPL and the second group is now 134-200 percent FPL.

•

States transitioning children with family income below 133 percent of the FPL from a
separate CHIP to a Medicaid Expansion must report these enrollments on the CMS64-21E form. States with a separate program for children eligible due to the loss of
Medicaid based on the loss of income disregards (the 2101(f) protection) should
report those enrollments on the CMS-21E form. Both effective January 1, 2014.

•

Each form (CMS-21E, CMS-PW, CMS-64.21E, CMS-64EC, and CMS 21 Waiver) for
the quarter and for the year should present enrollment counts, unduplicated within
program, of enrollees, disenrollees, and enrollment months for each program.

•

A child who was enrolled in more than one program (e.g., separate child health
program and a CHIP Medicaid expansion, or Medicaid expansion and traditional
Medicaid) at different times during the quarter or during the year should be only
counted in the program that he or she was last enrolled.

•

Any child, pregnant woman, or waiver adult reported as a new enrollee or
disenrollee during a quarter/year must also be reported as ever enrolled during the
quarter/year.

•

Children, pregnant women, or waiver adults should be grouped into service delivery
system categories based on the delivery system in which they were last covered for
basic services during the quarter/year.

•

A “new enrollee” is a child, pregnant woman, or waiver adult who was enrolled in the
program at any time during the quarter/year and was not enrolled on the last day of
the previous quarter/year.

•

Children, pregnant women, or waiver adults whose eligibility is retroactive to an
earlier quarter should be reported as new enrollees in the quarter in which their
1

APPENDIX

coverage became effective, not in the quarter in which they applied. They should be
reported as ever enrolled in both quarters.
•

A “disenrollee” is a child, pregnant woman, or waiver adult who was disenrolled from
the program at any time during the quarter/year who was not re-enrolled as of the
last day of the quarter/year.

•

A child, pregnant woman, or waiver adult who was enrolled only through the last day
of a quarter (no longer enrolled as of the first day of the next quarter) should be
counted as a disenrollee in the earlier quarter/year.

•

A child who “ages out” of a program during the quarter/year should be counted as a
disenrollee in that quarter/year. (Or a pregnant woman who gives birth to a child
during the quarter/year).

•

An “enrollment month” is any month in which a child, pregnant woman, or waiver
adult was enrolled for at least one day.

•

All of a child’s, pregnant woman’s, or waiver adult’s enrollment months for the
quarter should be counted under the service delivery system and program type in
which he or she was last covered for basic services during the quarter.

2