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pdfState Based Marketplace Data Collection Template:
Bi-Annual Reporting
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
i
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Table of Exhibits
Exhibit 1: Cancellations/Terminations ........................................................................................................................................................................... 1
Exhibit 2: Appeals and Complaints................................................................................................................................................................................. 1
Exhibit 3: Data Matching Issues (DMIs) ......................................................................................................................................................................... 2
Exhibit 4: Special Enrollment Periods (SEP) Plan Selection Type ................................................................................................................................... 8
Exhibit 5: Small Business Health Options (SHOP) .......................................................................................................................................................... 9
Exhibit 6: General Enrollment Metrics (Priority/Expanded Metrics) ........................................................................................................................... 11
i
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Exhibit 1: Cancellations/Terminations
Indicator Title
421
Cancelled or Terminated for Non-Payment
(gross)
422
Cancelled or Terminated for Other Reason
(gross)
Exhibit 2: Appeals and Complaints
Indicator Title
423
Appeals- Upheld (gross)
424
Appeals- Reversed (gross)
425
Appeals- Withdrawn, Dismissed, or Halted
(gross)
426
Appeals- Unresolved (net)
Description
Number of individuals who had their Plan Year (PY) 20XX Marketplace medical plan
cancelled or terminated by an issuer (or Marketplace, if applicable) for nonpayment of premium. This includes cancellations due to non-payment of the first
premium and terminations due to non-payment of the premium after the policy
has been effectuated. This is a gross measure. For example, if an individual has a
plan selection canceled in January, makes a new plan selection, and then has that
plan selection cancelled in March, this measure would be incremented by 2.
Number of individuals who had their PY 20XX Marketplace medical plan cancelled
or terminated for any reason other than non-payment. This includes
cancellations/terminations by the issuer or by the consumer. This is a gross
measure. For example, if an individual has a plan selection cancelled in January,
makes a new plan selection, and then has that plan selection cancelled in March,
this measure would be incremented by 2.
Description
Count of appeals that were upheld (i.e. unfavorable outcome for consumer). This
is a gross measure. For example, if two appeals are entered on a similar issue and
both are upheld, this metric should be incremented by 2.
Count of appeals that were reversed (i.e. favorable outcome for consumer). This is
a gross measure. For example, if two appeals are entered on a similar issue and
both are reversed, this metric should be incremented by 2.
Count of appeals that were withdrawn, dismissed, or otherwise halted. This is a
gross measure. For example, if two appeals are entered on a similar issue and
both are withdrawn/dismissed/otherwise halted, this metric should be
incremented by 2. If those appeals are re-opened within the same reference
period, these appeals should still be counted against withdrawn/dismissed/halted
regardless of whether they are also counted against appeals upheld or appeals
reversed.
Count of unique appeals that were unresolved but still active (i.e. not withdrawn
or dismissed).
1
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
427
Title
Median age for completed appeals
428
Average age for completed appeals
429
Number of Complaints (gross)
Exhibit 3: Data Matching Issues (DMIs)
Indicator Title
430
DMIs Generated - Annual Income (gross)
431
DMIs Generated - Citizenship/Immigration
Status (gross)
431.1
DMIs Generated - Citizenship (gross)
431.2
DMIs Generated - Immigration Status
(gross)
432
DMIs Generated - Incarceration (gross)
Description
Median age (in days) of appeals that were resolved. Only include appeals that
were upheld or reversed (no decimals; round to nearest day).
Average age (in days) of appeals that were resolved. Only include appeals that
were upheld or reversed.
Count of complaints that were received by the Marketplace. This is a gross
measure. For example, if a complaint is made, goes unresolved for a few days, and
is made again by the same complainant, this metric should be incremented by 2.
Description
Count of households that were subjected to a data matching inconsistency (DMI)
based on Annual Household Income. This is a gross measure. For example, if a
household receives an Annual Income DMI, resolves it, and later receives another
Annual Income DMI, this metric should be incremented by 2.
Count of individuals who were subjected to a data matching inconsistency (DMI)
based on Citizenship/Immigration status. This is a gross measure. For example, if
an individual receives a Citizenship/Immigration status DMI, resolves it, and later
receives another Citizenship/Immigration status DMI, this metric should be
incremented by 2.
Count of individuals who were subjected to a data matching inconsistency (DMI)
based on Citizenship. This is a gross measure. For example, if an individual receives
a Citizenship DMI, resolves it, and later receives another Citizenship DMI, this
metric should be incremented by 2.
Count of individuals who were subjected to a data matching inconsistency (DMI)
based on Immigration status. This is a gross measure. For example, if an individual
receives an Immigration status DMI, resolves it, and later receives another
Immigration status DMI, this metric should be incremented by 2.
Count of individuals who were subjected to a data matching inconsistency (DMI)
based on Incarceration. This is a gross measure. For example, if an individual
receives an Incarceration DMI, resolves it, and later receives another Incarceration
DMI, this metric should be incremented by 2.
2
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
433
Title
DMIs Generated - American Indian/Alaskan
Native (gross)
434
DMIs Generated – Non-ESC MEC (gross)
435
DMIs Generated - ESC MEC (gross)
436
DMIs Generated - Total (gross)
437
DMIs Resolved - Annual Income (gross)
438
DMIs Resolved - Citizenship/Immigration
Status (gross)
Description
Count of individuals who were subjected to a data matching inconsistency (DMI)
based on American Indian/Alaskan Native status. This is a gross measure. For
example, if an individual receives an American Indian/Alaska Native status DMI,
resolves it, and later receives another American Indian/Alaska Native status DMI,
this metric should be incremented by 2.
Count of individuals who were subjected to a data matching inconsistency (DMI)
based on Non-employer Sponsored Minimum Essential Coverage (Non-ESC MEC)
status. This is a gross measure. For example, if an individual receives a Non-ESC
MEC DMI, resolves it, and later receives another Non-ESC MEC DMI, this metric
should be incremented by 2
Count of individuals who were subjected to a data matching inconsistency (DMI)
based on Employer Sponsored Minimum Essential Coverage (ESC MEC) status. This
is a gross measure. For example, if an individual receives an ESC MEC DMI, resolves
it, and later receives another ESC MEC DMI, this metric should be incremented by
2.
Sum of households that were subjected to Annual Household Income data
matching inconsistency (DMI) and individuals who were subjected to any data
matching inconsistency of all other DMI types. Note this metric should be the sum
of the number of Annual Income DMIs at the household level and the number of
individuals with DMIs of all other types. This is a gross measure. For example, if an
individual receives a DMI, resolves it, and later receives another DMI, this metric
should be incremented by 2.
Count of households whose data matching inconsistency (DMI) based on Annual
Household Income was resolved. This is a gross measure. For example, if a
household receives an Annual Income DMI, resolves it, and later receives another
Annual Income DMI and resolves that, this metric should be incremented by 2.
Count of individuals whose data matching inconsistency (DMI) based on
Citizenship/Immigration status was resolved. This is a gross measure. For example,
if an individual receives a Citizenship/Immigration status DMI, resolves it, and later
receives another Citizenship/Immigration status DMI and resolves that, this metric
should be incremented by 2.
3
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
438.1
Title
DMIs Resolved – Citizenship (gross)
438.2
DMIs Resolved - Immigration Status (gross)
439
DMIs Resolved - Incarceration (gross)
440
DMIs Resolved - American Indian/Alaskan
Native (gross)
441
DMIs Resolved - Non ESC MEC (gross)
442
DMIs Resolved - ESC MEC (gross)
Description
Count of individuals whose data matching inconsistency (DMI) based on
Citizenship was resolved. This is a gross measure. For example, if an individual
receives a Citizenship DMI, resolves it, and later receives another Citizenship DMI
and resolves that, this metric should be incremented by 2.
Count of individuals whose data matching inconsistency (DMI) based on
Immigration status was resolved. This is a gross measure. For example, if an
individual receives an Immigration status DMI, resolves it, and later receives
another Immigration status DMI and resolves that, this metric should be
incremented by 2.
Count of individuals whose data matching inconsistency (DMI) based on
Incarceration was resolved. This is a gross measure. For example, if an individual
receives an Incarceration DMI, resolves it, and later receives another Incarceration
DMI and resolves that, this metric should be incremented by 2.
Count of individuals whose data matching inconsistency (DMI) based on American
Indian/Alaskan Native status was resolved. This is a gross measure. For example, if
an individual receives an American Indian/Alaskan Native status DMI, resolves it,
and later receives another American Indian/Alaskan Native status DMI and
resolves that, this metric should be incremented by 2.
Count of individuals whose data matching inconsistency (DMI) based on Nonemployer Sponsored Minimum Essential Coverage (Non-ESC MEC) status was
resolved. This is a gross measure. For example, if an individual receives a Non-ESC
MEC DMI, resolves it, and later receives another Non-ESC MEC DMI and resolves
that, this metric should be incremented by 2.
Count of individuals whose data matching inconsistency (DMI) based on Employer
Sponsored Minimum Essential Coverage (ESC MEC) status was resolved. This is a
gross measure. For example, if an individual receives a ESC MEC DMI, resolves it,
and later receives another ESC MEC DMI and resolves that, this metric should be
incremented by 2.
4
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
443
Title
DMIs Resolved - Total (gross)
444
DMIs Resulted in Change in Coverage/APTC
- Annual Income (gross)
445
DMIs Resulted in Change in Coverage/APTC
- Citizenship/Immigration Status (gross)
445.1
DMIs Resulted in Change in Coverage/APTC
- Citizenship (gross)
445.2
DMIs Resulted in Change in Coverage/APTC
- Immigration Status (gross)
Description
Sum of households whose Annual Household Income data matching
inconsistencies (DMIs) were resolved and individuals whose data matching
inconsistencies of all other DMI types were resolved. Note this metric should be
the sum of the number of Annual Household Income DMIs at the household level
and the number of individuals with DMIs of all other types that were resolved. This
is a gross measure. For example, if an individual receives a DMI, resolves it, and
later receives another DMI and resolves that, this metric should be incremented by
2.
Count of households whose APTC was removed or adjusted due to Annual
Household Income data matching inconsistency (DMI). This is a gross measure. For
example, if a household's APTC is adjusted/removed once for an Annual Income
DMI, reinstated, and then adjusted/removed a month later for an Annual Income
DMI, this metric should be incremented by 2.
Count of individuals whose APTC was removed and/or Marketplace medical
coverage was terminated due to Citizenship/Immigration status data matching
inconsistency (DMI). This is a gross measure. For example, if an individual's APTC is
removed and/or Marketplace medical coverage is terminated for a
Citizenship/Immigration status DMI, reinstated, and then APTC is removed and/or
Marketplace medical coverage is terminated a month later for a
Citizenship/Immigration status DMI, this metric should be incremented by 2.
Count of individuals whose APTC was removed and/or Marketplace medical
coverage was terminated due to Citizenship data matching inconsistency (DMI).
This is a gross measure. For example, if an individual's APTC is removed and/or
Marketplace medical coverage is terminated for a Citizenship DMI, reinstated, and
then APTC is removed and/or Marketplace medical coverage terminated a month
later for a Citizenship DMI, this metric should be incremented by 2.
Count of individuals whose APTC was removed and/or Marketplace medical
coverage was terminated due to an Immigration status data matching
inconsistency (DMI). This is a gross measure. For example, if an individual's APTC is
removed and/or Marketplace medical coverage is terminated for an Immigration
status DMI, reinstated, and then APTC is removed and/or Marketplace medical
coverage is terminated a month later for a Immigration status DMI, this metric
should be incremented by 2.
5
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
446
Title
DMIs Resulted in Change in Coverage/APTC
- Incarceration (gross)
447
DMIs Resulted in Change in Financial
Assistance - American Indian/Alaskan
Native (gross)
448
DMIs Resulted in Change in Coverage/APTC
- Non-ESC MEC (gross)
449
DMIs Resulted in Change in Coverage/APTC
- ESC MEC (gross)
450
DMIs Resulted in Change in Coverage/APTC
- Total (gross)
451
Open DMIs - Annual Income (net)
Description
Count of individuals whose APTC was removed and/or Marketplace medical
coverage was terminated due to Incarceration data matching inconsistency (DMI).
This is a gross measure. For example, if an individual's APTC is removed and
Marketplace medical coverage terminated for an Incarnation DMI, reinstated, and
then APTC is removed and Exchange medical coverage terminated a month later
for an Incarnation DMI, this metric should be incremented by 2.
Count of individuals whose financial assistance was removed or adjusted due to
American Indian/Alaskan Native status data matching inconsistency (DMI). This is a
gross measure. For example, if an individual's financial assistance is
adjusted/removed for an American Indian/Alaskan Native DMI, reinstated, and
then financial assistance is adjusted/removed a month later for an American
Indian/Alaskan Native DMI, this metric should be incremented by 2.
Count of individuals whose APTC was removed due to a Non-employer Sponsored
Minimum Essential Coverage (Non-ESC MEC) status data matching inconsistency
(DMI). This is a gross measure. For example, if an individual’s APTC is removed for
a Non-ESC MEC status DMI, reinstated, and then APTC is removed a month later
for a Non-ESC MEC status DMI, this metric should be incremented by 2.
Count of individuals whose APTC was removed due to an Employer Sponsored
Minimum Essential Coverage (ESC MEC) status data matching inconsistency (DMI).
This is a gross measure. For example, if an individual’s APTC is removed for an ESC
MEC status DMI, reinstated, and then APTC is removed a month later for an ESC
MEC status DMI, this metric should be incremented by 2.
Sum of households whose APTC was removed or adjusted due to Annual
Household Income data matching inconsistency (DMI) and individuals whose APTC
was removed/adjusted and/or Marketplace medical coverage was terminated due
to any data matching inconsistency of all other DMI types. Note this metric should
be the sum of the number of annual income DMIs at the household level and the
number of individuals with DMIs of all other types. This is a gross measure. For
example, if an individual’s APTC is removed for a DMI, reinstated, and then APTC is
removed a month later for a DMI, this metric should be incremented by 2.
Count of unique households with at least one unresolved Annual Household
Income data matching inconsistency (DMI). This count does not include DMIs that
have expired or are for canceled or terminated coverage.
6
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
452
Title
Open DMIs - Citizenship/Immigration
Status (net)
452.1
Open DMIs - Citizenship (net)
452.2
Open DMIs - Immigration Status (net)
453
Open DMIs - Incarceration (net)
454
Open DMIs - American Indian/Alaska
Native (net)
455
Open DMIs - Non ESC MEC (net)
456
Open DMIs - ESC MEC (net)
457
Open DMIs - Total (net)
Description
Count of unique individuals with at least one unresolved Citizenship/Immigration
status data matching inconsistency (DMI). This count does not include DMIs that
have expired or are for canceled or terminated coverage.
Count of unique individuals with at least one unresolved Citizenship data matching
inconsistency (DMI). This count does not include DMIs that have expired or are for
canceled or terminated coverage.
Count of unique individuals with at least one unresolved Immigration status data
matching inconsistency (DMI). This count does not include DMIs that have expired
or are for canceled or terminated coverage.
Count of unique individuals with at least one unresolved Incarceration data
matching inconsistency (DMI). This count does not include DMIs that have expired
or are for canceled or terminated coverage.
Count of unique individuals with at least one unresolved American Indian/Alaska
Native data matching inconsistency (DMI). This count does not include DMIs that
have expired or are for canceled or terminated coverage.
Count of unique individuals with at least one unresolved Non-Employer Sponsored
Minimum Essential Coverage data matching inconsistency (DMI). This count does
not include DMIs that have expired or are for canceled or terminated coverage.
Count of unique individuals with at least one unresolved Employer Sponsored
Minimum Essential Coverage data matching inconsistency (DMI). This count does
not include DMIs that have expired or are for canceled or terminated coverage.
Sum of unique households with at least one unresolved annual household income
data matching inconsistency (DMI) and unique individuals with at least one
unresolved data matching inconsistency of all other DMI types. This count does
not include DMIs that have expired or are for canceled or terminated coverage.
Note this metric should be the sum of the number of unique annual income DMIs
at the household level and the number of unique individuals with DMIs of all other
types.
7
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Exhibit 4: Special Enrollment Periods (SEP) Plan Selection Type
Indicator Title
Description
458
SEP Plan Selections - Loss of qualifying
The number of individuals with PY 20XX plan selections that were granted a special
health coverage (gross)
enrollment period (SEP) based on loss of qualifying health coverage. This is a gross
measure. For example, if an individual makes two PY 20XX SEP plan selections over
the course of the plan year based on loss of qualifying health coverage, this metric
should be incremented by 2. If an individual is being added to an existing plan
selection on an SEP basis (e.g. birth or marriage), only count the individuals being
added rather than all individuals on that plan selection.
459
SEP Plan Selections - Change in household
The number of individuals with PY 20XX plan selections that were granted a special
size (gross)
enrollment period (SEP) based on change in household size. This is a gross
measure. For example, if an individual makes two PY 20XX SEP plan selections over
the course of the plan year based on change in household size, this metric should
be incremented by 2. If an individual is being added to an existing plan selection on
an SEP basis (e.g. birth or marriage), only count the individuals being added rather
than all individuals on that plan selection.
460
SEP Plan Selections - Change in primary
The number of individuals with PY 20XX plan selections that were granted a special
place of living (gross)
enrollment period (SEP) based on change in primary place of living. This is a gross
measure. For example, if an individual makes two PY 20XX SEP plan selections over
the course of the plan year based on change in primary place of living, this metric
should be incremented by 2. If an individual is being added to an existing plan
selection on an SEP basis (e.g. birth or marriage), only count the individuals being
added rather than all individuals on that plan selection.
461
SEP Plan Selections - Change in eligibility
The number of individuals with PY 20XX medical plan selections that were granted
for Exchange coverage or financial
a special enrollment period (SEP) based on change in eligibility for Exchange
assistance (gross)
medical coverage or financial assistance. This is a gross measure. For example, if
an individual makes two PY 20XX SEP plan selections over the course of the plan
year based on change in eligibility for Exchange coverage or financial assistance,
this metric should be incremented by 2. If an individual is being added to an
existing plan selection on an SEP basis (e.g. birth or marriage), only count the
individuals being added rather than all individuals on that plan selection.
8
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
462
Title
SEP Plan Selections - Enrollment or plan
error (gross)
463
SEP Plan Selections - Other qualifying
changes (gross)
464
SEP Plan Selections - Total (gross)
Exhibit 5: Small Business Health Options (SHOP)
Indicator Title
465
Consumers with a Plan Selection (net)
466
Active Employers (net)
467
468
469
470
471
472
Active Employees (net)
Plan Selection by Issuer: Issuer 1
Plan Selection by Issuer: Issuer 2
Plan Selection by Issuer: Issuer 3
Plan Selection by Issuer: Issuer 4
Plan Selection by Issuer: Issuer 5
Description
The number of individuals with PY 20XX medical plan selections that were granted
a special enrollment period (SEP) based on enrollment or plan error. This is a gross
measure. For example, if an individual makes two PY 20XX SEP plan selections over
the course of the plan year based on enrollment or plan error, this metric should
be incremented by 2. If an individual is being added to an existing plan selection on
an SEP basis (e.g. birth or marriage), only count the individuals being added rather
than all individuals on that plan selection.
The number of individuals with PY 20XX plan selections that were granted a special
enrollment period (SEP) based on other qualifying changes. This is a gross
measure. For example, if an individual makes two PY 20XX SEP plan selections
over the course of the plan year based on other qualifying changes, this metric
should be incremented by 2. If an individual is being added to an existing plan
selection on an SEP basis (e.g. birth or marriage), only count the individuals being
added rather than all individuals on that plan selection.
The number of individuals with PY 20XX plan selections that were granted a special
enrollment period (SEP) on any basis. This is a gross measure. For example, if an
individual makes two PY 20XX SEP plan selections over the course of the plan year
on any basis this metric should be incremented by 2. If an individual is being added
to an existing plan selection on an SEP basis (e.g. birth or marriage), only count the
individuals being added rather than all individuals on that plan selection.
Description`
Count of unique individuals (employees & dependents) who have selected a PY
20XX Marketplace SHOP plan, and who have non-canceled coverage.
Count of unique employers who have selected a PY 20XX Marketplace SHOP plan,
and who have non-canceled coverage.
Count of unique employees active in the SHOP market.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
9
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495
496
497
Title
Plan Selection by Issuer: Issuer 6
Plan Selection by Issuer: Issuer 7
Plan Selection by Issuer: Issuer 8
Plan Selection by Issuer: Issuer 9
Plan Selection by Issuer: Issuer 10
Plan Selection by Issuer: Issuer 11
Plan Selection by Issuer: Issuer 12
Plan Selection by Issuer: Issuer 13
Plan Selection by Issuer: Issuer 14
Plan Selection by Issuer: Issuer 15
Name Issuer 1
Name Issuer 2
Name Issuer 3
Name Issuer 4
Name Issuer 5
Name Issuer 6
Name Issuer 7
Name Issuer 8
Name Issuer 9
Name Issuer 10
Name Issuer 11
Name Issuer 12
Name Issuer 13
Name Issuer 14
Name Issuer 15
Description`
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Name of Issuer 1.
Name of Issuer 2.
Name of Issuer 3.
Name of Issuer 4.
Name of Issuer 5.
Name of Issuer 6.
Name of Issuer 7.
Name of Issuer 8.
Name of Issuer 9.
Name of Issuer 10.
Name of Issuer 11.
Name of Issuer 12.
Name of Issuer 13.
Name of Issuer 14.
Name of Issuer 15.
10
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Exhibit 6: General Enrollment Metrics (Priority/Expanded Metrics)
Indicator Title
Description
1
Total Plan Selections (net)
Count of unique individuals who have selected a Plan Year (PY) 20XX Marketplace
medical plan. Count includes all new and re-enrolling consumers, regardless of
whether the consumer has paid the first month premium. Count does not include
plans that were canceled or terminated.
6
Number of Submitted Applications (gross)
6.1
Number of Account Transfers (gross)
7
Consumers on Applications Submitted
(gross)
7.1
Consumers on Account Transfers (gross)
Same as Indicator 1 in priority and expanded metrics.
Total count of submitted electronic and paper applications. When a consumer is
renewed into a plan, whether automatic or active, that should be counted as an
application submission. Updated applications should not be counted as an
additional application.
Same as Indicator 6 in priority and expanded metrics.
Total count of account transfers received by the Marketplace from Medicaid/CHIP
with at least one applicant determined ineligible for Medicaid or CHIP. This metric
only applies to SBEs that operate an account transfer process with the state
Medicaid/CHIP agency. An account transfer may also be counted as an application,
depending on the Marketplace.
Same as Indicator 6.1 in priority and expanded metrics.
Total count of individuals requesting coverage on submitted applications. Both
new consumers and consumers re-enrolling (automatic and active) in coverage
should be counted.
Same as Indicator 7 in priority and expanded metrics.
Total count of individuals on account transfers received by the Marketplace from
Medicaid/CHIP who were determined ineligible for Medicaid or CHIP. This metric
only applies to Marketplaces that operate an account transfer process with the
state Medicaid/CHIP agency.
Same as Indicator 7.1 in priority and expanded metrics.
11
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
8
9
9.1
Title
Consumers Determined Eligible or Assessed
for Medicaid/CHIP (gross)
Consumers Eligible for QHP (gross)
Consumers Eligible for QHP, with Financial
Assistance (gross)
Description
Count of individuals on submitted applications who are determined or assessed
eligible for enrollment in Medicaid or CHIP. This includes both new consumers and
consumers re-enrolling (automatic and active) in coverage should be counted. This
count is a subset of Consumers on Applications Submitted (Indicator 7). Eligibility
for Medicaid/CHIP takes precedence over eligibility for a QHP without financial
assistance. Individuals determined eligible for both Medicaid/CHIP and nonfinancial QHP should be counted but should not be counted in Indicator 9.
Same as Indicator 8 in priority and expanded metrics.
Count of individuals on submitted applications who were determined eligible for
enrollment in a PY 20XX Marketplace medical plan, regardless of whether they
applied for or are eligible for financial assistance. Both new consumers and
consumers re-enrolling (automatic and active) in coverage should be counted. This
count is a subset of Consumers on Applications Submitted (Indicator 7). Eligibility
for Medicaid/CHIP takes precedence over eligibility for a QHP without financial
assistance. Individuals determined eligible for both Medicaid/CHIP and a nonfinancial QHP should not be counted.
Same as Indicator 9 in priority and expanded metrics.
Count of individuals on submitted applications who were determined eligible for
enrollment in a PY 20XX Marketplace medical plan and eligible to receive APTC
and/or CSRs. Both new consumers and consumers re-enrolling (automatic and
active) in coverage should be counted. This count is a subset of Consumers
Determined Eligible for QHP (Indicator 9).
Same as Indicator 9.1 in priority and expanded metrics.
12
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
21
Title
Number of Plan Selections with Federal
Financial Assistance (net)
22
Number of Plan Selections with both CSR
and APTC (net)
23
24
24.5
Number of Plan Selections with APTC only
(net)
Number of Plan Selections with CSR only
(net)
Consumers with CSRs, American
Indian/Alaska Native (net)
Description
Count of unique individuals with a PY 20XX Marketplace medical plan selection,
where the consumer has elected to receive APTC in an amount greater than $0
and/or receives CSRs. This count includes consumers with APTC and CSRs
(Indicator 22), consumers with only APTC (Indicator 23), and consumers with only
CSRs (Indicator 24).
Same as Indicator 21 in expanded metrics.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer has elected to receive APTC in an amount
greater than $0 and receives CSR. Count includes consumers with APTC and CSRs.
Consumers with only APTC or with only CSRs should not be counted.
Same as Indicator 22 in expanded metrics.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer has elected to receive APTC in an amount
greater than $0. Consumers with CSRs should not be counted.
Same as Indicator 23 in expanded metrics.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer receives CSR. Consumers with APTC should
not be counted. Count may include consumers who are eligible to receive APTC
but have elected not to receive APTC.
Same as Indicator 24 in expanded metrics.
Count of consumers who selected a non-canceled PY 20XX Marketplace medical
plan with CSRs reserved for members of federally recognized tribes and Alaska
Native Claims Settlement Act shareholders.
Same as Indicator 24.5 in expanded metrics.
13
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
25
Title
Number of Plan Selections without Federal
Financial Assistance (net)
Description
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer is not eligible to receive APTC, is eligible but
elects not to receive APTC, and/or does not receive CSR.
29.1
Number of Plan Selections with Any
Financial Assistance (net)
29.5
Number of Plan Selections without Any
Financial Assistance (net)
46
Number of Plan Selections where Metal
Level is Platinum (net)
Same as Indicator 29.5 in expanded metrics.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan where metal level is Platinum.
47
Number of Plan Selections where Metal
Level is Gold (net)
Same as Indicator 46 in expanded metrics.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan where metal level is Gold.
48
Number of Plan Selections where Metal
Level is Silver (net)
Same as Indicator 47 in expanded metrics.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan where metal level is Silver.
Same as Indicator 25 in expanded metrics.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer has elected to receive federal financial
assistance and/or financial assistance from a state premium or cost sharing
subsidy program. States with no state subsidy program should mark N/A.
Same as Indicator 29.1 in expanded metrics.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer is not eligible to receive APTC, is eligible but
elects not to receive APTC, does not receive CSRs, and does not receive financial
assistance from a state premium or cost sharing subsidy program. States with no
state subsidy program should mark N/A.
Same as Indicator 48 in expanded metrics.
14
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
49
Title
Number of Plan Selections where Metal
Level is Bronze (net)
Description
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan where metal level is Bronze.
50
Number of Plan Selections where Metal
Level is Catastrophic (net)
Same as Indicator 49 in expanded metrics.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan where metal level is Catastrophic.
51
Consumers with a Plan Selection and
Income < 100% (net)
52
Consumers with a Plan Selection and
Income ≥ 100% FPL and ≤ 150% FPL (net)
52.1
Consumers with a Plan Selection and
Income ≥ 100% FPL and ≤ 138% FPL (net)
Same as Indicator 52 in expanded metrics.
Count of unique individuals in households with income greater than or equal to
100% and less than or equal to 138% of FPL who have selected a non-canceled PY
20XX Marketplace medical plan.
53
Consumers with a Plan Selection and
Income > 150% FPL and ≤ 200% FPL (net)
Same as Indicator 52.1 in expanded metrics.
Count of unique individuals in households with income greater than 150% and less
than or equal to 200% of FPL who have selected a non-canceled PY 20XX
Marketplace medical plan.
54
Consumers with a Plan Selection and
Income > 200% FPL and ≤ 250% FPL (net)
Same as Indicator 53 in expanded metrics.
Count of unique individuals in households with income greater than 200% and less
than or equal to 250% of FPL who have selected a non-canceled PY 20XX
Marketplace medical plan.
Same as Indicator 50 in expanded metrics.
Count of unique individuals in households with income less than 100% of FPL who
have selected a non-canceled PY 20XX Marketplace medical plan.
Same as Indicator 51 in expanded metrics.
Count of unique individuals in households with income greater than or equal to
100% and less than or equal to 150% of FPL who have selected a non-canceled PY
20XX Marketplace medical plan.
Same as Indicator 54 in expanded metrics.
15
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
54.1
Title
Consumers with a Plan Selection and
Income > 250% FPL and ≤ 300% FPL (net)
54.2
Consumers with a Plan Selection and
Income > 300% FPL and ≤ 350% FPL (net)
Same as Indicator 54.1 in expanded metrics.
Count of unique individuals in households with income greater than 300% and less
than or equal to 350% of FPL who have selected a non-canceled PY 20XX
Marketplace medical plan.
Consumers with a Plan Selections and
Income > 350% FPL and ≤ 400% FPL (net)
Same as Indicator 54.2 in expanded metrics.
Count of unique individuals in households with income greater than 350% and less
than or equal to 400% of FPL who have selected a non-canceled PY 20XX
Marketplace medical plan.
54.3
55
55.1
56
Description
Count of unique individuals in households with income greater than 250% and less
than or equal to 300% of FPL who have selected a non-canceled PY 2020X
Marketplace medical plan.
Consumers with a Plan Selections and
Income > 400% FPL (net)
Same as Indicator 54.3 in expanded metrics.
Count of unique individuals in households with income greater than 400% of FPL
who have selected a non-canceled PY 20XX Marketplace medical plan.
Consumers with a Plan Selection and
Income > 500% FPL (net)
Same as Indicator 55 in expanded metrics.
Count of unique individuals in households with income greater than 500% of FPL
who have selected a non-canceled PY 20XX Marketplace medical plan.
Same as Indicator 55.1 in expanded metrics.
Number of Plan Selections where Income as Count of unique individuals in households with non-reported income and who
a Percent of FPL is Unknown (net)
have selected a non-canceled PY 20XX Marketplace medical plan. Count should
include individuals who do not report income because they are not requesting
financial assistance.
Same as Indicator 56 in expanded metrics.
16
Expiration date: XX/XX/XXXX
OMB control number: 0938-1119
Indicator
169
172
Title
Total BHP Enrollees/Other (net)
Consumers Eligible for BHP/Other (net)
Description
Count of unique individuals who have enrolled in BHP or other related programs.
Count does not include enrollments that were canceled or terminated, or
individuals enrolled in Medicaid/CHIP programs that are not BHP.
Same as Indicator 169 in BHP priority and expanded metrics.
Count of all individuals determined or assessed eligible for BHP or other related
programs. Only individuals on submitted applications and requesting coverage are
included. Count all individuals determined/assessed eligible even if the individual
does not subsequently enroll in coverage.
Same as Indicator 172 in BHP priority and expanded metrics.
Paperwork Reduction Act 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
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1119. The time
required to complete this information collection is estimated to average 29.4 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.
17
| File Type | application/pdf |
| File Title | CMS-10371 SBM Bi-Annual Metrics (2025) |
| Subject | SBM Enrollment Metrics Guidelines |
| Author | CMS |
| File Modified | 2025-05-02 |
| File Created | 2025-05-02 |