GenIC #66 Eligibility Processing Data Report portal screen shots

CMS Unwinding Portal
Baseline and Monthly Instruments
Baseline Instrument screen shots

Baseline application processing metric tab

ALT TEXT: This is a screenshot of the first tab of the unwinding baseline instrument, the application
processing section. This screenshot includes the following: a free-text field for Metric 1 (Total pending
applications received between March 1, 2020 and the end of the month prior to the state’s unwinding
period); instructions for Metric 1 indicating that this metric is the sum of 1a and 1b; an unable to report
checkbox for Metric 1; a free-text field for Metric 1a (Pending MAGI and other non-disability
applications); an unable to report checkbox for Metric 1a; a free-text field for Metric 1b (Pending
disability-related applications); an unable to report checkbox for Metric 1b; a Metric 1 notes free-text
field; and instructions for Metric 1 notes free-text field, indicating to please include an explanation if the
state is unable to report a metric, deviates from the metric definition, or wishes to provide additional
context to help CMS understand the data.

Baseline renewals metric tab

ALT TEXT: This is a screenshot of the second tab of the unwinding baseline instrument, the renewals
section. This screenshot includes the following: a free-text field for Metric 2 (Total beneficiaries enrolled
as of the end of the month prior to the state’s unwinding period); an unable to report checkbox for
Metric 2; a Metric 2 notes free-text field; and instructions for Metric 2 notes free-text field, indicating to
please include an explanation if the state is unable to report a metric, deviates from the metric
definition, or wishes to provide additional context to help CMS understand the data.

Baseline state’s policy for completing renewals metric tab

ALT TEXT: This is a screenshot of the third tab of the unwinding baseline instrument, the state’s policy
for completing renewals section. This screenshot includes the following: instructions indicating to briefly
summarize the number of days in the renewal period, which is the time from the day a renewal process
is initiated to when it is expected to reach final determination; and a free-text field for Metric 3 (State’s
timeline for the renewal process).

Baseline Medicaid fair hearings metric tab

ALT TEXT: This is a screenshot of the fourth tab of the unwinding baseline instrument, the Medicaid fair
hearings section. This screenshot includes the following: a free-text field for Metric 4 (Total number of
Medicaid fair hearings pending more than 90 days at the end of the month prior to the state’s
unwinding period); an unable to report checkbox for Metric 4; a Metric 4 notes free-text field; and
instructions for Metric 4 notes free-text field, indicating to please include an explanation if the state is
unable to report a metric, deviates from the metric definition, or wishes to provide additional context to
help CMS understand the data.

Baseline instructions in header

ALT TEXT: This is a screenshot of the instructions at the top of the baseline instrument. The instructions
read as follows: The Medicaid and Children’s Health Insurance Program Eligibility and Enrollment Data
Specifications for Reporting During States’ Unwinding Period (“specifications”) explain the background,
metrics, and submission process for the submission of data to CMS during a state’s unwinding period.
States should defer to that document for detailed information about definitions and timelines for
submission. Each section contains a notes section. Please include an explanation if any of the following
apply: 1) The state deviates from the metric definitions in the specifications, 2) The state is unable to
provide data for any metrics or sub-metrics, 3) The state wishes to provide additional context to help
CMS understand the data reported. For any questions, please contact: Unwinding@mathematicampr.com.

Baseline header fields

ALT TEXT: This is a screenshot of the header fields at the top of the baseline instrument. The fields
include a Submission Date field, which is denoted as required and should be populated using
MM/DD/YYYY format, and an Unwinding Period Start Date field, which is denoted should be populated
using a month year format.

Monthly Instrument screen shots

Monthly application processing metrics tab (Metric 1)

ALT TEXT: This is a screenshot of a portion the first tab of the unwinding monthly instrument, the
application processing section. This screenshot includes the following: instructions indicating that Metric
1 and its sub-metrics are also on the baseline reporting form. Please re-report those figures if they have
not changed. It is not expected that baseline data will change. In the event that baseline data have
changed, please report new baseline data below, including an explanation in the notes section; and also
update the baseline reporting form; a free-text field for Metric 1 (Total pending applications received
between March 1, 2020 and the end of the month prior to the state’s unwinding period); instructions for
Metric 1 indicating that this metric is the sum of 1a and 1b; an unable to report checkbox for Metric 1; a
free-text field for Metric 1a (Total MAGI and other non-disability applications); an unable to report
checkbox for Metric 1a; a free-text field for Metric 1b (Total disability-related applications); an unable to
report checkbox for Metric 1b; a Metric 1 notes free-text field; and instructions for Metric 1 notes freetext field, indicating to please include an explanation if the state is unable to report a metric, deviates
from the metric definition, or wishes to provide additional context to help CMS understand the data.

Monthly application processing metrics tab (Metric 2)

ALT TEXT: This is a screenshot of a portion of the first tab of the unwinding monthly instrument, the
application processing section. This screenshot includes the following: a free-text field for 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); instructions for Metric 2 indicating that this metric is the sum of 2a and
2b; an unable to report checkbox for Metric 2; a free-text field for Metric 2a (Completed MAGI and
other non-disability related applications as of the last day of the reporting period); an unable to report
checkbox for metric 2a; a free-text field for Metric 2b (Completed disability-related applications as of
the last day of the reporting period); an unable to report checkbox for Metric 2b; a Metric 2 notes freetext field; and instructions for Metric 2 free-text field notes, indicating to please include an explanation
if the state is unable to report a metric, deviates from the metric definition, or wishes to provide
additional context to help CMS understand the data.

Monthly application processing metrics tab (Metric 3)

ALT TEXT: This is a screenshot of a portion of the first tab of the unwinding monthly instrument, the
application processing section. This screenshot includes the following: a free-text field for 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); instructions for Metric 3 indicating that this metric is the sum of
3a and 3b; an unable to report checkbox for Metric 3; a free-text field for Metric 3a (Pending MAGI and
other non-disability applications as of the last day of the reporting period); an unable to report checkbox
for Metric 3a; a free-text field for Metric 3b (Pending disability-related applications as of the last day of
the reporting period); an unable to report checkbox for Metric 3b; a Metric 3 notes free-text field; and
instructions for Metric 3 notes free-text field, indicating to please include an explanation if the state is
unable to report a metric, deviates from the metric definition, or wishes to provide additional context to
help CMS understand the data.

Renewals initiated metric tab (Metric 4)

ALT TEXT: This is a screenshot of the second tab of the unwinding monthly instrument, the renewals
initiated section. This screenshot includes the following: a free-text field for Metric 4 (Total beneficiaries
for whom a renewal was initiated in the reporting period); an unable to report checkbox for Metric 4; a
Metric 4 notes free-text field; and instructions for Metric 4 notes free-text field, indicating to please
include an explanation if the state is unable to report a metric, deviates from the metric definition, or
wishes to provide additional context to help CMS understand the data.

Renewals and outcomes metrics tab (Metric 5)

ALT TEXT: This is a screenshot of a portion of the third tab of the unwinding monthly instrument, the
renewals and outcomes section. This screenshot includes the following: a free-text field for Metric 5
(Total beneficiaries due for renewal in the reporting period); instructions for Metric 5 indicating that this
metric is the sum of 5a, 5b, 5c and 5d; an unable to report checkbox for Metric 5; a Metric 5 notes freetext field; and instructions for Metric 5 notes free-text field, indicating to please include an explanation
if the state is unable to report a metric, deviates from the metric definition, or wishes to provide
additional context to help CMS understand the data.

Renewals and outcomes metrics tab (Metric 5a)

ALT TEXT: This is a screenshot of a portion of the third tab of the unwinding monthly instrument, the
renewals and outcomes section. This screenshot includes the following: a free-text field for Metric 5a
(Of the beneficiaries included in Metric 5, the number renewed and retained in Medicaid or CHIP (those
who remained enrolled)); instructions for Metric 5a indicating that this metric is the sum of 5a(1) and
5a(2); an unable to report checkbox for Metric 5a; a free-text field for Metric 5a(1) (Number of
beneficiaries renewed on an ex parte basis); an unable to report checkbox for Metric 5a(1); a free-text
field for Metric 5a(2) (Number of beneficiaries renewed on using a pre-populated renewal form); an
unable to report checkbox for Metric 5a(2); a Metric 5a notes free-text field; and instructions for Metric
5a notes free-text field, indicating to please include an explanation if the state is unable to report a
metric, deviates from the metric definition, or wishes to provide additional context to help CMS
understand the data.

Renewals and outcomes metrics tab (Metrics 5b and 5c)

ALT TEXT: This is a screenshot of a portion of the third tab of the unwinding monthly instrument, the
renewals and outcomes section. This screenshot includes the following: a free-text field for Metric 5b
(Of the beneficiaries included in Metric 5, the number determined ineligible for Medicaid and CHIP (and
transferred to Marketplace)); an unable to report checkbox for Metric 5b; a Metric 5b notes free-text
field; instructions for Metric 5b notes indicating to please include an explanation if the state is unable to
report a metric, deviates from the metric definition, or wishes to provide additional context to help CMS
understand the data; a free-text field for Metric 5c (Of the beneficiaries included in Metric 5, the
number terminated for procedural reasons (i.e. failure to respond)); an unable to report checkbox for
Metric 5c; a Metric 5c notes free-text field; instructions for Metric 5c notes free-text field, indicating to
please include an explanation if the state is unable to report a metric, deviates from the metric
definition, or wishes to provide additional context to help CMS understand the data.

Renewals and outcomes metrics tab (Metrics 5d and 6)

ALT TEXT: This is a screenshot of a portion of the third tab of the unwinding monthly instrument, the
renewals and outcomes section. This screenshot includes the following: a free-text field for Metric 5d
(Of the beneficiaries included in Metric 5, the number whose renewal was not completed); an unable to
report checkbox for Metric 5d; a Metric 5d notes free-text field; instructions for Metric 5d notes freetext field, indicating to please include an explanation if the state is unable to report a metric, deviates
from the metric definition, or wishes to provide additional context to help CMS understand the data; a
calendar picker for Metric 6 (Month in which renewals due in the reporting month were initiated); an
unable to report checkbox for Metric 6; a Metric 6 notes free-text field; instructions for Metric 6 notes
free-text field ,indicating to please include an explanation if the state is unable to report a metric,
deviates from the metric definition, or wishes to provide additional context to help CMS understand the
data.

Renewals and outcomes metrics tab (Metric 7)

ALT TEXT: This is a screenshot of a portion of the third tab of the unwinding monthly instrument, the
renewals and outcomes section. This screenshot includes the following: a free-text field for Metric 7
(Number of beneficiaries due for a renewal since the beginning of the state’s unwinding period whose
renewal has not yet been completed); an unable to report checkbox for Metric 7; a Metric 7 notes freetext field; instructions for Metric 7 notes free-text field, indicating to please include an explanation if the
state is unable to report a metric, deviates from the metric definition, or wishes to provide additional
context to help CMS understand the data.

Medicaid fair hearings metric tab (Metric 8)

ALT TEXT: This is a screenshot of the fourth tab of the unwinding month instrument, the Medicaid fair
hearings section. This screenshot includes the following: a free-text field for Metric 8 (Total number of
Medicaid fair hearings pending more than 90 days at the end of the reporting period); an unable to
report checkbox for Metric 8; a Metric 8 notes free-text field; and instructions for Metric 8 notes freetext field, indicating to please include an explanation if the state is unable to report a metric, deviates
from the metric definition, or wishes to provide additional context to help CMS understand the data.

Monthly instructions in header

ALT TEXT: This is a screenshot of the instructions at the top of the monthly instrument. The instructions
read as follows: The Medicaid and Children’s Health Insurance Program Eligibility and Enrollment Data
Specifications for Reporting During States’ Unwinding Period (“specifications”) explain the background,
metrics, and submission process for the submission of data to CMS during a state’s unwinding period.
States should refer to that document for detailed information about definitions and timelines for
submission. Each section contains a notes section. Please include an explanation if any of the following
apply: 1) The state deviates from the metric definitions in the specifications, 2) The state is unable to
provide data for any metrics or sub-metrics, 3) The state wishes to provide additional context to help
CMS understand the data reported. For any questions, please contact: Unwinding@mathematicampr.com.

Monthly header fields

ALT TEXT: This is a screenshot of the header field at the top of the monthly instrument. The field is a
Submission Date field, which is denoted as required and should be populated using MM/DD/YYYY
format.