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SBM Three-Year Budget Template
ICR 202604-0938-015 · OMB 0938-1119 · Object 168074000.
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | SBM Three-Year Budget Template |
| Conversion State | complete |
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State-Based Exchange Budget FY 2025-2026 CCIIO/SMIPG This document is the 2026 SBE Budget Template. It contains five sections, A through E. Table A begins at cell B 6. Table B begins at cell B 15. Table C begins at cell B 20. Table D begins at B 35, and Table E starts at B 61. Users need to fill in data from each table, and totals automatically populate. Users need to fill in data for each table, and totals automatically populate on rows 13, 17, 33, 36, 41, 49, 54, 59, and 66. Section A is the General Information section. It includes rows 6-13, beginning with cell B6 and ending with cell D13. Cell C8 is a required field. Cell C9 is a required field. Fiscal Budget Year example: Oct. 1-Sept. 30 Cell C10 is a required field. Total Full Time Equivalents engaged in the Individual Marketplace activities. A. General Information State State Budget Year (indicate if Calendar or Fiscal) Details Notes (if needed) Select Your State If State Budget Year is Fiscal, indicate the date range Total Marketplace FTE Cell D11 is a required field. Does the state require issuers to pay a carrier assessment (user fee)? If yes, is it a broad or market wide assessment? Cell C12 is a required field. 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 General Notes/Comments (if needed) Section B is the Marketplace Effectuated Enrollment section and includes rows 15-17, beginning with cell B15 and ending B. Marketplace Effectuated Enrollment with cell E17. Cells C16 and D16 are required fields. Total QHP Enrollment for Plan Year Member Months are the count of accumulated members over the 12 month period for Individual Marketplace Member Months enrollment. This row is auto-calculated and no entry is required. Section C is Revenue and includes rows 20-33, beginning with cell B20 and ending with cell F33. Cells D21 and E21 are required fields. Cells D22 and E22 are required fields. If there are no carrier assessments collected or other state funding sources, then a note is required describing how operations are funded. Row 33 auto-calculates the totals for Section C (Revenue) and no entry is required. C. Revenue Total Marketplace Carrier Assessment Collected Revenue or Reimbursement from Medicaid/CHIP 0 0 Notes (if needed) Definition/Details 2025 Actual $ 2026 Projected $ $0 $0 2025 Actual $ 2026 Projected $ $0 $0 $0 $0 Notes (if needed/as requested) Indicate sources in the Notes column. Include Federal and state together. Total $ Revenue Row 36 auto-calculates the totals for the General Totals subGeneral Totals section and no entry is required. Personnel and Fringe Cells D37 and E37 are required fields. Cells D38 and E38 are required fields. Indirect Costs Facility and Other Non-IT Administrative Cells D39 and E39 are required fields. Other (list items in Notes column) Cells D40 and E40 are required fields. Row 41 auto-calculates the totals for the External Marketing External Marketing & Outreach Totals & Outreach Totals sub-section and no entry is required. Navigators/IPAs Direct Marketing & Outreach to Consumers Cells D43 and E43 are required fields. Education & Outreach to Agents/Brokers and Issuers Cells D44 and E44 are required fields. Cells D45 and E45 are required fields. Cells D46 and E46 are required fields. Example of non-paid media include development of outreach materials, graphic design, marketing content on websites, and campaigns. 2026 Projected Other State Revenue Sources (list sources below) Section D is Marketplace Expenditures and includes rows 3559, beginning with cell B35 and ending with cell F59. This D. Marketplace Expenditures (total revenue and expenditures should section is broken down into four sub-sections: General, balance out) External Marketing & Outreach, Call Center, and IT Platform. Cells D42 and E42 are required fields. 2025 Actual Paid Media/Advertising Non-Paid Media/Advertising Definition/Details Officer and director salaries, temporary help, etc. Travel, supplies, etc. Rent, utilities, repairs, printing, etc. Vendor costs should be built into other lines items. Grants or fees. Consumer-facing education, training, outreach activities, and materials. Agent/broker and issuerfacing education, training, outreach activities, and materials . Paid media, TV, Radio, etc. Efforts dedicated to engaging consumers, alliances, etc., social media. Notes (if needed/as requested) Cells D47 and E47 are required fields. Cells D48 and E48 are required fields. This should be entered as a number between 1 and 100. Row 49 auto-calculates the totals for the Call Center Totals sub-section and no entry is required. If call center totals are $0, then please provide a note detailing why. Cells D50 and E50 are required fields. Include fixed and variable cost in the the Maintenance and Operations total. Cells D51 and E51 are required fields. Cells D52 and E52 are required fields. Cells D53 and E53 are required fields. This should be entered as a number between 1 and 100. Row 54 auto-calculates the totals for the Call Center Totals sub-section and no entry is required. If IT platform totals are $0, then please provide a note detailing why. Cells D55 and E55 are required fields. Include fixed and variable cost in the the Maintenance and Operations total. Other (list items in Notes column) Training support materials, communications, research, website, event management. % of Total External Marketing & Outreach Allocated to Contractors Contractor allocation. Call Center Totals Maintenance and Operations Labor, back office labor, technology, operations, etc. DDI Efforts associated with development and enhancements. Other. Contractor allocation. Other (list items in Notes column) % of Total Call Center Allocated to Contractors Cells D63 and E63 are required fields. Cells D64 and E64 are required fields. If the Exchange has a reserve limit, provide a note detailing what the minimum and maximum reserve amount or months are and the total reserve the Exchange is allowed to maintain. Maintenance and Operations Labor, back office labor, technology, operations, etc. DDI Efforts associated with development and enhancements. Other. Contractor allocation. E. Net Gain/(Loss) Legislative Authority to have a reserve (Select Yes/No from drop-down choices) Total Reserve Number of Months of Reserve $0 $0 Definition/Details $0 $0 2025 Actual 2026 Projected $0 $0 Notes (if needed) N/A N/A Number of Months currently available for reserve. Number of Months of Allowable Reserve Cells D65 and E65 are required fields. Row 66 calculates totals for Section E (Net Gain/(Loss)) and no entry is required. If the Exchange has a net loss with not enough Total Reserve to cover the loss, then a note detailing how the loss will be covered is required in cell F66. $0 IT Platform Totals Cells D56 and E56 are required fields. Cells D57 and E57 are required fields. Other (list items in Notes column) Cells D58 and E58 are required fields. % of Total IT Platform Efforts Allocated to Contractors This should be entered as a number between 1 and 100. Row 59 auto-calculates the totals for Section D (Marketplace Total $ Expenditures Expenditures) and no entry is required. Section E is Net Gain/(Loss) and includes rows 61-66, beginning with cell B61 and endding with F66. $0 Number of Months allowed to have reserve available for. Total $ Net Gain/(Loss) Indicate in Notes if reserves/other funding source covers any loss. 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. 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 14 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. Note: Information Collection is estimated at 14hrs but may be less with recent streamlining and changes.