Eligbility-Processing-Data-Specs-July-2024

Medicaid and Children’s Health Insurance
Program Eligibility Processing Data Report
Specifications
Previously known as, Medicaid and Children’s Health Insurance Program
Eligibility and Enrollment Data Specifications for Reporting During Unwinding
Updated July 2024
Version 4

PRA Disclosure Statement: The Centers for Medicare & Medicaid Services (CMS) is collecting this mandatory report under the authority in
sections 1902(a)(4)(A), 1902(a)(6) and 1902(a)(75) of the Act and at 42 CFR § 431.16 to ensure proper and efficient administration of the
Medicaid program and section 2101(a) of the Act to promote the administration of the Children's Health Insurance Program (CHIP) in an
effective and efficient manner. This reported information will be used to assess the state's plans for processing renewals when states begin
restoring routine Medicaid and CHIP operations after the COVID-19 public health emergency ends. Under the Privacy Act of 1974 any
personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no
persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for
this information collection is 0938-1148 (CMS-10398 #66). The time required to complete this information collection is estimated to average 817 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Table of Contents
I.

Introduction ............................................................................................................................ 1
A. What’s new? ...................................................................................................................... 1
B. About the submission ........................................................................................................ 1
1. How frequently and when will the data be reported? .................................................. 1
2. How will the data be submitted? ................................................................................. 1
3. Can the data reported be changed after it has been submitted? ................................ 1
4. How can questions about data be answered? ............................................................ 1

II.

Data Specifications: Monthly Report ...................................................................................... 2
A. Monthly Report Metric Specifications ................................................................................ 2
1. Monthly Report Metrics 1-3: Application Processing .................................................. 2
2. Monthly Report Metric 4: Renewals Initiated .............................................................. 6
3. Monthly Report Metrics 5-7: Renewals and Outcomes............................................... 6
4. Monthly Report Metric 8: Medicaid Fair Hearings ..................................................... 11

III. Reporting Outcomes of Previously Pending Renewals ....................................................... 12
A. Introduction ...................................................................................................................... 12
B. Reporting Schedule ......................................................................................................... 12
C. Specifications for Reporting Outcomes of Previously Pending Renewals ...................... 12
1. What data are updated? ........................................................................................... 12
2. What do the updated data include and exclude? ...................................................... 14
3. Can states make corrections when submitting the pending renewal data? .............. 14
D. Frequently Asked Questions ........................................................................................... 14
IV. Change Log ........................................................................................................................... 16

Tables
Table 1: Summary of Monthly Period Reporting Specifications .................................................... 2
Table 2: Monthly Metrics 1, 1a, and 1b ......................................................................................... 3
Table 3: Monthly Metrics 2, 2a, and 2b ......................................................................................... 4
Table 4: Monthly Metrics 3, 3a, and 3b ......................................................................................... 5
Table 5: Monthly Metric 4 .............................................................................................................. 6
Table 6: Monthly Metrics 5, 5a, 5a(1), 5a(2), 5b, 5c, and 5d ........................................................ 7
Table 7: Monthly Metric 6 .............................................................................................................. 9
Table 8: Monthly Metric 7 .............................................................................................................. 9
Table 9: Monthly Metric 8 ............................................................................................................ 11
Table 10: Sample Timeline for Updating and Submitting Monthly Reports with Outcomes
of Previously Pending Renewals ......................................................................................... 12
Table 11: Illustrative Example on How to Update Prior Monthly Reports with Outcomes
of Previously Pending Renewals ......................................................................................... 13
Table 12: Change Log ................................................................................................................ 16

I. Introduction
A. What’s new?
This version of the Medicaid and Children’s Health Insurance Program Eligibility Processing Data Report
Specifications includes the following updates:
1. Removes the section pertaining to the Unwinding Baseline Report as states no longer update this
report for CMS.
2. Updates Section III, Reporting the Outcomes of Previously Pending Renewals, to account for ongoing
data reporting.
3. Makes non-substantive updates throughout the document to remove references to unwinding.
For additional details on the specific changes, please see Section IV for the Change Log.

B. About the submission
1. How frequently and when will the data be reported?
States submit monthly reports to CMS. The monthly report, as specified in section II, is due by the 8th
calendar day of each month. The updates to previously pending renewals, as specified in section III, is
due by the 15th calendar day of each month. Should the 8th or 15th calendar day fall on a weekend or
holiday, states may submit by the next business day.
2. How will the data be submitted?
These reports are submitted to CMS using the same portal in which states enter their Performance
Indicator (PI) data (https://sdis.medicaid.gov/user/login). This portal is set up to accept submissions from
those with PI submission credentials.
3. Can the data reported be changed after it has been submitted?
States may make corrections using the same link at which the data was originally submitted. In cases
where states are making corrections to their data, CMS requests that states provide information about the
reason for the change in the notes section of the metric to support CMS review and interpretation of the
data.
States should report on renewals initiated (metric 4) and each renewal disposition (metric 5 and its
submetrics) as of the last day of the reporting period. For example, the data included in the June 2024
report should only include renewals initiated in June 2024 and renewal outcomes as of June 30, 2024 for
those renewals due in June 2024. States should not make corrections to reflect work completed after the
last day of the month of the reporting period except as noted in section III.
4. How can questions about data be answered?
We realize that states may have questions or need help as they review the metrics in the reports and
reporting specifications.
•

States can access help at any time by emailing UnwindingMetricsTA@mathematica-mpr.com.

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II. Data Specifications: Monthly Report
This chapter provides detailed instructions on how to complete the Monthly Report. Table 1 summarizes
key details about monthly reporting. Step-by-step descriptions of each of the metrics, and how to compute
them, are found below.
Table 1: Summary of Monthly Period Reporting Specifications
What is the monthly
report?

The monthly report contains data on pending and completed applications and renewals
and pending fair hearings.
States report Medicaid and CHIP data in this report. 1 Data will not be reported
separately by program.

How do I submit it?

States log on to https://sdis.medicaid.gov/user/login.

When is it due?

By the 8th calendar day of the month following the reporting period. Should the 8th
calendar day fall on a weekend or holiday, states may submit by the next business day.

What if, after
submission, I need to
change or update data
previously reported?

States update the monthly report at the same link, https://sdis.medicaid.gov/user/login,
if they later discover they made a mistake, or if they did not have all of the data they
needed to complete the form when it was initially submitted.

What if I have
questions not
answered in these
instructions?

If the state has questions while completing the monthly report, please email the
technical assistance help desk at UnwindingMetricsTA@mathematica-mpr.com.

A. Monthly Report Metric Specifications
The monthly report begins with asking states to submit one key piece of information:
•

Submission Date. This field will be auto populated with the current date, in the format
MM/DD/YYYY. It is due by the 8th day of the month following the reporting period. Should the 8th
calendar day fall on a weekend or holiday, states may submit by the next business day.

1. Monthly Report Metrics 1-3: Application Processing
States report Monthly Report Metrics 1-3 and submetrics only until all pending applications that were
received between March 1, 2020, and the end of the month prior to the state’s unwinding period are
processed. Once a state has completed and reported the processing of all pending applications as 0 to
CMS, the fields may be left blank in future submissions.
Additionally, in the monthly reports, states will report on number of applications completed and those that
remain pending as of the last day in the reporting period covered by the report. Tables 2-4 provide
instructions for how to report these metrics.

Note that Monthly Metric 8, Medicaid Fair Hearings, will only include data on Medicaid fair hearings and not
separate CHIP reviews.

1

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Table 2: Monthly Metrics 1, 1a, and 1b

Metric 1: Total pending applications received between March 1, 2020 and the end of the month prior to the
state’s unwinding period
• This metric includes:
− All applications received by the Medicaid and CHIP state agency between March 1,
2020 and the end of the month prior to the state’s unwinding period for which a final
eligibility determination has not been made. This includes applications received
directly by the state and accounts transferred from the Federally-Facilitated
Marketplace or a State-Based Marketplace.
− All applications received during the timeframe outlined above should be counted,
How is the metric
regardless of the modality used for submission as described at 42 C.F.R. §435.907
defined?
(e.g., online, by phone, by mail, or in person).
• This metric is the sum of metrics 1a and 1b.
• This metric is a restatement of metric 1 in the baseline report. If a state identifies
pending applications that were previously unaccounted for in the baseline report, that
state should include those in this metric.
• This metric can be reported at the individual or household level as long as reporting is
consistent across application processing metrics and reporting periods.
•
Applications that were received and completed (i.e., a final eligibility determination was
What is excluded
made) before the state begins its unwinding period.
from this metric?
• Applications received during the unwinding period.
What is included in • If a state has any additional context that impacts the data that they feel CMS should be
aware of, they should use the free text field to report that information in narrative format
the Metric 1 Notes
for metrics 1, 1a, or 1b.
field?
• If a state reports the application processing metrics at the household level, please note
that in the free-text field so that CMS is aware.
• This field should be left blank if the state has nothing additional to report.
Metric 1a: Total MAGI and other non-disability applications
• This metric includes:
How is the metric
− All MAGI and other non-disability related applications (e.g., individuals determined on
defined?
the basis of being age 65 or older) received by the Medicaid and CHIP state agency
between March 1, 2020 and the end of the month prior to the state’s unwinding
period for which a final eligibility determination has not been made. This includes
applications received directly by the state and accounts transferred from the
Federally Facilitated Marketplace or a State-Based Marketplace.
o All MAGI and other non-disability related applications received during the
timeframe outlined above should be counted, regardless of the modality used for
submission as described at 42 C.F.R. §435.907 (e.g., online, by phone, by mail, or
in person).
• This metric is a subset of metric 1.
• This metric can be reported at the individual or household level and should correspond
to how the state reported metric 1.
•
Applications for individuals seeking coverage on a MAGI or other non-disability related
What is excluded
basis that were received and completed (i.e., a final eligibility determination was made)
from this metric?
before the state begins its unwinding period.
• Applications received during the unwinding period.

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Metric 1b: Total disability-related applications
• This metric includes:
How is the metric
− All disability-related applications received by the Medicaid and CHIP state agency
defined?
between March 1, 2020 and the end of the month prior to the state’s unwinding
period for which a final eligibility determination has not been made. This includes
applications received directly by the state and accounts transferred from the
Federally Facilitated Marketplace or a State-Based Marketplace.
o All disability-related applications received during the timeframe outlined above
should be counted, regardless of the modality used for submission as described at
42 C.F.R. §435.907 (e.g., online, by phone, by mail, or in person). A disabilityrelated application is an application for which the state must make a determination
of disability to determine the applicant’s eligibility. Disability-related applications
are subject to the 90-day timeliness standard at 42 CFR § 435.912(c)(3)(i).
• This metric is a subset of metric 1.
• This metric can be reported at the individual or household level and should correspond
to how the state reported metric 1.
• Applications for individuals seeking coverage on a disability related basis that were
What is excluded
received and completed (i.e., a final eligibility determination was made) before the state
from this metric?
begins its unwinding period.
• Applications received during the unwinding period.

Table 3: Monthly Metrics 2, 2a, and 2b

Metric 2: Of those applications included in Monthly Metric 1, the total number of applications completed as
of the last day of the reporting period
• This is defined as the cumulative number of applications counted in Monthly Metric 1
How is the metric
that have been completed as of the last day in the reporting period covered by this
defined?
report.
• A completed application is one in which a final eligibility determination has been made.
• This metric is the sum of metrics 2a and 2b.
• This metric can be reported at the individual or household level, as long as reporting is
consistent across application processing metrics and reporting periods.
Applications that have not been completed by the last day of the reporting period covered
What is excluded
by this report.
from this metric?
• If a state has any additional context that impacts the data that they feel CMS should be
aware of, they should use the free text field to report that information in narrative format
for metrics 2, 2a, or 2b.
• If a state reports the application processing metrics at the household level, please note
that in the free-text field so that CMS is aware.
• This field should be left blank if the state has nothing additional to report.
Metric 2a: Completed MAGI and other non-disability related applications as of the last day of the reporting
period
• This is defined as the cumulative number of MAGI and other non-disability related
How is the metric
applications (e.g., individuals determined on the basis of being age 65 or older) counted
defined?
in Monthly Metric 1a that have been completed as of the last day in the reporting period
covered by this report.
• A completed application is one in which a final eligibility determination has been made
and the state has either enrolled an eligible applicant or denied coverage for an
individual the agency could not determine to be eligible as of the last day of the
reporting period.
• This metric is a subset of metric 2.
• This metric can be reported at the individual or household level and should correspond
to how the state reported metric 2.
What is excluded
Applications that have not been completed by the last day of the reporting period covered
by this report.
from this metric?
What is included in
the Metric 2 Notes
field?

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Metric 2b: Completed disability-related applications as of the last day of the reporting period
• This is defined as the cumulative number of disability-related applications counted in
How is the metric
Monthly Metric 1b that have been completed as of the last day in the reporting period
defined?
covered by this report. A disability-related application is an application for which the
state must make a determination of disability to determine the applicant’s eligibility.
Disability-related applications are subject to the 90-day timeliness standard at 42 CFR §
435.912(c)(3)(i).
• A completed application is one in which a final eligibility determination has been made
and the state has either enrolled an eligible applicant or denied coverage for an
individual the agency could not determine to be eligible as of the last day of the
reporting period.
• This metric is a subset of metric 2.
• This metric can be reported at the individual or household level and should correspond
to how the state reported metric 2.
What is excluded
Applications that have not been completed by the last day of the reporting period covered
by this report.
from this metric?

Table 4: Monthly Metrics 3, 3a, and 3b

Metric 3: Of those applications included in Monthly Metric 1, the total number of applications that remain
pending as of the last day of the reporting period
• This is defined as the cumulative number of applications included in Monthly Metric 1
How is the metric
for which a final eligibility determination has not been made as of the last day of the
defined?
reporting period. It represents the remaining balance of applications that remain pending
at the end of the reporting period.
• This metric is the sum of metrics 3a and 3b.
• This metric can be reported at the individual of household level as long as reporting is
consistent across application processing metrics and reporting periods.
• Once the state has reached a final determination for all pending applications (reported
in Monthly Metric 1), states should populate “0” for this metric because no applications
remain pending. After a state has completed the processing of all pending applications,
no further reporting of application metrics (Monthly Metrics 1, 2 and 3 and submetrics) is
required.
Applications completed as of the last day of the reporting period.
What is excluded
from this metric?
• If a state has any additional context that impacts the data that they feel CMS should be
What do states
aware of, they should use the free text field to report that information in narrative format
include in the
for metrics 3, 3a, or 3b.
Metric 3 Notes
•
If a state reports the application processing metrics at the household level, please note
field?
that in the free-text field so that CMS is aware.
• This field should be left blank if the state has nothing additional to report.
Metric 3a: Pending MAGI and other non-disability applications as of the last day of the reporting period
• This is defined as the cumulative number of MAGI and non-disability related
How is the metric
applications (e.g., individuals determined on the basis of being age 65 or older) included
defined?
in Monthly Metric 1a for which a final eligibility determination has not been made as of
the last day of the reporting period. It represents the remaining balance of MAGI and
non-disability related applications that remain pending at the end of the reporting period.
• This metric is a subset of metric 3.
• This metric can be reported at the individual or household level and should correspond
to how the state reported metric 3.
What is excluded
MAGI and non-disability related applications completed as of the last day of the reporting
period.
from this metric?

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Metric 3b: Pending disability-related applications as of the last day of the reporting period
• This is defined as the cumulative number of disability-related applications counted in
How is the metric
Monthly Metric 1b for which a final eligibility determination has not been made as of the
defined?
last day of the reporting period. It represents the remaining balance of disability-related
applications that remain pending at the end of the reporting period. A disability-related
application is an application for which the state must make a determination of disability
to determine the applicant’s eligibility. Disability-related applications are subject to the
90-day timeliness standard at 42 CFR § 435.912(c)(3)(i).
• This metric is a subset of metric 3.
• This metric can be reported at the individual or household level and should correspond
to how the state reported Metric 3.
What is excluded
Disability-related applications completed as of the last day of the reporting period.
from this metric?

2. Monthly Report Metric 4: Renewals Initiated
States report on the number of renewals initiated in the monthly reports. Table 5 provides instructions for
how to report this metric.
Table 5: Monthly Metric 4

Metric 4: Total beneficiaries for whom a renewal was initiated in the reporting period
• This is defined as the total number of beneficiaries, including those receiving full or
How is the metric
limited benefits, with a renewal that was initiated between the first and last day of the
defined?
reporting period.
• A renewal is considered “initiated” when a state first begins the ex parte process, which
is typically when a state begins to check reliable data sources and other available
information to renew eligibility based on such reliable and available information.
• If a state has a mitigation in place to address ex parte renewals, a renewal is initiated
based on how the state begins the renewal process under such mitigation (typically
when a form is sent). Regardless of how a state expects the renewal process to end,
states report in this metric all beneficiaries for whom the state began the renewal
process in the reporting period.
• This metric is not cumulative and only includes data on renewals initiated in the
reporting period.
• This metric must be reported at the individual level, not the household level.
Renewals that were not initiated in the reporting period.
What is excluded
from this metric?
If a state has any additional context that impacts the data that they feel CMS should be
What do states
aware of, they should use the free text field to report that information in narrative format.
include in the
Metric 4 Notes
field?

3. Monthly Report Metrics 5-7: Renewals and Outcomes
States report on the number of beneficiaries due for renewal and the final disposition of renewals in the
monthly reports. Tables 6-9 provide instructions for how to report these metrics.

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Table 6: Monthly Metrics 5, 5a, 5a(1), 5a(2), 5b, 5c, and 5d

Metric 5: Total beneficiaries due for a renewal in the reporting period
• This is defined as the total number of beneficiaries, including those receiving full or
How is the metric
limited benefits, with a renewal due, or scheduled for completion, in the reporting period.
defined?
A renewal is considered due in the month that aligns with the last day of coverage for a
cohort (regardless of when the renewal is initiated), not the first date that bulk
terminations are effective.
− For example, a beneficiary who is determined ineligible and whose last day of
coverage is June 30, 2024 is considered to have a renewal due in the June reporting
period.
• This metric is not cumulative and should only include data on renewals due in the
reporting period, representing beneficiaries whose renewal processes were initiated in a
prior month, based on the state’s renewal policy. In this context, which renewals are
“due” relate to the state’s timeline for the renewal process. For example, if a state
initiated a batch of renewals on March 15th and has a timeline of 75 days for the
renewal process, CMS considers that batch of renewals “due” at the end of May.
• Note: When a state has no renewals due in a reporting period, the state may report “0”
and include a data note.
• This metric is the sum of metrics 5a, 5b, 5c, and 5d.
• This metric must be reported at the individual level, not household.
Renewals that have been initiated but are not due in the reporting period and renewals that
What is excluded
have not been initiated.
from this metric?
If a state has any additional context that impacts the data that they feel CMS should be
What do states
aware of, they should use the free text field to report that information in narrative format.
include in the
Metric 5 Notes
field?
Metric 5a: Of the beneficiaries included in Metric 5, the number renewed and retained in Medicaid or CHIP
(those who remained enrolled)
• This is defined as the total number of beneficiaries, including those receiving full or
How is the metric
limited benefits, whose renewal was due in the reporting period who were renewed and
defined?
retained in Medicaid or CHIP at the end of the reporting period.
• This metric is not cumulative and should only include those beneficiaries renewed
and retained in the reporting period.
• This metric is a subset of metric 5.
• This metric is the sum of metrics 5a(1) and 5a(2).
• This metric must be reported at the individual level, not household.
What is excluded
Any beneficiary whose renewal was due in the reporting period but their eligibility was not
retained in Medicaid or CHIP at the end of the reporting period.
from this metric?

What do states
If a state has any additional context that impacts the data that they feel CMS should be
include in the
aware of, they should use the free text field to report that information in narrative format for
Metric 5a Notes
metrics 5a, 5a(1), or 5a(2).
free text field?
Metric 5a(1): Number of beneficiaries renewed on an ex parte 2 basis
• This is defined as the total number of beneficiaries, including those receiving full or
How is the metric
limited benefits, whose renewal was due in the reporting period who were renewed and
defined?
retained in Medicaid or CHIP in the reporting period on an ex parte basis, meaning
eligibility was redetermined based on information available to the agency without
requiring additional information from the individual.
• This metric is not cumulative; states only report on those beneficiaries that were
renewed on an ex parte basis in the reporting period.
• This metric is a subset of metric 5a.
• This metric must be reported at the individual level, not household.
What is excluded
Any beneficiary not renewed through ex parte processes whose renewal was due in the
reporting period.
from this metric?

An ex parte renewal is sometimes referred to as auto renewal, passive renewal, or administrative renewal and is
described at 42 CFR 435.916).

2

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Metric 5a(2): Number of beneficiaries renewed using a renewal form
• This is defined as the total number of beneficiaries, including those receiving full or
How is the metric
limited benefits, whose renewal was due in the reporting period who were renewed and
defined?
retained in Medicaid or CHIP in the reporting period using a renewal form.
• Some states have an approved mitigation to check and use data sources to renew
coverage if they are able to do so after a beneficiary was sent a renewal form,
regardless of whether the form was returned. This is referred to as a “back-end ex parte
renewal.” States include any individuals who were renewed with this mitigation strategy
in this metric.
• This metric is not cumulative; states only report on those beneficiaries that were
renewed using a renewal form in the reporting period.
• This metric is a subset of metric 5a.
• This metric must be reported at the individual level, not household.
What is excluded
Any beneficiary not renewed through use of a form in the reporting period.
from this metric?
Metric 5b: Of the beneficiaries included in Metric 5, the number determined ineligible for Medicaid or CHIP
• This is defined as the total number of beneficiaries, including those receiving full or
How is the metric
limited benefits, whose renewal was due in the reporting period and who were
defined?
determined ineligible for Medicaid or CHIP. This includes all individuals for whom the
state has sufficient information to make a determination of ineligibility.
• This metric is not cumulative and only includes data on beneficiaries determined
ineligible for Medicaid or CHIP in the reporting period.
• Individuals who request voluntary termination or closure after their renewal is initiated
should be counted in this metric. Individuals the state verifies as being deceased or no
longer a state resident during the renewal process are also counted in this metric.
• This metric is a subset of metric 5.
• This metric must be reported at the individual level, not household.
Any beneficiary who remained eligible for Medicaid or CHIP coverage, any beneficiary the
What is excluded
state redetermines as ineligible based on a change in circumstances in between regular
from this metric?
renewals, and any beneficiary who requested voluntary closure prior to the initiation of their
renewal.
What do states
include in the
If a state has any additional context that impacts the data that they feel CMS should be
aware of, they should use the free text field to report that information in narrative format.
Metric 5b Notes
field?
Metric 5c: Of the beneficiaries included in Metric 5, the number terminated for procedural reasons (i.e.,
failure to respond)
• This is defined as the total number of beneficiaries, including those receiving full or
How is the metric
limited benefits, whose renewal was due in the reporting period and whose coverage
defined?
ended because the state has insufficient information to complete an eligibility
determination, also known as procedural reasons.
• Procedural reasons include instances where a beneficiary fails to return the renewal
form or other information necessary to complete a Medicaid or CHIP renewal.
• This metric is not cumulative and only includes data on beneficiaries whose renewal
is due and were terminated from Medicaid or CHIP for procedural reasons in the
reporting period.
• This metric is a subset of metric 5.
• This metric must be reported at the individual level, not household.
• Any beneficiary who was not terminated for procedural reasons in the reporting period,
What is excluded
which includes:
from this metric?
− (1) any beneficiary who the state determined ineligible, or verified at renewal as
deceased or no longer a state resident;
− (2) any beneficiary who was terminated for failure to respond to a request for
information related to a change in circumstances in between regular renewals; and
− (3) any beneficiary the state would have terminated for a procedural reason, except
the termination was not effectuated because of a state’s mitigation plan or adoption of
strategies that allow the state to hold procedural terminations.

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What do states
include in the
If a state has any additional context that impacts the data that they feel CMS should be
aware of, they should use the free text field to report that information in narrative format.
Metric 5c Notes
field?
Metric 5d: Of the beneficiaries included in Metric 5, the number whose renewal was not completed
• This is defined as the total number of beneficiaries, including those receiving full or
How is the metric
limited benefits, whose renewals were due in the reporting period but were not
defined?
completed by the end of the reporting period. In other words, a final eligibility
determination had not been made as of the end of the reporting period.
• This metric is also known as “pending renewals.”
• If the state is holding procedural terminations in a particular month(s), the state should
include the beneficiaries whose renewal was due but who are not being procedurally
terminated during the reporting period in this metric.
• Individuals who were sent advance notice of termination for failure to return their
renewal form but return their renewal form before their coverage is terminated should
also be reported in this metric.
• This metric is not cumulative and only includes data on incomplete renewals,
including those for whom procedural terminations were held, that were due in the
reporting period.
• This metric is a subset of metric 5.
• This metric must be reported at the individual level, not household.
• Any beneficiary whose renewal was completed.
What is excluded
• Any beneficiary the state has not initiated a renewal regardless of the month the
from this metric?
individual’s renewal is due.
• If a state has any additional context that impacts the data that they feel CMS should be
What do states
aware of, they should use the free text field to report that information in narrative format.
include in the
•
If the state is holding procedural terminations, please include a note for the relevant
Metric 5d Notes?
month and, if possible, include the number of affected individuals.

Table 7: Monthly Metric 6

Metric 6: Month in which renewals due in the reporting period were initiated
States expand a drop-down menu and select the month in which the renewals that were
How is the metric
due in the reporting period covered by the report were initiated; this should be based on
defined?
the state’s timeline for the renewal process.
• If a state initiates a cohort due in a particular month across multiple months, please
What do states
include those months in the notes. The portal only permits states to select a single
include in the
month via the drop-down, however, states can add additional months in the notes.
Metric 6 Notes?
• If a state has any additional context that impacts the data that they feel CMS should be
aware of, they should use the free text field to report that information in narrative format.

Table 8: Monthly Metric 7

Metric 7: Number of beneficiaries initiated and due for a renewal whose renewal has not yet been
completed
• This is defined as the total number of beneficiaries, including those receiving full or
How is the metric
limited benefits, due for renewal whose renewal has been initiated but not been fully
defined?
processed. This is commonly referred to as the “renewal backlog,” representing all
renewals that have been initiated and scheduled for completion, but are not complete as
of the end of the reporting period.
• States that are holding procedural terminations should report the beneficiaries whose
renewal was due but for whom the state is holding the procedural termination in this
metric until these renewals reach a final disposition.
• This metric is cumulative; it counts all renewals that have been initiated to date and
were due prior to or as of the last day of the reporting period covered by this report (per
the state’s timeline for the renewal process), but whose renewals were not fully
processed as of the last day in the reporting period.
• States should be cautious of simply adding the numbers previously reported in 5d, as
doing so would not reflect renewals that may have been completed after the month in
which it was due.
• This metric must be reported at the individual level, not household.

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What is excluded
from this metric?

All renewals that have been completed, and any renewals the state has not initiated,
regardless of when the renewal is due.

What do states
include in the
Metric 7 Notes
field?

• If a state has any additional context that impacts the data that they feel CMS should be
aware of, they should use the free text field to report that information in narrative format.
• If the state is holding procedural terminations, please include a note for the relevant
month and if possible, include the number of affected individuals.

Page 10 of 16

4. Monthly Report Metric 8: Medicaid Fair Hearings
States must report Medicaid fair hearings that have been pending more than 90 days at the end of the
reporting period. Table 9 provides instructions for how to report this metric.
Table 9: Monthly Metric 8

Metric 8: Total number of Medicaid fair hearings pending more than 90 days at the end of the reporting
period
• This metric includes:
How is the metric
− All pending fair hearings, including those meeting the criteria for an expedited
defined?
resolution in accordance with 42 C.F.R. § 431.224(a), for which the state has not
taken final administrative action within 90 days of the date the agency received a
request for a fair hearing in accordance with 42 C.F.R. § 431.221(a)(1) as of the end
of the reporting period.
− All pending fair hearings for which the state has not taken action within 90 days from
the date the enrollee filed a managed care organization (MCO), prepaid inpatient
health plan (PIHP), or prepaid ambulatory health plan (PAHP) appeal, not including
the number of days the enrollee took to subsequently file for a State fair hearing.
− This includes Medicaid fair hearing requests received both before and after the end of
the continuous enrollment condition.
− All pending Medicaid fair hearings governed by the rules at 42 CFR part 431 subpart
E, not just fair hearings related to eligibility determinations.
− For states utilizing Medicaid expansion CHIP, all pending fair hearings, including
those meeting the criteria for an expedited resolution in accordance with 42 C.F.R. §
457.1160(a) or 42 C.F.R. § 457.1260(f), for which the state has not taken final
administrative action within 90 days of the date the agency received a request for a
fair hearing in accordance with 42 C.F.R. § 457.1130(a) as of the end of the reporting
period.
•
Fair
hearings for which a final fair hearing decision was issued and a state has taken
What is excluded
final administrative action in accordance with 42 CFR 431.244(f). A final fair hearing
from this metric?
decision may include a dismissal of the fair hearing request.
• Appeals still pending with the managed care plan which have not yet proceeded to a
State fair hearing governed by the rules at 42 CFR part 431 subpart E.
• Separate CHIP review data.
• If a state has any additional context that impacts the data that they feel CMS should be
What do states
aware of, they should use the free text field to report that information in narrative format.
include in the
For example, please specify if the state is not able to report solely Medicaid fair
Metric 8 Notes
hearings data and has included separate CHIP reviews in the reported information.
field?
• If data are available, states may include in the Metric 8 Notes field the number of fair
hearings reported in the total that are pending more than 90 days because the appellant
requested a delay or failed to take a required action (see 42 CFR 431.244(f)(4)(i)(A)).
• This field should be left blank if the state has nothing additional to report.

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III. Reporting Outcomes of Previously Pending Renewals
A. Introduction
States may not always complete renewals by the renewal due date. These renewals are considered
“pending” renewals and are reported in submetric 5d of the monthly renewal report described in Section
II. To understand the disposition of renewals that are initially reported as pending, CMS issued revised
specifications to collect these data. Subsections B and C outline the key details of this reporting.

B. Reporting Schedule
States report the updated monthly report with the outcomes of previously pending renewals by the 15th of
the month in accordance with the sample schedule in Table 10 below.
•

Column 1 represents the original monthly report and Column 2 demonstrates the due date of each
report.

•

Each updated monthly report will contain the dispositions of pending renewals reflected “as of” three
full months following the applicable reporting period, as shown in Column 3.

•

Lastly, Column 4 demonstrates the due date for each updated report. Should the 15th calendar day
fall on a weekend or holiday, states may submit by the next business day.

States submit an updated monthly report consistent with the example timeframes outlined in Table 10.
Table 10: Sample Timeline for Updating and Submitting Monthly Reports with Outcomes of
Previously Pending Renewals
Column 1

Column 2

Column 3

Column 4

Monthly report

Original data report due
date

Updated data report “as
of date” for previously
pending renewals

Updated data report due
to CMS

June (2024)

July 8

September 30

October 15, 2024

July (2024)

August 8

October 31

November 15, 2024

August (2024)

September 8

November 30

December 15, 2024

C. Specifications for Reporting Outcomes of Previously Pending Renewals
1. What data are updated?
For each monthly report, states update the monthly metric 5 and its submetrics (monthly metrics 5a,
5a(1), 5a(2), 5b, 5c, and 5d), as needed, to reflect the outcomes of renewals previously reported as
pending (monthly metric 5d of the original monthly report). As a reminder, metric 5 represents the total
number of beneficiaries due for renewal in the reporting period, and the submetrics (5a, 5a(1), 5a(2), 5b,
5c, and 5d) represent the dispositions of those renewals. The submetrics are as follows:
•

5a, total beneficiaries renewed and retained in Medicaid and CHIP

•

5a(1), total beneficiaries renewed on an ex parte basis

•

5a(2), total beneficiaries renewed using a renewal form

•

5b, total beneficiaries determined ineligible for Medicaid or CHIP

•

5c, total beneficiaries who were terminated for procedural reasons
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•

5d, total beneficiaries whose renewal was not completed (“pending renewals”)

In updating the monthly metrics, states report the dispositions of pending renewals as of the last day of
the third month after the original reporting period. For example, when states update the July 2024
monthly report, states report the status or disposition of previously pending renewals as of October 31,
2024. When states update the August 2024 monthly report, states report the status of previously pending
renewals as of November 30, 2024.
Table 11 below presents an illustrative example of how CMS expects states to update prior monthly
reports to incorporate the outcomes of previously pending renewals.
•

Column 2 represents the original monthly report, reflecting outcomes as of the end of the reporting
period (March in this example) and showing 200 pending renewals. 3

•

Column 3 reflects the information states need to collect – the disposition of the 200 renewals
reported as pending in Column 2, as of June 30, the last day of the third month after the March
reporting period. States do not report the values shown in Column 3 to CMS.

•

Column 4 reflects the values states will input into the data collection portal, along with the notes in
Column 5.

Table 11: Illustrative Example on How to Update Prior Monthly Reports with Outcomes of
Previously Pending Renewals
Column 1

Column 2

Column 3

Column 4

Column 5

Metric

Original March
2024 Monthly
Report, as
submitted to CMS
by April 8, 2024

Outcomes of 200
previously pending
renewals as of
June 30, 2024

Updated July
Monthly Report, as
submitted to CMS
by July 15, 2024

Reporting Notes
with Updated July
Monthly Report, as
submitted to CMS
by July 15, 2024

5. Renewals due

1000

1000

5a. Number
renewed and
retained in Medicaid
or CHIP

550

+100

650

5a(1). Number
renewed on ex parte
basis

300

+0

300

5a(2). Number
renewed using a
renewal form

250

+100

350

7/15/24: Outcomes
updated to include
disposition of
previously pending
renewals

5b. Number
determined ineligible
for Medicaid or
CHIP using a
renewal form

200

+50

250

7/15/24: Outcomes
updated to include
disposition of
previously pending
renewals

7/15/24: Outcomes
updated to include
disposition of
previously pending
renewals

For states that have made corrections since the monthly report was first submitted to CMS, Column 2 will be the
state’s most recent submission.

3

Page 13 of 16

Column 1

Column 2

Column 3

Column 4

Column 5

Metric

Original March
2024 Monthly
Report, as
submitted to CMS
by April 8, 2024

Outcomes of 200
previously pending
renewals as of
June 30, 2024

Updated July
Monthly Report, as
submitted to CMS
by July 15, 2024

Reporting Notes
with Updated July
Monthly Report, as
submitted to CMS
by July 15, 2024

5c. Number
terminated for
procedural reasons

50

+50

100

7/15/24: Outcomes
updated to include
disposition of
previously pending
renewals

5d. Number whose
renewal was not
completed (“pending
renewals”)

200

-200

0

7/15/24: Outcomes
updated to include
disposition of
previously pending
renewals

2. What do the updated data include and exclude?
The updates to monthly metric 5 and its submetrics reflect the disposition of previously pending renewals
(5d). Outcomes of pending renewals are added to the appropriate outcome based on how they were
adjudicated: renewed on an ex parte basis (5a1), renewed using a renewal form (5a2), determined
ineligible for Medicaid or CHIP using a renewal form (5b), or terminated for procedural reasons (5c).
Because the updates to the monthly report include the outcomes of previously pending renewals, these
outcomes are subtracted from the data reported in the pending renewals submetric (5d) in the original
monthly report. When a state submits their updated report, only renewals still pending as of the end of the
last day of the third month following the end of the applicable reporting period remain in submetric 5d.
These updates do not include a revised outcome for a renewal that reached a final disposition (i.e.,
reported in monthly metric 5a (including 5a(1) and 5a(2), 5b, or 5c)) as of the end of the original
reporting period because the individual experienced a change in circumstances following the renewal.
States do not include outcomes of renewals when an individual returns a form during the reconsideration
period.
3. Can states make corrections when submitting the pending renewal data?
Yes. CMS continues to advise states to make corrections in the data collection portal as soon as they are
identified. As part of this effort to collect the outcomes of previously pending renewals, CMS is not
asking for states to re-validate previously submitted data. However, the submission of pending renewal
data presents the final opportunity for states to make corrections to previously reported data. Any
corrections reflect the status of outcomes (other than those pending) as of the end of the original reporting
period. CMS advises states making corrections to use the relevant notes field to provide context to CMS,
as the state deems necessary.

D. Frequently Asked Questions
The following questions and answers pertain to the revised data reports that include outcomes of
previously pending renewals due to CMS on the 15th of the month.
1. What is the difference between an “update” and a “correction”?

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−

CMS is using “update” in this context to refer to changes made to a monthly report to reflect the
outcomes of previously pending renewals three months after the original monthly report
submission.

−

CMS is using “correction” to refer to changes made to a monthly report to revise previously
reported data. Such corrections reflect the status of outcomes as of the end of the original
reporting period and may include changes such as fixing typos, correcting data reported for the
wrong submetric, or other inaccuracies identified.

2. Which metrics are updated?
−

States update the outcome metrics: 5a, 5a(1), 5a(2), 5b, 5c, and 5d. CMS would not generally
expect changes to metric 5, renewals due in the reporting period, unless the state is also reporting
corrections (see question 3 below).

3. What, if anything, do states include in the notes field for corrections?
−

If the state makes corrections, please add to the notes for relevant metrics: “The data also reflect
corrections not previously reported.”

4. The state identified an issue and reinstated coverage for beneficiaries who were reported as
procedurally terminated. How should these reinstatements be reflected as a correction or an update?
−

Reinstatements of coverage following a termination are not included as a correction nor an
update.

5. How can the state reflect the status of individuals who were procedurally terminated, but returned
their renewal form during the reconsideration period?
−

The reporting detailed in Section III collects the outcomes for individuals whose renewals were
previously reported as pending. Individuals who returned their renewal form during the
reconsideration period would have already been terminated for procedural reasons, and thus are
not included as part of this update.

−

If the state is tracking the number of individuals that return renewal forms during the
reconsideration period and their outcomes, and would like to share this information with CMS,
please feel free to include it in the notes field for metric 5c.

6. Do states include the status of individuals who completed a renewal, but later experienced a change in
circumstance in the updated reports?
−

No. The purpose of metrics 5 (and its submetrics), 6, and 7 of the data report is to collect the
outcomes for individuals’ renewals. As such, the state does not update the status of outcomes for
individuals for whom the state previously determined eligible to reflect the result of a
redetermination based on a change in circumstances that occurs after the renewal.

7. What if my state is unable to report the dispositions of previously pending renewals as described in
Section III of this document?
−

If a state is unable to report these data, please notify CMS by sending an email to
UnwindingMetricsTA@mathematica-mpr.com as soon as possible for technical assistance.

Page 15 of 16

IV. Change Log
Table 12: Change Log
No.

Change

Date

1

Updated baseline report submission due date, consistent with COVID-19 Unwinding FAQs
released by CMS in October 2022

12/2022

2

Added additional reporting guidance when submission date falls on holiday or weekend

12/2022

3

Added guidance that states should note in the free-text field if they are reporting application
processing metrics at the household level

12/2022

4

Added definition of disability-related application, consistent with COVID-19 Unwinding
FAQs released by CMS in October 2022

12/2022

5

Added context related to the Consolidated Appropriations Act, 2023

10/2023

6

Removed guidance around selecting “unable to report” for all metrics

10/2023

7

Added guidance around Medicaid fair hearings that should be included and excluded in the
unwinding metric reports

10/2023

8

Clarified expectations around reporting metrics at the household vs. individual level

10/2023

9

Clarified guidance for metric 5b (beneficiaries determined ineligible for Medicaid or CHIP) to
remove language around transfers to the Marketplace

10/2023

10

Removed “annual” from specifications for reporting Medicaid renewals initiated and
outcomes

10/2023

11

Removed “prepopulated” from specifications for reporting metric 5a(2) (beneficiaries
renewed using a renewal form)

10/2023

12

Added guidance for state reporting related to mitigation strategies

10/2023

13

Added Chapter IV with guidance for reporting pending renewals

10/2023

14

Removed Chapter II reporting guidance pertaining to the Unwinding Baseline Report

7/2024

15

Made minor edits to guidance for metrics 4, 5, 5a, 5a(1), 5a(2), 5b, 5c, 5d, 6, 7, and 8

7/2024

16

Updated Chapter III, Reporting the Outcomes of Previously Pending Renewals, to account
for ongoing data reporting

7/2024

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