CMS-10371 Cooperative Agreements to Support Establishment of State

Center for Consumer Information & Insurance Oversight
Centers for Medicare & Medicaid Services
Department of Health & Human Services

SBM Weekly Indicators: Layout for State's Data Submission
This document is the submission format for states with state based marketplaces to submit data to the federal government. This format does not require the submission of individual-level, granular data. The data will be used to assess the Marketplace progress in operational performance, QHP
plan premiums and subsidies, and enrollment/eligibility activity for initial years of operations.
QHP Data in this layout are specific to medical QHPs ands stand-alone dental plans (not vision) and coverage offered through the marketplaces (not Medicaid or CHIP coverage).
If no data match the restrictions of a particular data element, enter "-777". If the data are believed to be reportable in the future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is not possible to report a data element because
of the way the marketplace is operated, enter "-999" to indicate the data elements are not applicable.
Reporting Schedule: Weekly during Open Enrollment; aggregated to 4 weeks of data during other parts of the year. For each report, states should report cumulative data from the start of Open Enrollment (November 15, 2014). The first scheduled reporting due date is November 25, 2014.
Questions should be directed to Nick Sukachevin at Nickom.Sukachevin@cms.hhs.gov or Carly Rhyne at Carly.Rhyne@cms.hhs.gov

Indicator
Number

1
2

State (select cell to reveal drop down box)

Select One:

Reference Period (DD/MM/YY) - (DD/MM/YY)

Select One:

NOTE: First Reference Period is 11/15/14-11/22/14. ***If
applicable, report any early 2015 QHP re-enrollments (performed
before 11/15/14) during this reporting period.***

Date of Report (DD/MM/YY)

Select One:

Date of Report (if not listed in dropdown):

Category

Measure

Initial Applications - Application Level (see Glossary)

Compl Appl: Electronic

Number of Applications Completed, by Electronic and Paper

3
4
5
6
7
8
9
10

13
14
15

Number of Individuals Applying for Coverage through the
Individuals Appl: Total
Marketplace (Individual Level)
Determined Eligible QHP / Assessed Eligible
Medicaid/CHIP
For QHPs: An individual is QHP Eligible if they
Number of Individuals Determined Eligible for Enrollment
submitted a completed application (or had a complete
into a QHP (whether or not applying for financial assistance,
application submitted on their behalf) and the SBM
and whether or not enrolled with financial assistance) by
has deemed the individual eligible for QHP enrollment
Financial Assistance [FA] (APTC Only, APTC + CSRs)
(either provisional or final eligibility) during the
reference period. These individuals may or may not
have enrolled in coverage (meaning picked a QHP or
paid the first premium) by the end of the reference
period.
Number of Individuals Determined Eligible for Enrollment
into a QHP (Individual Level) by Language Preference

18
19

22
23
24
25
26
27
28
29
30
31

Eligible: Without FA
Eligible with FA: APTC Only
Eligible with FA: APTC + CSRs
Eligible by Language Preference: No Language Preference
Eligible by Language Preference: Spanish

Number of Individuals Determined Eligible for Enrollment Eligible by Gender: Male
into a QHP by Gender

Eligible by Gender: Female
Eligib assessment: Medicaid (if breakout possible)

Distribution of Assessed Eligible Individuals by Medicaid and
CHIP
Eligib assessment: CHIP (if breakout possible)
Eligib assessment: Medicaid + CHIP

Plan Selection: Effective (not effectuated) Enrollment
Number of Individuals with QHP Plan Selection: TOTAL
During the Reference Period. Individuals Who were
Individuals Enrolled: Total
Calculate Covered Lives
deemed QHP eligible, selected a QHP and a financial
assistance [FA] amount (if eligible), and the SBM
approved the QHP selection during the reference
Number of Individuals with QHP Plan Selection by Language Plan Selection by Language Preference: No Language Preference
period
Preference
Plan Selection by Language Preference: Language Spanish
Indiviudal Level

20
21

Eligible: Total

Eligible by Language Preference: Other Language

16

17

Compl Appl: Paper
Compl Appl: Total

11
12

Indicator for Cell

Plan Selection by Language Preference: Other Language

Number of Individuals Selecting a 2015 QHP Who Were Not Plan Selection for New Enrollees: Total
Enrolled in a 2014 Marketplace Plan (New Enrollment).
Enter Stand Alone Dental Plan new enrollments separately Plan Selection for New Enrollees by FA: Enrollment New without FA
in SADP column.
Plan Selection for New Enrollees by FA: Enrollment New with FA
Calculate Covered Lives
Number of Individuals Selecting a 2015 QHP Who Were Plan Selection for Re-enrollees: Total
Enrolled in a 2014 Marketplace Plan (Re-Enrollment). Enter
Stand Alone Dental Plan Re-enrollments separately in SADP Plan Selection for Re- enrollees by FA: Re-enrollment without FA
column.
Plan Selection for Re-enrollees by FA: Re-enrollment with FA
Calculate Covered Lives
Plan Selection without FA: Total

Number of Individuals Selecting a QHP by FA (No FA, APTC
Only, and APTC+CSRs)
Plan Selection by FA: APTC Only
Calculate Covered Lives

Plan Selection by FA: APTC + CSRs

Number of Individuals Selecting a QHP by Gender
Calculate Covered Lives

Plan Selection by Gender: Male
Plan Selection by Gender: Female

32

Plan Selection by Age: AGE1<18

33

Plan Selection by Age: AGE2 18-25

34

Plan Selection by Age: AGE3 26-34

35

Number of Individuals Selecting a QHP by Age Group
Calculate Covered Lives

Plan Selection by Age: AGE4 35-44

36

Plan Selection by Age: AGE5 45-54

37

Plan Selection by Age: AGE6 55-64

38

Plan Selection by Age: AGE7 >=65

39

Plan Selection by Gender: Male: AGE1<18

40

Plan Selection by Gender and Age: Male: AGE2 18-25

41

Plan Selection by Gender and Age: Male: AGE3 26-34

42

Plan Selection by Gender and Age: Male: AGE4 35-44

43

Plan Selection by Gender and Age: Male: AGE5 45-54

44

Plan Selection by Gender and Age: Male: AGE6 55-64

45

Number of Individuals Selecting a QHP by Gender and Age Plan Selection by Gender and Age: Male: AGE7 >=65
Group
Plan Selection by Gender and Age: Female: AGE1<18
Calculate Covered Lives

46
47

Plan Selection by Gender and Age: Female: AGE2 18-25

48

Plan Selection by Gender and Age: Female: AGE3 26-34

49

Plan Selection by Gender and Age: Female: AGE4 35-44

50

Plan Selection by Gender and Age: Female: AGE5 45-54

51

Plan Selection by Gender and Age: Female: AGE6 55-64

52

Plan Selection by Gender and Age: Female: AGE7 ≥65

53

Plan Selection by Metal Level: Catastrophic

54

Plan Selection by Metal Level: Bronze

55

Number of Individuals Selecting a QHP by Metal Level
Calculate Covered Lives

Plan Selection by Metal Level: Silver

56

Plan Selection by Metal Level: Gold

57

Plan Selection by Metal Level: Platinum

58

Plan Selection by Age and Metal Level: AGE1<18: Catastrophic

59

Plan Selection by Age and Metal Level: AGE1<18: Bronze

60

Plan Selection by Age and Metal Level: AGE1<18: Silver

61

Plan Selection by Age and Metal Level: AGE1<18: Gold

62

Plan Selection by Age and Metal Level: AGE1<18: Platinum

63

Plan Selection by Age and Metal Level: AGE2 18-25: Catastrophic

64

Plan Selection by Age and Metal Level: AGE2 18-25: Bronze

65

Plan Selection by Age and Metal Level: AGE2 18-25: Silver

66

Plan Selection by Age and Metal Level: AGE2 18-25: Gold

Special Enrollment Period (SEP):
2014 Coverage
(Applies only to 11/15/201412/31/2014, NOT Including
Stand-alone Dental Plans)

Enrollment: 2015 Coverage
(Not Including Stand-alone
Dental Plans)

Enrollment:
Stand-alone Dental Plans:
2015 Coverage

Special Enrollment Period (SEP):
2014 Coverage
(Applies only to 11/15/201412/31/2014, NOT Including
Stand-alone Dental Plans)

Enrollment: 2015 Coverage
(Not Including Stand-alone
Dental Plans)

Name Issuer 1

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135

Name Issuer 2

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136

Name Issuer 3

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137

Name Issuer 4

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138

Name Issuer 5

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139

Name Issuer 6

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140

Name Issuer 7

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141

Name Issuer 8

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142

Name Issuer 9

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143

Name Issuer 10

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144

Name Issuer 11

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145

Name Issuer 12

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146

Name Issuer 13

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147

Name Issuer 14

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148

Name Issuer 15

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149

Median Individ Age Level: AGE1<18

150

Median Individ Age Level: AGE2 18-25

151

Median Individ Age Level: AGE3 26-34

Indicator
Number

Category

Measure

Indicator for Cell

67

Plan Selection by Age and Metal Level: AGE2 18-25: Platinum

68

Plan Selection by Age and Metal Level: AGE3 26-34: Catastrophic

69

Plan Selection by Age and Metal Level: AGE3 26-34: Bronze

70

Plan Selection by Age and Metal Level: AGE3 26-34: Silver

71

Plan Selection by Age and Metal Level: AGE3 26-34: Gold

72

Plan Selection by Age and Metal Level: AGE3 26-34: Platinum

73

Plan Selection by Age and Metal Level: AGE4 35-44: Catastrophic

74
75
76

Number of Individuals Selecting a QHP by Age and Metal
Level
Calculate Covered Lives

Plan Selection by Age and Metal Level: AGE4 35-44: Bronze
Plan Selection by Age and Metal Level: AGE4 35-44: Silver
Plan Selection by Age and Metal Level: AGE4 35-44: Gold

77

Plan Selection by Age and Metal Level: AGE4 35-44: Platinum

78

Plan Selection by Age and Metal Level: AGE5 45-54: Catastrophic

79

Plan Selection by Age and Metal Level: AGE5 45-54: Bronze

80

Plan Selection by Age and Metal Level: AGE5 45-54: Silver

81

Plan Selection by Age and Metal Level: AGE5 45-54: Gold

82

Plan Selection by Age and Metal Level: AGE5 45-54: Platinum

83

Plan Selection by Age and Metal Level: AGE6 55-64: Catastrophic

84

Plan Selection by Age and Metal Level: AGE6 55-64: Bronze

85

Plan Selection by Age and Metal Level: AGE6 55-64: Silver

86

Plan Selection by Age and Metal Level: AGE6 55-64: Gold

87

Plan Selection by Age and Metal Level: AGE6 55-64: Platinum

88

Plan Selection by Age and Metal Level: AGE7 >=65: Catastrophic

89

Plan Selection by Age and Metal Level: AGE7 >=65: Bronze

90

Plan Selection by Age and Metal Level: AGE7 >=65: Silver

91

Plan Selection by Age and Metal Level: AGE7 >=65: Gold

92

Plan Selection by Age and Metal Level: AGE7 >=65: Platinum

93

Plan Selection by FA and Metal Level: Enrolled Without FA: Catastrophic

94

Plan Selection by FA and Metal Level: Enrolled without FA: Bronze

95

Plan Selection by FA and Metal Level: Enrolled without FA: Silver

96

Plan Selection by FA and Metal Level: Enrolled without FA: Gold

97
98

Number of Individuals Selecting a QHP by FA (without FA, Plan Selection by FA and Metal Level: Enrolled without FA: Platinum
with FA) and Metal Level
Plan Selection by FA and Metal Level: Enrolled with FA: Catastrophic
Calculate Covered Lives

99

Plan Selection by FA and Metal Level: Enrolled with FA: Bronze

100

Plan Selection by FA and Metal Level: Enrolled with FA: Silver

101

Plan Selection by FA and Metal Level: Enrolled with FA: Gold

102

Plan Selection by FA and Metal Level: Enrolled with FA: Platinum

103

Plan Selection with FA by FPL: FA and FPL1

104

Plan Selection with FA by FPL: FA and FPL2

105

Plan Selection with FA by FPL: FA and FPL3

106
107
108

Number of Individuals with FA Selecting a QHP by FPL
(Among Indiviudals Receiving FA)
Calculate Covered Lives

Plan Selection with FA by FPL: FA and FPL4
Plan Selection with FA by FPL: FA and FPL5
Plan Selection with FA by FPL: FA and FPL6

109

Plan Selection with FA by FPL: FA and FPL7

110

Plan Selection with FA by FPL: FA and FPL8

111

Plan Selection with FA by FPL: FA and FPL9 (unknown)

119

Plan Selection by Issuer: Issuer 1

120

Plan Selection by Issuer: Issuer 2

121

Plan Selection by Issuer: Issuer 3

122

Plan Selection by Issuer: Issuer 4

123

Plan Selection by Issuer: Issuer 5

124

Plan Selection by Issuer: Issuer 6

125

Plan Selection by Issuer: Issuer 7

126

Plan Selection by Issuer: Issuer 8

127

Plan Selection by Issuer: Issuer 9

128

Plan Selection by Issuer: Issuer 10

129

Plan Selection by Issuer: Issuer 11

130

Plan Selection by Issuer: Issuer 12

131

Plan Selection by Issuer: Issuer 13

132

Plan Selection by Issuer: Issuer 14

133
134

152

Enrollment:
Stand-alone Dental Plans:
2015 Coverage

Number of Individuals Selecting a QHP by Issuer
Calculate Covered Lives

Median Individual-Policy QHP Premium by Age GroupCalculate cumulative since November 15, 2014

Plan Selection by Issuer: Issuer 15

Median Individ Age Level: AGE4 35-44

153

Median Individ Age Level: AGE5 45-54

154

Median Individ Age Level: AGE6 55-64

155

Median Individ Age Level: AGE7 >=65

156

Median Individual-Policy QHP Premium Before APTC ($):
(Only individuals who enroll with APTC) Calculate
cumulative since November 15, 2014

Median Indiv Premium: Before APTC

157

Median Individual-Policy QHP Premium After APTC
Deducted ($) (Only individuals who enroll with APTC)
Calculate cumulative since November 15, 2014

Median individ Premium: After APTC

Indicator
Number

Category

Measure

Indicator for Cell

158

Average Per Person Full Premium for Plans with APTC
Individuals Before APTC Applied. [Average Individual
Premium Before APTC Deducted ($)] All QHPs

Ave indiv premium all QHPs:Before APTC

159

Average Per Person Full premium for Plans With APTC
Individuals, After APTC Applied. Average Individual
Premium After APTC Deducted ($) All QHPs

Ave indiv premium all QHPs:After APTC

160

Average Per Person Full Premium for Plans With APTC
Individuals, Before APTC Applied. [Average Individual
Premium Before APTC Deducted ($)]

Ave Indiv Premium: Before APTC

161

Average Per Person Premium for Plans With APTC
Individuals, After APTC Applied. Average Individual
Premium After APTC Deducted ($)

Ave Indiv premium: After APTC

162
163
164
165

Ave Individ Premium: APTC: Catastrophic
Ave Individ Premium:APTC: Bronze

Average Per Person Full Premium Before APTC Deducted
by Metal Level ($) Calculate cumulative since November Ave Individ Premium: APTC: Silver
15, 2014.
Ave Individ Premium: APTC: Gold

166

Ave Individ Premium: APTC: Platinum

167

Ave Individ Premium: No APTC:Catastrophic

168

Ave Individ Premium: No APTC:Bronze

169

Average Per Person Premium Without APTC by Metal Level
Ave Individ Premium: No APTC:Silver
($) Calculate cumulative since November 15, 2014.

170

Ave Individ Premium: No APTC:Gold

171

Ave Individ Premium: No APTC:Platinum

172

173
174
175

176
177

Average APTC Payment Selected, by tax household ($) See
Ave APTC Selected
glossary. Calculate cumulative since November 15, 2014.

Number of Enrollments Using Assistance (at Application
Level)

180
181

Effect by Language Preference: Other Language
Effectuated Enrollment New Enrollee: Total

Effectuated Enrollment by New Enrollees: Number of
Individuals with Effectuated Enrollment in a 2015 QHP who Effectuated Enrollment New Enrollee by FA: Effect New without FA
Were NOT Enrolled in a 2014 Marketplace Plan (New
Enrollment)
Effectuated Enrollment New Enrollee by FA: Effect New with FA
Calculate Covered Lives

182
183

Effectuated Enrollment for Re-enrollees: Total

Effectuated Enrollmenbt by Re-enrollees: Number of
individuals with Effectuated Enrollment in a 2015 QHP who
Effectuated Enrollment for Re-enrollees by FA: Effect new without FA
were Enrolleed in a 2014 Marketplace Plan (Re-enrollments)
Calculate Covered Lives

184
185
186
187
188
189

Enrollment Using Assistance: No

Effectuated Enrollment Individuals who have
Number of Individuals with Effectuated Enrollment in QHP:
submitted an application (or had application
Individ Effect:Total
TOTAL
submitted on their behalf), were deemed QHP Eligible
Calculate Covered Lives
and selected a QHP, the SBM has approved the QHP
selection, and the first premium payment was
Effect by Language Preference: No Language Preference
received (either directly by the SBM or by the issuer). Number of Individuals with Effectuated Enrollment in QHP
by Language Preference
Effect by Language Preference: Spanish
Individual Level

178
179

Enrollment Using Assistance: Yes

Effectuated Enrollment for Re-enrollees by FA: Effect new with FA
Effect without FA: Total

Number of Individuals with Effectuated Enrollment in QHP
by FA (no FA, APTC Only, and APTC + CSRs)
Effect with FA: APTC Only
Calculate Covered Lives

Effect with FA: APTCs+CSRs

Number of Individuals with Effectuated Enrollment in QHP Effect by Gender: Male
by Gender
Effect by Gender: Female
Calculate Covered Lives

190

Effect by Age: AGE1<18

191

Effect by Age: AGE2 18-25

192
193
194

Effect by Age: AGE3 26-34

Number of Individuals with Effectuated Enrollment in QHP
by Age Group
Effect by Age: AGE4 35-44
Calculate Covered Lives
Effect by Age: AGE5 45-54

195

Effect by Age: AGE6 55-64

196

Effect by Age: AGE7 >=65

197

Effect by Gender: Male: AGE1<18

198

Effect by Gender and Age: Male: AGE2 18-25

199

Effect by Gender and Age: Male: AGE3 26-34

200

Effect by Gender and Age: Male: AGE4 35-44

201

Effect by Gender and Age: Male: AGE5 45-54

202

Effect by Gender and Age: Male: AGE6 55-64

203

Number of Individuals with Effectuated Enrollment in QHP Effect by Gender and Age: Male: AGE7 >=65
by Gender and Age Group
Effect by Gender and Age: Female: AGE1<18
Calculate Covered Lives

204
205

Effect by Gender and Age: Female: AGE2 18-25

206

Effect by Gender and Age: Female: AGE3 26-34

207

Effect by Gender and Age: Female: AGE4 35-44

208

Effect by Gender and Age: Female: AGE5 45-54

209

Effect by Gender and Age: Female: AGE6 55-64

210

Effect by Gender and Age: Female: AGE7 ≥65

211

Effect by Level: Catastrophic

212
213
214

Effect by Level: Bronze

Number of Individuals with Effectuated Enrollment in QHP
by Metal Level
Effect by Level: Silver
Calculate Covered Lives
Effect by Level: Gold

215

Effect by Level: Platinum

216

Effect by Age and Metal Level: AGE1<18: Catastrophic

217

Effect by Age and Metal Level: AGE1<18: Bronze

218

Effect by Age and Metal Level: AGE1<18: Silver

219

Effect by Age and Metal Level: AGE1<18: Gold

220

Effect by Age and Metal Level: AGE1<18: Platinum

221

Effect by Age and Metal Level: AGE2 18-25: Catastrophic

222

Effect by Age and Metal Level: AGE2 18-25: Bronze

223

Effect by Age and Metal Level: AGE2 18-25: Silver

224

Effect by Age and Metal Level: AGE2 18-25: Gold

225

Effect by Age and Metal Level: AGE2 18-25: Platinum

226

Effect by Age and Metal Level: AGE3 26-34: Catastrophic

227

Effect by Age and Metal Level: AGE3 26-34: Bronze

228

Effect by Age and Metal Level: AGE3 26-34: Silver

229

Effect by Age and Metal Level: AGE3 26-34: Gold

230

Effect by Age and Metal Level: AGE3 26-34: Platinum

231

Effect by Age and Metal Level: AGE4 35-44: Catastrophic

232
233
234

Number of Individuals with Effectuated Enrollment in a
QHP by Age and Metal Level
Calculate Covered Lives

Effect by Age and Metal Level: AGE4 35-44: Bronze
Effect by Age and Metal Level: AGE4 35-44: Silver
Effect by Age and Metal Level: AGE4 35-44: Gold

Special Enrollment Period (SEP):
2014 Coverage
(Applies only to 11/15/201412/31/2014, NOT Including
Stand-alone Dental Plans)

Enrollment: 2015 Coverage
(Not Including Stand-alone
Dental Plans)

Enrollment:
Stand-alone Dental Plans:
2015 Coverage

Indicator
Number

Category

Measure

Indicator for Cell

235

Effect by Age and Metal Level: AGE4 35-44: Platinum

236

Effect by Age and Metal Level: AGE5 45-54: Catastrophic

237

Effect by Age and Metal Level: AGE5 45-54: Bronze

238

Effect by Age and Metal Level: AGE5 45-54: Silver

239

Effect by Age and Metal Level: AGE5 45-54: Gold

240

Effect by Age and Metal Level: AGE5 45-54: Platinum

241

Effect by Age and Metal Level: AGE6 55-64: Catastrophic

242

Effect by Age and Metal Level: AGE6 55-64: Bronze

243

Effect by Age and Metal Level: AGE6 55-64: Silver

244

Effect by Age and Metal Level: AGE6 55-64: Gold

245

Effect by Age and Metal Level: AGE6 55-64: Platinum

246

Effect by Age and Metal Level: AGE7 >=65: Catastrophic

247

Effect by Age and Metal Level: AGE7 >=65: Bronze

248

Effect by Age and Metal Level: AGE7 >=65: Silver

249

Effect by Age and Metal Level: AGE7 >=65: Gold

250

Effect by Age and Metal Level: AGE7 >=65: Platinum

251

Effect by FA and Metal Level: Enrolled without FA: Catastrophic

252

Effect by FA and Metal Level: Enrolled without FA: Bronze

253

Effect by FA and Metal Level: Enrolled without FA: Silver

254

Effect by FA and Metal Level: Enrolled without FA: Gold

Number of Individuals with Effectuated Enrollment in QHP Effect by FA and Metal Level: Enrolled without FA: Platinum
by FA (Without FA, With FA) by Metal Level
Effect by FA and Metal Level: Enrolled with FA: Catastrophic
Calculate Covered Lives

255
256
257

Effect by FA and Metal Level: Enrolled with FA: Bronze

258

Efffect by FA and Metal Level: Enrolled with FA: Silver

259

Effect by FA and Metal Level: Enrolled with FA: Gold

260

Effect by FA and Metal Level: Enrolled with FA: Platinum

261

Effect with FA by FPL: FA and FPL1

262

Effect with FA by FPL: FA and FPL2

263

Effect with FA and FPL: FA and FPL3

264

Effect with FA by FPL: FA and FPL4

Number of Individuals with FA Effect Enrolled in a QHP by
FPL (Among Individuals Receiving FA)
Effect with FA by FPL: FA and FPL5
Calculate Covered Lives

265
266

Effect with FA by FPL: FA and FPL6

267

Effect with FA by FPL: FA and FPL7

268

Effect with FA by FPL: FA and FPL8

269

Effect with FA and FPL: FA and FPL9 (unknown)

270

SHOP

271

SHOP: Employers Appl: Total

Number of SHOP Participating Employers (Effectuated
Enrollment) Calculate cumulative since January 1, 2015.

SHOP: Employers Effect: Total

Average Number of SHOP Employees per Participating
Employer (Effectuated Enrollment) Calculate cumulative SHOP: Ave Enrolled Employees in Empl Gr
since January 1, 2015.
Average Employer Premium Contribution Percent
(Effectuated Enrollment) Calculate cumulative since January SHOP: Ave Percent Empl Contrib
1, 2015.
Number of Employees (covered lives, including dependents)
Enrolled through SHOP (Effectuated Enrollment) Calculate SHOP: Enrolled Employees: Total
cumulative since January 1, 2015.

272

273

274
275

Number of Employers who completed an application
through SHOP

Operations

Call Center Volume

276

Call Center Wait Time (in seconds)

277

Call Center Abandonment Rate

278

Average Call Handle Time (in seconds)

279

Number of Mail/Written Correspondence Received

280

Number of Website Visits

281

Number of Website Unique Visitors

282

Number of Website Page Views

283
284

Call Ctr: Total Calls
Call Ctr: Ave Wait Time
Call Ctr: Aband Rate
Call Ctr: Ave Handle Time
Written+Fax: Total
Website: Visits: Total
Website: Visitors: Total
Website: Views:Total

Number of Trained/Certified Assistors Calculate cumulative
Train+Cert Assist: Total
since November, 2014.
Website Time Offline (in seconds)

Website Offline: Total Time

Special Enrollment Period (SEP):
2014 Coverage
(Applies only to 11/15/201412/31/2014, NOT Including
Stand-alone Dental Plans)

Enrollment: 2015 Coverage
(Not Including Stand-alone
Dental Plans)

Enrollment:
Stand-alone Dental Plans:
2015 Coverage

Glossary of Data Elements for Weekly and Other Marketplace Metrics Reported by States
Category

Data Coding

Initial Applications-Application level
Individual Market Only

Measure/Indicator

Definition / Clarification

Applies to any numeric indicator

If no data match the restrictions of a particular data element, enter "-777". If the data are believed to be reportable in the
future, but are not reportable at the time that the data are submitted, enter "-888" to indicate the data are not available. If it is
not possible to report a data element because of the way the marketplace is operated, enter "-999" to indicate the data
elements are not applicable.

Initiated Electronic Applications
Number of Applications Completed, by
Electronic and Paper

Eligible for enrollment into a QHP

An initiated application submitted via electronic channels includes applications where data is provided through the web portal
by the applicant or inputted into the system electronically by call center staff or other assisters. The applicant must have a
registered account, started the application, and provided enough information to hit "save."
A completed application is defined as an application that was submitted during the reference period with sufficient
information to begin processing eligibility for any type of coverage (QHP or Medicaid/CHIP). For electronic applications, these
applications where the applicant has ‘hit submit’ and the application is accepted for further processing.
An individual is QHP Eligible if s/he submitted a completed application (or had a complete application submitted on their
behalf) and the SBM has deemed the individual eligible for QHP enrollment (either provisional or final eligibility) during the
reference period. These individuals may or may not have enrolled in coverage (meaning picked a QHP or paid the first
premium) by the end of the reference period.
• Individuals deemed eligible for Medicaid or CHIP are not considered QHP Eligible.

Unit/population of interest includes all of the following:
• Individuals deemed ineligible for QHP coverage with financial assistance (APTC and/or CSR)
• Individuals that requested their application not be considered for financial assistance
Determined Eligible QHP
Eligible
without
Financial
Assistance
(FA)
• Individuals deemed eligible for QHP coverage with financial assistance (APTC and/or CSR) but did not select financial
/ Assessed Eligible
assistance.
Medicaid/CHIP
Individuals that do not fall into "Total Eligible with FA: APTC only" or "Total Eligible with FA: APTCs+CSRs" should be counted in
Individual Market Only
"Eligible without FA"
Eligible with FA: APTC Only: Total
Number of individuals determined eligible for enrollment to a QHP with only an APTC
Eligible with APTCs + CSRs: Total
Number of individuals determined eligible for enrollment to a QHP with both an APTC and CSR
Eligib assessment: Medicaid
For SBMs with integrated eligibility systems: report the number of individuals assessed for Medicaid or CHIP eligibility based
on Medicaid MAGI during the reference period. This data element includes all Medicaid MAGI assessments, whether the
Eligib assessment: CHIP
individuals are found to be eligible or ineligible.
Eligib assessment: Medicaid + CHIP
Number of Individuals enrolled in QHP

Number of individuals Selecting a 2015
QHP Who Were Not Enrolled in a 2014
Marketplace Plan (New Enrollment)

If a state does not break out Medicaid or CHIP, please provide the number of individuals determined eligible for Medicaid or
CHIP in this cell.
Number of individuals that received effective enrollment during the reference period. These individuals were deemed QHP
eligible, selected a QHP and a financial assistance amount (if eligible), and the SBM approved the QHP selection during the
reference period.

Units/population of interest: Individuals enrolled in any 2015 Marketplace QHP who were not enrolled in ANY Marketplace
QHP at any time during the 2014 coverage year. For Stand Alone Dental Plans (SADP): Individuals enrolled in any 2015
Marketplace SADP who were not enrolled in any Marketplace SADP at any time in 2014. Calculate SADP new enrollments and
report separately in SADP column.

Number of individuals Selecting a 2015
QHP Who Were Enrolled in a 2014
Marketplace Plan (Re-Enrollments)

Units/population of interest: Individuals enrolled in any 2015 Marketplace QHP who were enrolled in a Marketplace QHP at
some point during the 2014 coverage year (regardless of current status of the 2014 policy). For Stand Alone Dental Plans
(SADP): Individuals enrolled in any 2015 Marketplace SADP who were enrolled in a Marketplace SADP at some point in 2014
(regardless of current status of 2014 policy). Calculate SADP re-enrollments and report separately in SADP column.

Total Number of Individuals enrolled in a QHP without Financial Assistance (FA)
Enrolled without FA
Individuals that do not fall into "Total Enrolled with FA: APTC only" or "Total Enrolled with FA: APTCs+CSRs" should be counted
in "Enrolled without FA"
Enrolled with FA
Total Number of Individuals Submitting Enrollment in a QHP with APTC only OR with both APTC and CSRs
Total Enrolled with FA: APTC only
Total Number of Individuals Submitting Enrollment in a QHP with APTC only
Total Enrolled with FA: APTCs+CSRs
Total Number of Individuals Submitting Enrollment in a QHP with both APTC and CSR
Unit/population of interest: Individuals enrolled in Individual-only QHPs (excludes individuals enrolled in multi-member/family
Median Individual-Policy QHP Premium policies). Full Premium Before Any Financial Assistance Applied. (All Individual-only QHPs; Include those with and Financial
By Age Group
Assistance.)
Median Individual Premium Before APTC Unit/population of interest: Individuals enrolled in Individual-only QHPs (excludes individuals enrolled in multi-member/family
deducted ($)
policies) and who enroll with APTC. Calculate based on full premium amount, before the APTC is deducted.
Unit/population of interest: Individuals enrolled in Individual-only QHPs (excludes individuals enrolled in multi-member/family
Median Individual Premium After APTC
policies) and who enroll with APTC. Calculate based on the balance of the premium owed, after the APTC is deducted. (Full
Deducted ($)
premium minus APTC.)
Average Per Person Full Premium for Plans
with APTC Individuals Before APTC
Unit/population of interest: All enrolled individuals (= # in Indicator 17). Sum the full premiums of all QHPs before the APTC is
Enrollment Activity
Applied. [Average Individual Premium deducted. Then divide by the number of individuals covered by all QHPs (Indicator 17).
Individual Market Only
Before APTC Deducted ($)] All QHPs
Average Per Person Full premium for Plans
With APTC Individuals, After APTC
Unit/population of interest: All enrolled individuals (= # in Indicator 17). Sum the premiums for all QHP enrollees; after the
Applied. Average Individual Premium APTC is deducted. Then divide by the number of individuals covered by all QHPs (Indicator 17).
After APTC Deducted ($) All QHPs
Average Per Person Full Premium for Plans
Unit/population of interest: Individuals who enroll with an APTC (includes enrollees in multi-enrollee policies). Sum the
With APTC Individuals, Before APTC
premiums of QHPs which are associated with an APTC before the APTC is deducted. Then divide by the number of individuals
Applied. [Average Individual Premium
covered by those plans associated with an APTC (sum of indicators 28 and 29).
Before APTC Deducted ($)]
Average Per Person Premium for Plans
With APTC Individuals, After APTC
Applied. Average Individual Premium
After APTC Deducted ($)

Unit/population of interest: Individuals who enroll with an APTC (includes enrollees multi-enrollee policies). Sum the
premiums of QHPs which are associated with an APTC after the APTC is deducted. Then divide by the number of individuals
covered by those plans associated with an APTC (sum of indicators 28 and 29).

Reflects the average monthly APTC that the tax household selects. The population included are tax households with individuals
Average APTC payment selected, by tax
that received effective enrollment during the reference period, and qualified for APTC, including those who qualify for an APTC
household.
but select $0 .

Please provide data at the application level; if the State can capture only at the individual level, please indicate this. This metric
is intended to capture all recorded types of assistance either with submission of application for QHP enrollment or with
selection of a QHP. Describes whether individuals received assistance with either submission of application for QHP
enrollment or with selection of a QHP. **This does not include insurance agents and brokers.**
1) Any (i.e. at least one type of the assistors list below)
2) None (i.e., no recorded assistance)
Enrollment Using Assistance (Yes/no)

CCIIO recognizes that some assistance is provided but not recorded, and therefore cannot be reported. Also, not all states have
each of these types of assistance. We are not distinguishing between certified and non-certified assistors; they are considered
equivalent for the purposes of this layout. Individuals may have more than one type of assistance.
- Navigator
- In-Person Assistor (IPA)
- Certified Application Counselor (CAC)
- Authorized Representative
- Other (includes Community Health Center and other types of assistance not categorized above)Describes whether individuals
received assistance with either submission of application for QHP enrollment or with selection of a QHP.

Special Enrollment Period: 2014 Coverage

Units/population of interest: Total number of Individuals who enrolled in 2014 QHP after Nov. 15, 2014 for coverage ending on
December 31, 2014. Do not include enrollments in stand-alone dental plans. Record Using Special Enrollment Period Column.

Stand-alone Dental Plans: 2015 Coverage

Units/population of interest: Total number of Individuals who enrolled in a 2015 Stand-Alone Dental Plan. Record Using StandAlone Dental Plan column.

New Columns

Effectuated Enrollment
Individual Market Only

Effectuated enrollment occurs when an individual has submitted an application (or had application submitted on their behalf),
Number of Individuals with Effectuated
was deemed QHP Eligible and selected a QHP, the SBM has approved the QHP selection, and the first premium payment was
Enrollment in QHP
received (either directly by the SBM or by the issuer).

Number of Individuals with Effectuated
Please exclude individuals eligible for APTC but where no APTC is not applied to the premium. Also, please exclude individuals
Enrollment with APTCs only, and APTCs
eligible for CSR, but is not in a plan with CSR.
and CSRs:

Number of Employers who completed an Unit of interest: Report the number of employers who completed an application for a SHOP QHP for coverage beginning in the
2015 coverage year (January 1, 2015 and thereafter).
application through SHOP
Number of SHOP Participating Employers
(Effectuated Enrollment) Calculate
cumulative since January 1, 2015.
Average Number of SHOP Employees per
Participating Employer (Effectuated
Enrollment) Calculate cumulative since
January 1, 2015.
Average Employer Premium Contribution
Percent (Effectuated Enrollment)
Calculate cumulative since January 1,
2015.
Number of Employees (covered lives,
including dependents) Enrolled through
SHOP (Effectuated Enrollment) Calculate
cumulative number of employees that
effectuate coverage beginning on January
1, 2015.
# Enrollment Assisters completing
Marketplace training
# Enrollment Assisters registered and
certified
Total call volume
Average call wait time
(Average speed of answer- ASA)
Average call handle time (AHT)
Operations
Abandonment Rate
Total website page views
Total website visits
Total website unique visitors
# of registered users
Number of Mail/Written Correspondence
Received
Website Time Offline

FPL

Unit of interest: Report the number of employers with at least one employee who has effectuated enrollment in a SHOP QHP
beginning on January 1, 2015.
Calculate the average number of employees who have effectuated coverage in a SHOP QHP for 2015 coverage out of the total
employees on the employee rosters submitted by employers.

Calculate the average percent that all employers participating in SHOP in 2015 are contributing to their employees' premiums.

Unit of interest: Total number of covered lives (including employees and their dependents) across all SHOP QHPs who have
effectuated coverage for the 2015 coverage year.

Number of enrollment assisters who completed Marketplace training during the reference period.
Number of enrollment assisters who were registered and certified during the reference period. Please exclude agents and
brokers.
Number of calls that entered the integrated voice response system during the reference period.
Average length of time for which a call is connected to automated call distribution system before answered (average time a
caller waits in queue before being connected to an agent) during the reference period. Average is for the reporting time
period. Reported in timestamp format (hh:mm:ss).
Average amount of time an agent spends on call. Average is for the reporting time period. Quarterly reporting is a Quarterly
average. Reported in timestamp format (mm:ss).
Count of total number of calls abandoned (numerator)in the queue (Calls that terminate or drop before reaching an agent or
being answered) divided by total call volume (denominator). Carry answer to 2 decimal points.
Count of page views across the whole Marketplace site during the reference period.
Count of unique visits to the marketplace website during the reference period.
Count of unique visitors to the marketplace website during the reference period.
Count of secure accounts established (registered users) during the reference period.
Number of letters or written inquiries received via mail or fax; please exclude correspondence not related to Marketplace
functions, health insurance, or coverage for any insurance affordability program.
Please include only unplanned time offline.
FPL (Federal Poverty Level) is calculated based on the projected, total, annual modified adjusted gross income (MAGI) for the
taxpayer’s family. FPL is based on the same MAGI as the SBM uses to determine eligibility of APTC.
- MAGI includes the sum of the income of the taxpayer and the lawfully present individuals for whom the taxpayer properly
claims a deduction for personal exemption for the taxable year. For additional information see Health Insurance Premium Tax
- To report FPL, MAGI should be compared to the HHS poverty guidelines (current levels found here
http://aspe.hhs.gov/poverty/13poverty.cfm), which is adjusted for the size of the family and state of residence.
- For the purposes of the SBM Supplemental Data Submission, MAGI may or may not be verified. States should report FPL
based on incomes as of the most recent eligibility determination.
- For individuals that do not request an eligibility determination for financial assistance, MAGI may not be available. If MAGI is
unavailable, populate the cell for the number of people with unknown FPL and enter -888 for each FPL category to signal data
unavailable. Entering zero would signify no individuals at that income level.
The breakouts of FPL based on annual household income are:

Data Breakouts

Age

1) <100%
2) ≥100 - ≤138%
3) >138 - ≤150%
4) >150 - ≤200%
5) >200 - ≤250%
6) >250 - ≤300%
7) >300- ≤400%
8) > 400%
9) Unkown
Age of the individual as of the most recent effective enrollment date.
1. < 18 years

2) 18-25

3) 26-34

4) 35-44

5) 45-54

6) 55-64

7) ≥65
8) Unknown