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Redline - Performance Indicators Data Dictionary

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Medicaid and CHIP Eligibility and Enrollment Performance Indicators
Data Dictionary
Effective JuneSeptember 30, 20265

1. CALL VOLUME
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year roundyear-round
Indicator
Number
1a

Data
Breakout

Variable
Name
Total Call
Center
Volume

Description
The total number of calls received by each call center during the calendar month. Include all
calls received by each call center including calls handled by an interactive voice response
(IVR) system, calls handled by a live agent, and calls abandoned before reaching a live agent.
The total call center volume should equal the sum of the call volume at each individual call
center reported.
States may define “call center” as any call center, hotline or combination of hotlines that take
a significant number of calls regarding Medicaid or CHIP. Call centers and help lines that take
calls in the following areas should be included if they receive a significant volume of calls and
the agency can accurately track and report call volume: questions about Medicaid or CHIP
eligibility; taking over-the-phone applications; questions about enrollment, including
enrollment into Medicaid/CHIP managed care plans; renewal-related questions; and local or
county-based phone lines that handle inquiries about both health and human services
programs. If the “call center” is not a traditional call center, or receives calls for other human
services programs, please include that information in the data limitation.
Report data for all calls received, including those that can be handled solely by an automatic
system.

1. CALL VOLUME
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year roundyear-round
Indicator
Number
1b

Data
Breakout

Variable
Name

Description

Individual Call The subset of calls reported in sub-indicator 1a received by each individual call center during
Center
the calendar month.
Volumes
Report this indicator for each call center in the state, even if there is only one. If the state has
more than 10 call centers that receive Medicaid/CHIP related calls, it should consolidate the
call centers into “main” call centers, if appropriate. For example, if MCO X has three total call
centers, then the state should combine these call centers into one “MCO X” call center and
report combined data from the three call centers. The state should contact CMS with any
questions or concerns.

2. CALL CENTER WAIT TIME
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year roundyear-round
Indicator
Number
2a

Data
Breakout

Variable
Name

Description

Average Call
Center Wait
Time

For each call center or helpline reported in Indicator 1, the average wait time in whole
minutes measured from the time each call connects to the call center to the time the call is
answered by a live agent (if the call is answered by an agent) or the time the caller ends the
call (if the call is not answered by an agent). For each call, wait time should include the time
the caller spends navigating through the IVR as well as the time spent waiting in the queue to
speak to an agent. All calls received by each call center during its hours of operation should
be included for the calendar month. If the state tracks wait time in seconds, round increments
of 0 to 29 seconds down to the nearest whole minute, and round increments of 30 to 59
seconds up to the nearest whole minute. If the average wait time is less than 29 seconds
enter 0 and provide an explanation in the data limitations field. If average wait time cannot be
provided, leave this field blank (missing/null) and provide an explanation in the data
limitations field.
The top-line total should be calculated as the weighted average of each individual call
center’s wait time during the calendar month. The weighting should be based on the call
volumes reported in Indicator 1, “Total Call Center Volume.” For example, if a state reported
data for 3 call centers in Indicator 1, the weighted average for the call center wait time should
be:
Call center total weighted average wait time =
call center 1 average wait time * (call center 1 volume/call center total volume) +
call center 2 average wait time * (call center 2 volume/call center total volume) +
call center 3 average wait time * (call center 3 volume/call center total volume)

Call Center
Wait Times
(for each
individual call
center)

The average wait time in whole minutes for calls received by each individual call center
during its hours of operation, for the calendar month.
Report this indicator for each call center in the state, even if there is only one. If the state has
more than 10 call centers that receive Medicaid/CHIP related calls, it should consolidate the
call centers into “main” call centers, if appropriate. For example, if MCO X has three total call
centers, then the state should combine these call centers into one “MCO X” call center and

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report combined data from the three call centers. The state should contact CMS with any
questions or concerns.

3. ABANDONMENT RATE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year roundyear-round
Indicator
Number
3a

Data
Breakout

Variable
Name

Description

Average Call
Center
Abandonment
Rate

For each call center or helpline reported in Indicator 1, the abandonment rate equals the
number of calls abandoned by the caller (numerator) divided by total call volume
(denominator). Calls abandoned by the caller at any time prior to reaching a live agent
should be counted as abandoned calls, including those abandoned while navigating the IVR
system or while in queue to speak to a live agent. States should select the appropriate
footnote option, if one exists, that is applicable to their data (e.g., “Calls handled to
completion by the automated system are counted as abandoned calls”). The acceptable
range for this number is between 0 and 1, with a zero valuezero-value representing 0% (no
calls abandoned), a value of 0.5 representing 50% (half of calls are abandoned), and a
value of one representing 100% (all calls abandoned).
The top-line total should be calculated as the weighted average of each individual call
center’s abandonment rate during the calendar month. The weighting should be based on
the call volumes reported in Indicator 1, “Total Call Center Volume.”
For example, if a state reported data for 3 call centers in Indicator 1, the weighted average
for the call center wait time should be:
Call center total weighted average abandonment =
call center 1 average abandonment rate * (call center 1 volume/call center total volume) +
call center 2 average abandonment rate * (call center 2 volume/call center total volume) +
call center 3 average. abandonment rate * (call center 3 volume/call center total volume)

Individual Call
Center
Abandonment
Rate (for each

The abandonment rate for each individual call center or helpline reported in Indicator 1. The
abandonment rate equals the number of calls abandoned by caller (numerator) divided by
total call volume (denominator).

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individual call
center)

Report this indicator for each call center in the state, even if there is only one. If the state
has more than 10 call centers that receive Medicaid/CHIP related calls, it should consolidate
the call centers into “main” call centers, if appropriate. For example, if MCO X has three total
call centers, then the state should combine these call centers into one “MCO X” call center
and report combined data from the three call centers. The state should contact CMS with
any questions or concerns.

4. Percent Eligible at Applications for Adult Group or 1115 Demo
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year roundyear-roundTHIS INDICATOR WAS WEEKLY AND HAS BEEN
REMOVED
Indicator
Number

Data
Breakout

Variable Name

Description

Percent of total
eligible
applications

Among individuals who received a final eligibility determination at application in the month:
Percentage who were determined eligible for the Adult Group or an 1115 demonstration
that provides MEC (Minimum Essential Coverage) as required by the Affordable Care
Actand demonstrated compliance with Community Engagement

Number of total
eligible
applications
subject to CE

The total number of people individuals who were determined eligible as part of the population
expected to demonstrate compliance with CE

5. NUMBER OF APPLICATIONS RECEIVED
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
5a

Data
Breakout

Variable Name

Description

Total Applications
Received

Total number of applications received by any state agency with the authority to make
Medicaid/CHIP eligibility determinations, including the Medicaid agency, a separate
CHIP agency (if one exists in the state), and a state-based marketplace (if one exists in
the state) during the calendar month. The unit of measurement for this indicator is the
number of applications, not individuals. Applications should be counted in the reporting
period in which they are received.
Applications for both MAGI and non-MAGI populations should be included. Report
applications received through all doorways, including those received by a separate
CHIP agency or any applications requesting financial assistance for health insurance

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coverage that are received by the state-based marketplace (SBM), and not just
applications received directly by the Medicaid agency.
If the state uses a combined application for some or all Medicaid applicants that also
screens individuals for other social service programs (such as SNAP), these
applications should be included whenever the Medicaid program or CHIP is among the
programs the person is being evaluated for.
If the state has separate applications for different Medicaid populations (e.g., a family
Medicaid application and an ABD application), all applications should be included in
these indicators.
5a
(continued)

Exclusions for this indicator:
• Accounts transferred from the FFM. Account transfers should be reported under
Indicator 6 (Number of Electronic Accounts Transferred).
• Individuals who enter a state’s eligibility determination system via an administrative
data transfer rather than by submitting an application (e.g., SSI recipients who are
auto-enrolled into Medicaid; ELE determinations; and transfers from an existing
1115 demonstration to eligibility groups under a SPA resulting from changes in
state eligibility categories)
• Individuals who receive a redetermination at annual renewal or outside the annual
renewal process (for example, due to change in circumstance).
Sub-indicator 5a should equal the sum of sub-indicators applications received by
Medicaid agency (sub-indicator 5b), applications received by CHIP agency (subindicator 5h), and applications received by SBM (sub-indicator 5n).

Applications
Received by
Medicaid Agency

Total number of applications received by the Medicaid agency during the calendar
month. If the state has an integrated application for Medicaid and CHIP and these
applications are entered into a single eligibility and enrollment system, include the total
number of applications received for Medicaid and CHIP in this indicator, even if the
state has a separate CHIP agency. The unit of measurement for this indicator is the
number of applications, not individuals. Applications should be counted in the reporting
period in which they are received.
Applications for both MAGI and non-MAGI populations should be included. If the state
has separate applications for different Medicaid populations (e.g., a family Medicaid
application and an ABD application), all applications should be included in these
indicators. If the state uses a combined application for some or all Medicaid applicants

that also screens individuals for other social service programs (such as SNAP), these
applications should be included when Medicaid or CHIP is among the programs the
person is being evaluated for.
Exclusions for sub-indicator 5a apply to sub-indicator 5b. Applications received via an
integrated online Marketplace/Medicaid/CHIP portal should not be reported in this
indicator; they should be reported in sub-indicator 5n.
Sub-indicator 5b should equal the sum of the applications received by Medicaid
agency, by channel (sub-indicators 5c, 5d, 5e, 5f, and 5g).
5c

Applications
Received by
Medicaid
Agency, by
Channel

Online
Applications
Received by
Medicaid Agency

Applications received by Medicaid agency that the applicant filled out and submitted
through a web portal or website. Online applications that have been initiated but not yet
submitted should not be reported.

Mail Applications
Received by
Medicaid Agency

Paper applications received by the Medicaid agency that the applicant mailed to the
Medicaid agency.

In-person
Applications
Received by
Medicaid Agency

Applications that an applicant submitted in-person to a Medicaid agency or caseworker.

Phone
Applications
Received by
Medicaid Agency

Applications that an applicant submitted to the Medicaid agency by answering
questions from a call center or hotline agent.

Other
Applications
Received by
Medicaid Agency

All other applications received by the Medicaid agency that cannot be classified as
online, mail, in-person, or phone applications. If this is a non-zero value, the data
limitations field must include an explanation describing these applications.

Applications
Received by
CHIP Agency

Applications
Received by
Medicaid
Agency, by
Channel

Refer to sub-indicator 5b for inclusion and exclusion criteria.

Refer to sub-indicator 5b for inclusion and exclusion criteria.
Refer to sub-indicator 5b for inclusion and exclusion criteria.

Refer to sub-indicator 5b for inclusion and exclusion criteria.

Refer to sub-indicator 5b for inclusion and exclusion criteria.
Total number of applications received by a separate CHIP agency during the calendar
month. If the state does not have a separate CHIP agency and a separate CHIP
application and eligibility and enrollment system, leave the field blank (to indicate this is

non-applicable). States with a single, streamlined Medicaid and CHIP application and
eligibility and enrollment system should report all applications received in subindicators 5b-5g, even if they have a separate CHIP agency, and should leave subindicator 5h blank. Applications should be counted in the reporting period in which they
are received.
Exclusion for sub-indicator 5a apply to sub-indicator 5h.
Sub-indicator 5h should equal the sum of applications received by CHIP agency, by
channel (sub-indicators 5i, 5j, 5k, 5l and 5m).
5i

Online
Applications
Received by
CHIP Agency

Applications received by separate CHIP agency that the applicant filled out and
submitted through a web portal or website. Online applications that have been initiated
but not yet submitted should not be reported.

Mail Applications
Received by
CHIP Agency

Paper applications received by the separate CHIP agency that the applicant mailed to
the separate CHIP agency.

In-person
Applications
Received by
CHIP Agency

Applications that an applicant submitted in-person to a separate CHIP agency or
caseworker.

Phone
Applications
Received by
CHIP Agency

Applications that an applicant submitted to the separate CHIP agency by answering
questions from a call center or hotline agent.

Other
Applications
Received by
CHIP Agency

All other applications received by the separate CHIP agency that cannot be classified
as online, mail, in-person, or phone applications. If this is a non-zero value, the data
limitations field must include an explanation describing these applications.

Applications
Received by
CHIP
Agency, by
Channel

Refer to sub-indicator 5h for inclusion and exclusion criteria.

Applications
Total number of applications requesting financial assistance for health insurance
Received by SBM coverage that have been received by the SBM during the calendar month, including
applications received via an integrated online Marketplace/Medicaid/CHIP portal.

Requests for financial assistance for health insurance coverage include requests for
Advanced Premium Tax Credit (APTC), Medicaid, and CHIP. Applications not
requesting financial assistance should be excluded.

6. NUMBER OF ELECTRONIC ACCOUNTS TRANSFERRED
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
6a

Data
Breakout

Variable
Name

Description

Total Account Total number of accounts electronically transferred from the FFM to the Medicaid/CHIP
Transfers
agency during the calendar month. SBMs should not report transfers. Accounts moving
Received from between a new integrated system and a legacy system should not be included.
the FFM
An account is defined as the set of application and verification data necessary to make an
eligibility determination for an insurance affordability program as required in §435.1200. Only
electronic account transfers should be included; case referrals should not be included if an
electronic account transfer is not made. This indicator should include both assessments and
determinations of eligibility made by the FFM before transfer to the Medicaid/CHIP agency
during the calendar month, as well as non-MAGI referrals and requests for a full Medicaid
determination.
Sub-indicator 6a may be less than the sum of sub-indicators 6e through 6h.

Transfers
INDICATOR REMOVED (included in sub-indicator 6a).
Received from
FFM

Transfers
INDICATOR REMOVED.
Received from
NonIntegrated
SBM

6. NUMBER OF ELECTRONIC ACCOUNTS TRANSFERRED
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number

Data
Breakout

Variable
Name

Description

Transfers
INDICATOR REMOVED.
Received from
an Unknown
Source
By Transfer
Type

Determined
Account
Transfers
Received

Total number of electronic accounts during the calendar month in which an individual received
a final determination that they were eligible for Medicaid or CHIP from the FFM before
account transfer to the state. This indicator only applies to states that have delegated
responsibility to the FFM to conduct eligibility determinations (“determination” states).

Assessed
Account
Transfers
Received

Total number of electronic accounts transferred to the Medicaid/CHIP agency without a final
determination of eligibility during the calendar month, including transfer accounts assessed as
eligible by the FFM as well as those initially assessed as ineligible but for which a request for
full determination was made. This indicator does not apply to states that have delegated
responsibility to the FFM to conduct eligibility determinations (“determination” states) and
should be left blank by these states.

Request for
Full
Determination
Transfers
Received

The total number of electronic account transfers during the calendar month in which an
individual was initially assessed or determined as ineligible for Medicaid or CHIP, but the
applicant requested a transfer to the agency for a full determination. Individuals who were
assessed or determined as eligible for Medicaid or CHIP before their account was transferred
should not be included in this category.
This indicator may include account transfers also counted in sub-indicator 6e or sub-indicator
6f.

Transfers of
Unknown
Type
Received

Total number of electronic accounts transferred during the calendar month that are not
captured in sub-indicators 6e, 6f, and 6g. If this is a non-zero value, the data limitations field
must include any relevant information about the source(s) of these transfers.

Total Transfer INDICATOR REMOVED.
Accounts Sent

6. NUMBER OF ELECTRONIC ACCOUNTS TRANSFERRED
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number

Data
Breakout

Variable
Name

Description

Total Transfer Total number of accounts electronically transferred from the Medicaid/CHIP agency to the
Accounts Sent FFM during the calendar month. All SBMs should leave all fields in this section blank (“not
to FFM
applicable”).

Transfers to
NonIntegrated
SBM Systems

Total number of accounts electronically transferred from the Medicaid/CHIP agency to an
SBM with a non-integrated eligibility determination system during the calendar month. Most
SBMs (those with integrated eligibility systems for the SBM and Medicaid/CHIP programs)
should leave this indicator blank (“not applicable”).

7. NUMBER OF RENEWALS
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
7a

Data
Breakout

Variable Name

Description

Number of
Total number of annual renewals that came up for redetermination by the Medicaid or CHIP
Renewals up for agency during the calendar month. These data should include annual renewals only, and
Annual
exclude beneficiaries redetermined due to a change in circumstances or a program change.
Redetermination All annual renewals that came up for redetermination should be included, regardless of the
disposition (including pending, determined eligible, determined ineligible, and/or ineligible
due to failure to return documentation). All Medicaid and CHIP enrollees who were due for
annual renewal in the calendar month should be included, including individuals with limited
benefit packages and individuals with comprehensive benefit packages. The unit of
measurement for this indicator is the number of individuals, not households. If a state is
only able to report renewals at the household level, the state should document in the freetext data limitation field.
Sub-indicator 7a should equal the sum of renewals by determination type (sub-indicators
7b, 7c, 7d, and 7e).

By
Medicaid MAGI
Determination renewals
Type

Total number of Medicaid (i.e. funded under Title XIX of the Social Security Act) renewals
that came up for annual redetermination during the calendar month and will be
redetermined under MAGI rules.
Refer to sub-indicator 7a for inclusion and exclusion criteria.

Medicaid Non- Total number of Medicaid (i.e. funded under Title XIX of the Social Security Act) renewals
MAGI Renewals that came up for annual redetermination during the calendar month and will be
redetermined under non-MAGI rules.
Refer to sub-indicator 7a for inclusion and exclusion criteria.

CHIP Renewals Total number of CHIP (i.e., funded under Title XXI of the Social Security Act, including
through MCHIP programs) renewals that came up for annual redetermination during the
calendar month.
Refer to sub-indicator 7a for inclusion and exclusion criteria.

7. NUMBER OF RENEWALS
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
7e

Data
Breakout

Variable Name

By
Unknown Type
Determination
Type

Description
Total number of renewals that came up for annual redetermination during the calendar
month but cannot be classified as Medicaid MAGI, Medicaid non-MAGI, or CHIP renewals.
Refer to sub-indicator 7a for inclusion and exclusion criteria.

8. TOTAL ENROLLMENT
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number

Data
Breakout

Variable
Name
Total
Medicaid
Enrollees

Description
Total unduplicated number of individuals enrolled in Medicaid (i.e. funded under Title XIX of the
Social Security Act) and eligible for comprehensive benefits as of the last day of the calendar
month, including those with retroactive, conditional, and presumptive eligibility. This indicator is
a point-in-time count of program enrollment, and not solely a count of those newly enrolled
during the calendar month.
Include only those individuals who are eligible for comprehensive benefits, which is defined as
coverage that qualifies as Minimum Essential Coverage (MEC). Individuals eligible for only
limited benefits, such as emergency Medicaid, family planning-only coverage and limited
benefit dual eligible individuals should not be included. Medicaid 1115 Demonstration
populations should be included as long as the benefits are comprehensive. Pregnant women
and dually eligible individuals should be included as long as they receive comprehensive
benefits.
All individuals whose coverage is funded under Title XXI of the Social Security Act, including
through MCHIP programs, are excluded from this sub-indicator.
Sub-indicator 8a should equal the sum of Medicaid MAGI enrollees (sub-indicator 8b) and
Medicaid non-MAGI enrollees (sub-indicator 8e).
When the state submits data for this sub-indicator for the current reporting month, the state is
also required to update the data on this sub-indicator for the prior month’s updated report.

Medicaid
MAGI
Enrollment

Total MAGI
Enrollees

Total unduplicated number of individuals enrolled in Medicaid (i.e. funded under Title XIX of the
Social Security Act) as of the last day of the calendar month who are in an eligibility group that
is subject to the MAGI determination rules.
Sub-indicator 8b should equal the sum of MAGI child enrollees (sub-indicator 8c) and MAGI
adult enrollees (sub-indicator 8d).
Refer to sub-indicator 8a for inclusion and exclusion criteria.
When the state submits data for this sub-indicator for the current reporting month, the state is
also required to update the data on this sub-indicator for the prior month’s updated report.

8. TOTAL ENROLLMENT
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number

Data
Breakout

Variable
Name

Medicaid
MAGI
Enrollment

MAGI Child
Enrollees

Description
Total unduplicated number of individuals enrolled in Medicaid (i.e. funded under Title XIX of the
Social Security Act) as of the last day of the calendar month who are children and who are in
an eligibility group that is subject to the MAGI determination rules. A state should use its
definition of "child" as included in its Medicaid or CHIP state plan.
Refer to sub-indicator 8a for inclusion and exclusion criteria.
When the state submits data for this sub-indicator for the current reporting month, the state is
also required to update the data on this sub-indicator for the prior month’s updated report.

MAGI Adult
Enrollees

Total unduplicated number of individuals enrolled in Medicaid (i.e. funded under Title XIX of the
Social Security Act) as of the last day of the calendar month, who are not children, and who are
in an eligibility group that is subject to the MAGI determination rules.
Refer to sub-indicator 8a for inclusion and exclusion criteria.
When the state submits data for this sub-indicator for the current reporting month, the state is
also required to update the data on this sub-indicator for the prior month’s updated.

Medicaid
non-MAGI
Enrollment

Total NonMAGI
Enrollees

Total unduplicated number of individuals enrolled in Medicaid (i.e. funded under Title XIX of the
Social Security Act) as of the last day of the calendar month who are in an eligibility group that
is subject to non-MAGI determination rules.
Sub-indicator 8e should equal the sum of non-MAGI child enrollees (sub-indicator 8f) and nonMAGI adult enrollees (sub-indicator 8g).
Refer to sub-indicator 8a for inclusion and exclusion criteria.
When the state submits data for this sub-indicator for the current reporting month, the state is
also required to update the data on this sub-indicator for the prior month’s updated report.

8. TOTAL ENROLLMENT
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number

Data
Breakout

Variable
Name

Medicaid
non-MAGI
Enrollment

Non-MAGI
Child
Enrollees

Description
Total unduplicated number of individuals enrolled in Medicaid (i.e. funded under Title XIX of the
Social Security Act) as of the last day of the calendar month who are children and who are in
an eligibility group that is subject to non-MAGI determination rules. A state should use its
definition of "child" as included in its Medicaid or CHIP state plan.
Refer to sub-indicator 8a for inclusion and exclusion criteria.
When the state submits data for this indicator for the current reporting month, the state is also
required to update the data on this sub-indicator for the prior month’s updated report.

Non-MAGI
Adult
Enrollees

Total unduplicated number of individuals enrolled in Medicaid (i.e. funded under Title XIX of the
Social Security Act) as of the last day of the calendar month who are not children and who are
in an eligibility group that is subject to non-MAGI determination rules.
Refer to sub-indicator 8a for inclusion and exclusion criteria.
When the state submits data for this sub-indicator for the current reporting month, the state is
also required to update the data on this sub-indicator for the prior month’s updated report.

Total CHIP
Enrollees

Total unduplicated number of individuals enrolled in CHIP (i.e., funded under Title XXI of the
Social Security Act, including through MCHIP programs) as of the last day of the calendar
month, including those with retroactive, conditional, and presumptive eligibility. CHIP children
in a premium grace period should be included, while CHIP children subject to a waiting period
or premium lock-out period are considered eligible but not enrolled and should be excluded.
Include only those individuals who are eligible for comprehensive benefits, defined as coverage
that qualifies as MEC. Pregnant women covered by CHIP should be included as long as they
receive comprehensive benefits.
This sub-indicator is a point-in-time count of program enrollment, and not solely a count of
those newly enrolled during the calendar month.
When the state submits data for this sub-indicator for the current reporting month, the state is
also required to update the data on this sub-indicator for the prior month’s updated report.

Any state and the District of Columbia that elects to provide coverage to 1) the adult group described in 42 § C.F.R. 435.119 under
the state plan or 2) to certain individuals generally described at § 435.119 who are enrolled in a section 1115 demonstration that
provides minimum essential coverage (MEC) to such population (“applicable 1115 waiver”) must apply community engagement
requirements described in section 1902(xx) of the Social Security Act (the Act) as a condition of eligibility for applicants or
beneficiaries. In accordance with § 435.562, these states must report data in the monthly reports about the final determination on
applications for individuals who were specified excluded individuals described in § 435.554 or applicable individuals in § 435.551 at
application. CMS collects this data through sub-indicators 9n, 9o, 9p, 10m, 10n, and 10o of the monthly report. States begin reporting
sub-indicators 9n, 9o, 9p, 10m, 10n, and 10o for the reporting month the community engagement requirement under section
1902(xx) of the Act is effective in the state. States that do not provide Medicaid to applicable individuals described in section
1902(xx) of the Act do not need to report sub-indicators 9n, 9o, 9p, 10m, 10n, and 10o to CMS.

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9. TOTAL NUMBER OF INDIVIDUALS DETERMINED ELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
9a

Data
Breakout

Variable Name

Description

Total Medicaid
Eligible

Total number of individuals determined eligible for Medicaid (i.e. funded under Title XIX of
the Social Security Act) under either MAGI or non-MAGI rules during the calendar month.
This count should include determinations following an initial application as well as all
redeterminations (triggered by either the annual renewal process or other change in
circumstances). Individuals determined eligible for CHIP (i.e. funded under Title XXI of the
Social Security Act, including through MCHIP programs) are not included in this indicator.
All determinations made in the calendar month should be included, even if the individual will
not be enrolled into the program during the calendar month or is found retroactively eligible.
Include final determinations made by any state agency, including the Medicaid agency, a
separate CHIP agency, and an SBM. Include determinations made on accounts assessed
by the FFM and transferred to Medicaid for final determination. Do not include final eligibility
determinations made by the FFM and transferred to Medicaid for enrollment. If an individual
receives a MAGI and then a non-MAGI determination, both of these separate
determinations should be counted. Individuals determined eligible at application or annual
renewal who receive a subsequent determination due to a change in circumstance should
have both determinations counted separately.
Sub-indicator 9a should equal the sum of eligible determinations by determination type
(sub-indicators 9b and 9c).
Sub-indicator 9a should equal the sum of sub-indicator 9d (Medicaid Eligibility Determined
at Application), sub-indicator 9g (Medicaid Eligibility at Annual Renewal), sub-indicator 9h
(Medicaid Eligible via Administrative Determination), and sub-indicator 9i (Medicaid Eligible
via Other Method).

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9. TOTAL NUMBER OF INDIVIDUALS DETERMINED ELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
9b

Data
Breakout

Variable Name

Description

Medicaid MAGI
By
Determination Eligibility
Determinations
Type

Total number of individuals determined eligible for Medicaid (i.e. funded under Title XIX of
the Social Security Act) under MAGI rules during the calendar month.

Medicaid nonMAGI Eligibility
Determinations

Total number of individuals determined eligible for Medicaid (i.e. funded under Title XIX of
the Social Security Act) under non-MAGI rules during the calendar month.

By Reason
Medicaid
for
Eligibility
Determination Determined at
Application

Total number of individuals determined eligible for Medicaid (i.e. funded under Title XIX of
the Social Security Act) under either MAGI or non-MAGI rules during the calendar month
based on applications for coverage submitted to any state agency (Medicaid, CHIP, or the
SBM). Include accounts assessed as eligible and transferred from the FFM. Do not include
accounts determined eligible by the FFM.

Refer to sub-indicator 9a for inclusion and exclusion criteria.

Sub-indicator 9d should equal the sum of sub-indicator 9e (Medicaid Eligibility at Application
under MAGI Rules) and sub-indicator 9f (Medicaid Eligibility at Application under non-MAGI
Rules).
Refer to sub-indicator 9a for inclusion and exclusion criteria.
9e

Medicaid
Eligibility at
Application
under MAGI
Rules

Total number of individuals determined eligible for Medicaid (i.e. funded under Title XIX of
the Social Security Act) under MAGI rules during the calendar month based on applications
for coverage submitted to any state agency (Medicaid, CHIP, or the SBM). Include accounts
assessed as eligible and transferred from the FFM. Do not include accounts determined
eligible by the FFM.
Refer to sub-indicator 9a for inclusion and exclusion criteria.

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9. TOTAL NUMBER OF INDIVIDUALS DETERMINED ELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
9f

Data
Breakout

Variable Name

Description

By Reason
Medicaid
Total number of individuals determined eligible for Medicaid (i.e. funded under Title XIX of
for
Eligibility at
the Social Security Act) under non-MAGI rules during the calendar month based on
Determination Application
applications for coverage submitted to any state agency (Medicaid, CHIP, or the SBM).
under non-MAGI Include accounts assessed as eligible and transferred from the FFM. Do not include
Rules
accounts determined eligible by the FFM.
Refer to sub-indicator 9a for inclusion and exclusion criteria.

Medicaid
Total number of individuals determined eligible for Medicaid (i.e. funded under Title XIX of
Eligibility
the Social Security Act) at annual renewal under either MAGI or non-MAGI rules during the
Determined at
calendar month. Individuals redetermined outside of the annual renewal process (for
Annual Renewal example, due to a change in circumstance) should not be reported here, as they are
captured in the sub-indicator for “Medicaid Eligible via Other Method” (9i).
Refer to sub-indicator 9a for inclusion and exclusion criteria.

Medicaid
Eligible via
Administrative
Determination

Total number of individuals determined eligible for Medicaid (i.e. funded under Title XIX of
the Social Security Act) during the calendar month without submitting an application, under
the process by which a state determines a cohort of individuals eligible through targeted
enrollment strategies outlined in CMS guidance issued on May 17, 2013. This includes
enrolling certain SNAP participants and parents of CHIP beneficiaries without requiring an
application. Unless your state has been approved by CMS to make this type of
determination, leave this field blank (not applicable).
Refer to sub-indicator 9a for inclusion and exclusion criteria.

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9. TOTAL NUMBER OF INDIVIDUALS DETERMINED ELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
9i

Data
Breakout

Variable Name

By Reason
Medicaid
for
Eligible via
Determination Other Method

Description
Total number of individuals determined eligible for Medicaid (i.e. funded under Title XIX of
the Social Security Act) under both MAGI and non-MAGI rules during the calendar month
that are not captured in sub-indicators 9d, 9g, and 9h. This number should include
redeterminations made outside of the annual renewal process (for instance, due to a selfreported change in circumstance). This number should also include administrative
determinations for any individuals who did not submit an application for coverage, including
SSI beneficiaries and certain Express Lane Eligibility (ELE) new enrollees. The data
limitations field should include a description of any determinations reported in this field.
Refer to sub-indicator 9a for inclusion and exclusion criteria.

Total CHIP
Eligible

Total number of individuals determined eligible for CHIP (i.e. funded under Title XXI of the
Social Security Act, including through MCHIP programs) during the calendar month. This
number should include determinations following an initial application as well as all
redeterminations (triggered by either the annual renewal process or other change in
circumstances).
All determinations made in the calendar month should be included, even if the individual will
not be enrolled into the program during the calendar month or is found retroactively eligible.
Include final determinations made by any state agency, including the Medicaid agency, a
separate CHIP agency, and an SBM. Include CHIP determinations made on accounts
assessed by the FFM and transferred to the state agency for final determination. Do not
include final CHIP eligibility determinations made by the FFM and transferred to the state
agency for enrollment. Individuals determined eligible at application or annual renewal who
receive a subsequent determination due to a change in circumstance should have both
determinations counted separately in the month in which each occurs.
Sub-indicator 9j should equal the sum of sub-indicator 9k (Determined CHIP Eligible at
Application), sub-indicator 9l (Determined CHIP Eligible at Annual Renewal), and subindicator 9m (All Others Determined CHIP Eligible).

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9. TOTAL NUMBER OF INDIVIDUALS DETERMINED ELIGIBLE

Formatted Table

Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
9k

Data
Breakout

Variable Name

Description

By Reason
Determined
Total number of individuals determined eligible for CHIP (i.e. funded under Title XXI of the
for
CHIP Eligible at Social Security Act, including through MCHIP programs) during the calendar month that
Determination Application
follows the applicant submitting an application for coverage to any state agency (Medicaid,
CHIP, or the SBM). Include accounts assessed as eligible and transferred from the FFM. Do
not include accounts determined eligible by the FFM.
Refer to sub-indicator 9j for inclusion and exclusion criteria.

Determined
Total number of individuals determined eligible for CHIP (i.e. funded under Title XXI of the
CHIP Eligible at Social Security Act, including through MCHIP programs) at annual renewal during the
Annual Renewal calendar month. Individuals redetermined outside of the annual renewal process (for
example, due to a change in circumstance) should not be reported here, as they are
captured in the sub-indicator for “All Others Determined CHIP Eligible” (9m).
Refer to sub-indicator 9j for inclusion and exclusion criteria.

All Others
Determined
CHIP Eligible

Total number of individuals determined eligible for CHIP (i.e. funded under Title XXI of the
Social Security Act, including through MCHIP programs) during the calendar month who are
not captured in sub-indicator 9k and sub-indicator 9l. This includes redeterminations made
outside of the annual renewal process (for instance, due to a change in circumstance).
Refer to sub-indicator 9j for inclusion and exclusion criteria.

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9. TOTAL NUMBER OF INDIVIDUALS DETERMINED ELIGIBLE

Formatted Table

Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number

Data
Breakout

9no

By
Community
Engagement
aAt
Applications

Variable Name

Description

Number of
individuals
determined
eligible whoith
are who are
determined to
be a specified
excluded
individualsion

Total number of individuals who applied and were determined eligible for the Medicaid adult
group described in § 435.119 or an applicable 1115 waiver; and were determined to be a
specified excluded individual at application as described in § 435.554. Total number of
individuals determined to be specified excluded individuals and eligible for Medicaid eligible
for Medicaid under Community Engagement as a result of being specified excluded
individuals as determined by Section 71119 of the WFTC legislation amended Section
1902 of the Social Security Act.

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All determinations made in the calendar month should be included, even if the individual will
not be enrolled into the program during the calendar month or is found retroactively eligible.
Include final determinations made by any state agency, including the Medicaid agency, a
separate CHIP agency, and an SBM. Include determinations made on accounts assessed
by the FFM and transferred to Medicaid for final determination. Do not include final eligibility
determinations made by the FFM and transferred to Medicaid for enrollment. If an individual
receives a MAGI and then a non-MAGI determination, both of these separate
determinations should be counted. Individuals determined eligible at application or Semiannual renewal who receive a subsequent determination due to a change in circumstance
should have both determinations counted separately.

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9. TOTAL NUMBER OF INDIVIDUALS DETERMINED ELIGIBLE

Formatted Table

Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
9on

Data
Breakout

Variable Name

Description

Number of
Total number of individuals who applied and were determined eligible for the Medicaid adult
individuals
group described in § 435.119 or an applicable 1115 waiver and demonstrated community
demonstrating
engagement (in accordance with § 435.552) or were deemed to have demonstrated
community
community engagement based on a mandatory exception(in accordance with § 435.552) as
engagement or
described in §435.552 and §435.553.
meeting a
mandatory
exception.
Number of
Total number of individuals determined eligible for Medicaid under Community Engagement
individuals
as a result of demonstrating community engagement or a mandatory exception dor
determined
specified excluded individuals as determined by Section 71119 of the WFTC
eligible who are legislation amended Section 1902 of the Social Security Act.
applicable
individuals and This count should include determinations following an initial application. Please, exclude
redeterminations (triggered by either the annual renewal process or other change in
either
demonstrateding circumstances). Individuals determined eligible for CHIP (i.e. funded under Title XXI of the
Social Security Act, including through MCHIP programs) are not included in this indicator.
community
engagement or All determinations made in the calendar month should be included, even if the individual will
were deemed to not be enrolled into the program during the calendar month or is found retroactively eligible.
have
Include final determinations made by any state agency, including the Medicaid agency, a
demonstrated
separate CHIP agency, and an SBM. Include determinations made on accounts assessed
community
by the FFM and transferred to Medicaid for final determination. Do not include final eligibility
engagement by determinations made by the FFM and transferred to Medicaid for enrollment. If an individual
meeting a
receives a MAGI and then a non-MAGI determination, both of these separate
mandatory
determinations should be counted. Individuals determined eligible at application or Semiexception.
annual renewal who receive a subsequent determination due to a change in circumstance
should have both determinations counted separately.

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9. TOTAL NUMBER OF INDIVIDUALS DETERMINED ELIGIBLE

Formatted Table

Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
9po

Data
Breakout

Variable Name

Description

Number of
individuals
determined
eligible who are
applicable
individuals and
were deemed to
have
demonstrated
community
engagement by
meeting a
sShort-term
hardship
exception

Total number of individuals who applied and were determined eligible for the Medicaid adult
group described in § 435.119 or an applicable 1115 waiver and were deemed to have
demonstrated community engagement for one or more months based on a short-term
hardship exception described in § 435.555. Total number of individuals determined eligible
for Medicaid under Community Engagement as a result of short term hardship exception as
determined by Section 71119 of the WFTC legislation amended Section 1902 of the Social
Security Act.

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This count should include determinations following an initial application. Please, exclude
redeterminations (triggered by either the annual renewal process or other change in
circumstances). Individuals determined eligible for CHIP (i.e. funded under Title XXI of the
Social Security Act, including through MCHIP programs) are not included in this indicator.
All determinations made in the calendar month should be included, even if the individual will
not be enrolled into the program during the calendar month or is found retroactively eligible.
Include final determinations made by any state agency, including the Medicaid agency, a
separate CHIP agency, and an SBM. Include determinations made on accounts assessed
by the FFM and transferred to Medicaid for final determination. Do not include final eligibility
determinations made by the FFM and transferred to Medicaid for enrollment. If an individual
receives a MAGI and then a non-MAGI determination, both of these separate
determinations should be counted. Individuals determined eligible at application or Semiannual renewal who receive a subsequent determination due to a change in circumstance
should have both determinations counted separately.

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10. TOTAL NUMBER OF INDIVIDUALS DETERMINED INELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
10a

Data
Breakout

Variable Name
Total Medicaid
Ineligible

Description
Total number of individuals determined ineligible for Medicaid (i.e. funded under Title
XIX of the Social Security Act) under either MAGI or non-MAGI rules during the
calendar month. This number should include determinations following an initial
application as well as all redeterminations (triggered by either the annual renewal
process or other change in circumstances). Include final determinations made by any
state agency, including the Medicaid agency, a separate CHIP agency, and an SBM.
Include individuals determined ineligible due to not meeting program eligibility
requirements as well as those for whom the agency was not able to obtain enough
information to make an eligibility determination (procedural denials). Include individuals
determined ineligible by a state agency after their account was assessed and
transferred from the FFM. Do not include final eligibility determinations made by the
FFM.
Individuals who are determined ineligible for Medicaid and ineligible for CHIP should be
counted both in the number of individuals determined ineligible for Medicaid under this
indicator and in the number of individuals ineligible for CHIP under sub-indicator 10g.
Individuals who request disenrollment during the calendar month should not be included
in this indicator.
Sub-indicator 10a should equal the sum of sub-indicator 10b (Ineligibility Established)
and sub-indicator 10c (Eligibility Cannot be Established).
Sub-indicator 10a should equal the sum of sub-indicator 10d (Ineligible at Application),
sub-indicator 10e (Ineligible at Annual Renewal), and sub-indicator 10f (Ineligible via
Other Application Type).

10. TOTAL NUMBER OF INDIVIDUALS DETERMINED INELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
10b

Data
Breakout

Variable Name

By
Medicaid
Determination Determination –
Reason
Ineligibility
Established

Description
Total number of individuals determined ineligible for Medicaid (i.e. funded under Title
XIX of the Social Security Act) under either MAGI or non-MAGI rules during the
calendar month based on information known to the state agency making the
determination (for instance, individuals determined ineligible due to death, aging out,
citizenship status, changes in household composition, or higher income).
Refer to sub-indicator 10a for inclusion and exclusion criteria.

10c

Medicaid
Determination –
Eligibility Cannot be
Established

Total number of individuals determined ineligible for Medicaid (i.e. funded under Title
XIX of the Social Security Act) under either MAGI or non-MAGI rules during the
calendar month because the state did not have sufficient information to determine
ineligibility (procedural denials). Potential reasons that a state would not be able to
definitively establish ineligibility include: applicants failed to complete or return renewal
forms or other required documentation, or renewing households who were lost to follow
up.
Refer to sub-indicator 10a for inclusion and exclusion criteria.

10d

By Type of
Medicaid
Determination Determination –
Ineligible at
Application

Total number of individuals determined ineligible for Medicaid (i.e. funded under Title
XIX of the Social Security Act) under either MAGI or non-MAGI rules during the
calendar month as a result of the applicant submitting an application for coverage to
any state agency (Medicaid, CHIP, or the SBM). Include individuals determined
ineligible by a state agency after their account was assessed and transferred from the
FFM. Do not include final eligibility determinations made by the FFM.
Refer to sub-indicator 10a for inclusion and exclusion criteria.

10. TOTAL NUMBER OF INDIVIDUALS DETERMINED INELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number

Data
Breakout

Variable Name

10e

By Type of
Medicaid
Determination Determination –
Ineligible at Annual
Renewal

10f

Medicaid
Determination –
Ineligible via Other
Application Type

Description
Total number of individuals who, during the calendar month, were determined ineligible
for Medicaid (i.e. funded under Title XIX of the Social Security Act) at annual renewal
under either MAGI or non-MAGI rules. Individuals redetermined outside of the annual
renewal process (for example, due to a change in circumstance) should not be reported
here, as they are captured in the sub-indicator for “Medicaid Determination – Ineligible
via Other Application Type” (10f).
Refer to sub-indicator 10a for inclusion and exclusion criteria.
Total number of individuals determined ineligible for Medicaid (i.e. funded under Title
XIX of the Social Security Act) under both MAGI and non-MAGI rules during the
calendar month who are not captured in sub-indicator 10d and sub-indicator 10e. This
could include redeterminations made outside of the annual renewal process (for
instance, due to a change in circumstance).
Refer to sub-indicator 10a for inclusion and exclusion criteria.

10. TOTAL NUMBER OF INDIVIDUALS DETERMINED INELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
10g

Data
Breakout

Variable Name
Total CHIP
Ineligible

Description
Total number of individuals determined ineligible for CHIP (i.e. funded under Title XXI of
the Social Security Act, including through MCHIP programs) during the calendar month.
This number should include determinations following an initial application as well as all
redeterminations (triggered by either the annual renewal process or other change in
circumstances). Include final determinations made by any state agency, including the
Medicaid agency, a separate CHIP agency, and an SBM. Include individuals
determined ineligible for CHIP due to not meeting program eligibility requirements as
well as those for whom the agency was not able to obtain enough information to make
an eligibility determination (procedural denials). Include individuals determined ineligible
by a state agency after their account was assessed and transferred from the FFM. Do
not include final eligibility determinations made by the FFM.
Individuals who are determined ineligible for Medicaid and ineligible for CHIP should be
counted both in the number of individuals determined ineligible for Medicaid and in the
number of individuals ineligible for CHIP. Individuals determined eligible for Medicaid
who do not receive a CHIP denial should not be included in this sub-indicator.
Individuals who request disenrollment or are disenrolled for failure to make premium
payments during the calendar month should not be included in this indicator. Similarly,
children subject to a waiting period or premium lock-out period are considered eligible
but not enrolled and should also be excluded from this sub-indicator.
Sub-indicator 10g should equal the sum of sub-indicator 10h (Ineligibility Established)
and sub-indicator 10i (Eligibility cannot be Established).
Sub-indicator 10g should equal the sum of sub-indicator 10j (Ineligible at Application),
sub-indicator 10k (Ineligible at Annual Renewal), and sub-indicator 10l (Ineligible via
Other Application Method).

10. TOTAL NUMBER OF INDIVIDUALS DETERMINED INELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
10h

Data
Breakout

Variable Name

Description

By
CHIP Determination Total number of individuals determined ineligible for CHIP (i.e. funded under Title XXI of
Determination – Ineligibility
the Social Security Act, including through MCHIP programs) during the calendar month
Reason
Established
based on information known to the state agency making the determination (for instance,
individuals determined ineligible due to death, aging out, citizenship status, changes in
household composition, or higher income).
Refer to sub-indicator 10g for inclusion and exclusion criteria.

10i

CHIP Determination Total number of individuals determined ineligible for CHIP (i.e. funded under Title XXI of
– Eligibility Cannot the Social Security Act, including through MCHIP programs) during the calendar month
be Established
because the state did not have sufficient information to determine ineligibility. Potential
reasons that a state would not be able to definitively establish ineligibility include:
applicants failed to complete or return renewal forms or other required documentation,
or renewing households were lost to follow up.
Refer to sub-indicator 10g for inclusion and exclusion criteria.

10j

By
CHIP Determination Total number of individuals determined ineligible for CHIP (i.e. funded under Title XXI of
Determination – Ineligible at
the Social Security Act, including through MCHIP programs) during the calendar month
Type
Application
as a result of the applicant submitting an application for coverage to any state agency
(Medicaid, CHIP, or the SBM). Include individuals determined ineligible by a state
agency after their account was assessed and transferred from the FFM Include
individuals determined ineligible by a state agency after their account was assessed
and transferred from the FFM. Do not include final eligibility determinations made by the
FFM.
Refer to sub-indicator 10g for inclusion and exclusion criteria.

10. TOTAL NUMBER OF INDIVIDUALS DETERMINED INELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
10k

Data
Breakout

Variable Name

Description

By
CHIP Determination Total number of individuals determined ineligible for CHIP (i.e. funded under Title XXI of
Determination – Ineligible at
the Social Security Act, including through MCHIP programs) at annual renewal during
Type
Annual Renewal
the calendar month. Individuals redetermined outside of the annual renewal process (for
example, due to a change in circumstance) should not be reported here, as they are
captured in the sub-indicator for “CHIP Determination – Ineligible via Other Application
Type” (10l).
Refer to sub-indicator 10g for inclusion and exclusion criteria.

10l

CHIP Determination
– Ineligible via
Other Application
Type

Total number of individuals determined ineligible for CHIP (i.e. funded under Title XXI of
the Social Security Act, including through MCHIP programs) during the calendar month
who are not captured in sub-indicator 10j and sub-indicator 10k. This could include
redeterminations made outside of the annual renewal process (for instance, due to a
change in circumstance).
Refer to sub-indicator 10g for inclusion and exclusion criteria.

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10. TOTAL NUMBER OF INDIVIDUALS DETERMINED INELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number

Data
Breakout

10m

By
Community
Engagement
at Application

Variable Name

Description

Number of
Total number of individuals who applied and were determined eligible for the Medicaid
individuals
adult group described in § 435.119 or applicable 1115 waiver except community
determined
engagement;
ineligible fFor failure
to meet CE, an
• and were determined ineligible for Medicaid due to not meeting failure to
exclusion or an
demonstrate compliance with the the community engagement requirement
exceptiondue to not
• Individuals who did not meet the Medicaid community engagement requirement
meeting the
are those for whom the state had sufficient information to determine that the
community
individual was not a specified excluded individual or was an applicable individual
engagement
who, did not demonstrate or was deemed to have demonstrated community
requirement
engagement, as described in § 435.551 - § 435.5575Total number of individuals
determined ineligible for Medicaid as a result for failure to meet Community
Engagement, an exclusion, or an exception requirement as determined by
Section 71119 of the WFTC legislation amended Section 1902 of the Social
Security Act.

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This number should include determinations following an initial application. Exclude all
redeterminations. Include final determinations made by any state agency, including the
Medicaid agency, a separate CHIP agency, and an SBM. Include individuals
determined ineligible by a state agency after their account was assessed and
transferred from the FFM. Do not include final eligibility determinations made by the
FFM.

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Individuals who request disenrollment during the calendar month should not be included
in this indicator.

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10. TOTAL NUMBER OF INDIVIDUALS DETERMINED INELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
10n

Data
Breakout

Variable Name
Number of
individuals
determined
ineligible fFor
pProcedural
rReasons

Description
Total number of individuals determined ineligible for Medicaid for procedural reasons
under community engagement who otherwise met program eligibility criteria (for
example, income and residency ) but did not provide sufficient information necessary for
the state to determine if the individual was a specified excluded individual or was an
applicable individual who, demonstrated or was deemed to have demonstrated
community engagement as described in § 435.551 - § 435.557 as determined by
Section 71119 of the WFTC legislation amended Section 1902 of the Social
Security Act.

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Individuals who request disenrollment during the calendar month should not be included
in this indicator.
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10. TOTAL NUMBER OF INDIVIDUALS DETERMINED INELIGIBLE
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
10o

Data
Breakout

Variable Name
Number of
individuals
determined
ineligible fFor all
other reasons

Description
Total number of individuals determined ineligible for Medicaid for all other reasons
(excluding failure to demonstrate CE as described in § 435.552 - § 435.555 and
procedural reasons) under community engagement as determined by Section 71119 of
the WFTC legislation amended Section 1902 of the Social Security Act.
This number should include determinations following an initial application. Exclude all
redeterminations. Include final determinations made by any state agency, including the
Medicaid agency, a separate CHIP agency, and an SBM. Include individuals
determined ineligible by a state agency after their account was assessed and
transferred from the FFM. Do not include final eligibility determinations made by the
FFM.

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Individuals who request disenrollment during the calendar month should not be included
in this indicator.
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11. NUMBER OF PENDING APPLICATIONS OR REDETERMINATIONS
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number

Data
Breakout

Variable
Name

11a

Pending at
Medicaid
Agency

Number
Pending at
Medicaid
Agency

Description
Total number of applications and redeterminations pending at Medicaid agency as of the last
day of the month. This includes all applications that have been received by the agency
(regardless of the date of application) and outstanding redeterminations (regardless of when
the individual came up for renewal), but which have not yet been determined as of the last
day of the month. Include all pending applications and renewals in the queue that are not
complete for any reason, including due to outstanding verification items on the part of the
applicant or renewing household. Online applications that have been initiated but not yet
submitted to the Medicaid agency should not be reported. Account transfers that received a
final determination from the FFM (in FFM determination states) should also be excluded.
If the state has an integrated application and eligibility and enrollment system for Medicaid
and CHIP, then all pending Medicaid and CHIP applications and redeterminations should be
included in this count.

11b

Pending at
Medicaid
Agency Type

States where the number of pending applications and redeterminations reported in subindicator 11a is of individuals should report “I” in this field. States where the reported number
is of pending cases that may include a mix of individuals and households should report “A” in
this field.

11c

Pending at
Number
Separate
Pending at
CHIP Agency CHIP Agency

Total number of applications and redeterminations pending at the separate CHIP agency as
of the last day of the month. This includes all applications that have been received by the
agency (regardless of the date of application) and outstanding redetermination (regardless of
when the individual came up for renewal), but which have not yet been determined as of the
last day of the month. Online applications that have been initiated but not yet submitted to the
separate CHIP agency should not be reported.
If the state does not have a separate CHIP agency, or if the state has an integrated
application and eligibility and enrollment system for Medicaid and CHIP, then all pending
Medicaid and CHIP applications and redeterminations should be included in this count, and
this sub-indicator and sub-indicator 11d should be left blank.

11. NUMBER OF PENDING APPLICATIONS OR REDETERMINATIONS
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
11d

Data
Breakout

Variable
Name

Pending at
Pending at
Separate
Separate
CHIP Agency CHIP Agency
Type

Description
States where the number of pending applications and redeterminations reported in subindicator 11c is of individuals should report “I” in this field. States where the reported number
is of pending cases that may include a mix of individuals and households should report “A” in
this field.

12. PROCESSING TIME FOR DETERMINATIONS AT APPLICATION
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
12a

Data Breakout

Variable Name

Description

Median
Processing
Time at
Medicaid
Agency – All
Determinations
at Application

For all applicants (regardless of date of application) who received a determination at
application (as reported through sub-indicator 9d and sub-indicator 10d) from the
Medicaid agency in the calendar month, report the median number of calendar days
elapsed between the date the Medicaid agency received the initial application (start
date) and the day the determination at initial application was made (end date). The set
of determinations included in the calculation of median processing time for this
measure includes Medicaid and CHIP determinations made by the Medicaid agency;
MAGI and non-MAGI determinations; and determinations where the applicant was
determined eligible as well as those where the applicant was determined ineligible. All
final determinations made within the calendar month should be included, regardless of
when the application was submitted. If the state has an integrated Medicaid and CHIP
application and eligibility and enrollment system, all Medicaid and CHIP
determinations made at application should be reported in this sub-indicator, and subindicators 12o–12v should be left blank.
If multiple household members applied on a single application, the processing time
should be calculated and reported separately for each individual who received a
determination. Individuals with presumptive eligibility should not be included in this
Indicator, as they have not yet received a final determination.
Determinations made by the Medicaid agency on transfer applications received from
the FFM are included. The date that the Medicaid agency received the account
transfer is the start date and the day of the determination is the end date. Final
eligibility determinations made by the FFM and transferred to the state should be
excluded.
This sub-indicator only applies to determinations at application, and does not apply to
determinations at annual renewal, change in circumstance, or via other method.

12. PROCESSING TIME FOR DETERMINATIONS AT APPLICATION
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
12b

Data Breakout
Type of
Determination

12c

12d

Source of
Application

Variable Name

Description

Median
The median processing time, in days, as defined in sub-indicator 12a, but only for the
Processing
set of final determinations that the Medicaid agency made using MAGI rules.
Time at
Refer to sub-indicator 12a for inclusion and exclusion criteria.
Medicaid
Agency – MAGI
Determinations
at Application
Median
Processing
Time at
Medicaid
Agency – nonMAGI
Determinations
at Application

The median processing time, in days, as defined in sub-indicator 12a, but only for the
set of final determinations that the Medicaid agency made using non-MAGI rules. No
CHIP determinations (i.e. funded under Title XXI of the Social Security Act, including
through MCHIP programs) should be included in this calculation.

Median
Processing
Time at
Medicaid
Agency – Direct
Application

The median processing time, in days, as defined in sub-indicator 12a, but only for the
set of final determinations that the Medicaid agency made on Medicaid or CHIP
applications that the applicant submitted directly to the state, including applications
submitted directly to an SBM.

Refer to sub-indicator 12a for inclusion and exclusion criteria.

12. PROCESSING TIME FOR DETERMINATIONS AT APPLICATION
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number

Data Breakout

Variable Name

12e

Source of
Application

12f

Number of MAGI
Less than 24
Determinations at
hours
Application, by
Processing Time at
Medicaid Agency

Description

Median
The median processing time, in days, as defined in sub-indicator 12a, but only for the
Processing
set of final determinations that the Medicaid agency made on Medicaid or CHIP
Time at
applications that were transferred to it by the FFM. States with an SBM should leave
Medicaid
this field blank (“not applicable”).
Agency –
Refer to sub-indicator 12a for inclusion and exclusion criteria.
Transfer
Application from
FFM
The number of final determinations made by the Medicaid agency on applications
using MAGI rules that occurred within 24 hours of the time that the application was
received by the agency. This includes determinations made by the Medicaid agency
on transfer applications received from the FFM.
Refer to sub-indicator 12a for inclusion and exclusion criteria.
The sum of this sub-indicator and sub-indicators 12f, 12g, 12h, 12i, and 12j, and 12k
should equal the sum of sub-indicator 9e (Medicaid Eligibility at Application under
MAGI Rules) and the total number of ineligibility determinations at initial application
that the Medicaid agency made under MAGI rules in the previous month (i.e. the
portion of sub-indicator 10d that were determined under MAGI rules).

12g

24 Hours – 7
Days

The number of final determinations made by the Medicaid agency on applications
using MAGI rules that occurred between 24 hours and 7 days of when the application
was received by the agency.
Refer to sub-indicator 12a for inclusion and exclusion criteria.

12h

8 Days – 30
Days

The number of final determinations made by the Medicaid agency on applications
using MAGI rules that occurred between 8 and 30 days of when the application was
received by the agency.
Refer to sub-indicator 12a for inclusion and exclusion criteria.

12. PROCESSING TIME FOR DETERMINATIONS AT APPLICATION
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
12i

12j

Data Breakout

Variable Name

Description

Number of MAGI
31 Days – 45
Determinations at
Days
Application, by
Processing Time at
Medicaid Agency

The number of final determinations made by the Medicaid agency on applications
using MAGI rules that occurred between 31 and 45 days of when the application was
received by the agency.

More than 45
Days

The number of final determinations made by the Medicaid agency on applications
using MAGI rules that occurred more than 45 days after the date that the application
was received by the agency.

Refer to sub-indicator 12a for inclusion and exclusion criteria.

Refer to sub-indicator 12a for inclusion and exclusion criteria.
12k

12l

Number of nonLess than 30
MAGI
Days
Determinations at
Application, by
Processing Time at
Medicaid Agency

31 – 60 Days

The number of final determinations made by the Medicaid agency on applications
using non-MAGI rules that occurred within 30 days of the date that the application
was received by the agency. This includes determinations made by the Medicaid
agency on transfer applications received from the FFM.
Refer to sub-indicator 12a for inclusion and exclusion criteria.
The sum of this sub-indicator and sub-indicators 12k, 12l, 12m, and 12n, and 12o
should equal the sum of sub-indicator 9f (Medicaid Eligibility at Application under NonMAGI Rules) and the total number of ineligibility determinations at initial application
that the Medicaid agency made under Non-MAGI rules in the previous month (i.e. the
portion of sub-indicator 10d that were determined under non-MAGI rules).
The number of final determinations made by the Medicaid agency on applications
using non-MAGI rules that occurred between 31 and 60 days of when the application
was received by the agency.
Refer to sub-indicator 12a for inclusion and exclusion criteria.

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12. PROCESSING TIME FOR DETERMINATIONS AT APPLICATION
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
12m

12n

Data Breakout

Variable Name

Number of non61 – 90 Days
MAGI
Determinations at
Application, by
Processing Time at
Medicaid Agency
More than 90
days

Description
The number of final determinations made by the Medicaid agency on applications
using non-MAGI rules that occurred between 60 and 90 days of when the application
was received by the agency.
Refer to sub-indicator 12a for inclusion and exclusion criteria.
The number of final determinations made by the Medicaid agency on applications
using non-MAGI rules that occurred more than 90 days after the date that the
application was received by the agency.
Refer to sub-indicator 12a for inclusion and exclusion criteria.

12. PROCESSING TIME FOR DETERMINATIONS AT APPLICATION
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
12o

Data Breakout

Variable Name

Description

Median
Processing
Time at CHIP
Agency

For all applicants (regardless of date of application) who received a final
determination from the separate CHIP agency in the calendar month, report the
median number of calendar days elapsed between the date the agency received the
application (start date) and the day the final determination was made (end date). The
set of determinations included in the calculation of median processing time for this
measure includes both determinations where the applicant was determined eligible as
well as those where the applicant was determined ineligible. All determinations within
the calendar month should be included, regardless of when the application was
submitted.
If multiple household members applied on a single application, the processing time
should be calculated and reported separately for each individual who received a
determination. Individuals with presumptive eligibility should not be included in this
Indicator, as they have not yet received a final determination.
This includes determinations made by the separate CHIP agency on transfer
applications received from the FFM.
This indicator only applies to determinations at application, and does not apply to
determinations at annual renewal, change in circumstance, or via other method.
In states without a separate CHIP agency, and in states with an integrated Medicaid
and CHIP application and eligibility and enrollment system, all Medicaid and CHIP
determinations should be reported in sub-indicators 12a–12n, and this indicator as
well as sub-indicators 12p–12v should be left blank (not applicable).

12. PROCESSING TIME FOR DETERMINATIONS AT APPLICATION
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
12p

12q

12r

Data Breakout
Source of CHIP
Application

Variable Name

Description

Median
Processing
Time at CHIP
Agency – Direct
Application

The median processing time in days as defined in sub-indicator 12o, but only for the
set of final determinations that the separate CHIP agency made on applications that
the applicant submitted directly to the state.
Refer to sub-indicator 12o for inclusion and exclusion criteria.

Median
The median processing time in days as defined in sub-indicator 12o, but only for the
Processing
set of final determinations that the separate CHIP agency made on applications that
Time at CHIP
were transferred to it by the FFM. States that share an integrated eligibility system
Agency –
with the SBM should leave this field blank (not applicable).
Transfer
Refer to sub-indicator 12o for inclusion and exclusion criteria.
Application from
FFM
Number of CHIP
Less than 24
Determinations at
Hours
Application, by
Processing Time at
CHIP Agency

The number of final determinations made by the separate CHIP agency on
applications using MAGI rules that occurred within 24 hours of the time that the
application was received by the agency. The sum of this sub-indicator and subindicators 12r, 12s, 12t, 12u, and 12v, should equal the total number of
determinations at initial application that the separate CHIP agency made under MAGI
rules in the previous month. This includes determinations on transfer applications that
the separate CHIP agency received from the FFM, SBM, or Medicaid agency.
In states without a separate CHIP agency, this sub-indicator and sub-indicators 12s,
12t, 12u, and 12v should be left blank (not applicable).
Refer to sub-indicator 12o for inclusion and exclusion criteria.

12s

24 Hours – 7
Days

The number of final determinations made by the separate CHIP agency on
applications using MAGI rules that occurred between 24 hours and 7 days of when
the application was received by the agency.
Refer to sub-indicator 12o for inclusion and exclusion criteria.

12. PROCESSING TIME FOR DETERMINATIONS AT APPLICATION
Reporting Period: Calendar Month
Reporting Frequency: Monthly, year- round
Indicator
Number
12t

12u

Data Breakout

Variable Name

Description

Number of CHIP
8 Days – 30
Determinations at
Days
Application, by
Processing Time at
CHIP Agency

The number of final determinations made by the separate CHIP agency on
applications using MAGI rules that occurred between 8 and 30 days of when the
application was received by the agency.

31 Days – 45
Days

The number of final determinations made by the separate CHIP agency on
applications using MAGI rules that occurred between 31 and 45 days of when the
application was received by the agency.

Refer to sub-indicator 12o for inclusion and exclusion criteria.

Refer to sub-indicator 12o for inclusion and exclusion criteria.
12v

More than 45
Days

The number of final determinations made by the separate CHIP agency on
applications using MAGI rules that occurred more than 45 days after the date that the
application was received by the agency.
Refer to sub-indicator 12o for inclusion and exclusion criteria.