GenIC #66 Eligibility Processing Data Report excel workbook

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Unwinding Eligibility and Enrollment Data Reporting Template
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The ongoing COVID-19 outbreak and implementation of federal policies to address the public health emergency (PHE) have disrupted routine
Medicaid, Children's Health Insurance Program (CHIP), and Basic Health Program (BHP) eligibility and enrollment operations. Medicaid and
CHIP enrollment has grown to historic levels due in large part to the continuous enrollment requirement that states implemented as a
condition of receiving a temporary 6.2 percentage point federal medical assistance percentage increase under section 6008 of the Families
First Coronavirus Response Act (P.L. 116-127) ("continuous enrollment condition"). States will have a large volume of eligibility and
enrollment actions to complete when the PHE ends, and the Centers for Medicare & Medicaid Services (CMS) released State Health Official
letter #22-001, "Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the Children's Health
Insurance Program (CHIP), and Basic Health Program (BHP) Upon Conclusion of the COVID-19 Public Health Emergency," which outlines
timelines and guidance for states to restore routine operations in a manner that promotes continuity of coverage for eligible individuals and
facilitates seamless coverage transitions for those who become eligible for other insurance affordability programs (e.g., Marketplace).
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CMS will require states to report on specific metrics described in this "Unwinding Eligibility and Enrollment Data Reporting Template"
(Unwinding Data Report). These metrics are designed to demonstrate states' progress towards restoring timely application processing and
initiating and completing renewals of eligibility for all Medicaid and CHIP enrollees consistent with the guidance outlined in SHO #22-001.
States will complete a baseline and subsequent monthly Unwinding Data Report and submit these reports to CMS using the same portal in
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which states enter their Performance Indicator (PI) data and which is set up to accept submissions from those with PI submission credentials.
States may use the Unwinding Data Report excel workbook as a planning tool to review the metrics before submitting their baseline and
monthly reports through the PI portal.
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We realize that states may have questions or need help as they review the metrics in the report and reporting specifications2. States can
access help anytime by emailing UnwindingMetricsTA@mathematica-mpr.com. CMS will also be hosting an all-state webinar in which they
will review the metrics and how to submit their Unwinding Data Report; the webinar will be recorded and posted on Medicaid.gov so that
states can access it at any time.
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https://sdis.medicaid.gov/user/login
https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/index.html
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OMB Control Number 0938-1148
Expiration date: 3/31/2021

NAME OF STATE/TERRITORY:
SUBMISSION DATE: MM/DD/YYYY
UNWINDING PERIOD START DATE: MM/YYYY

BASELINE REPORT

APPLICATION PROCESSING

NUMBER

STATE NOTES/ADDITIONAL
INFORMATION ABOUT THE DATA

NUMBER

STATE NOTES/ADDITIONAL
INFORMATION ABOUT THE DATA

DESCRIPTION OF
STATE'S
RENEWAL
TIMELINE POLICY

Column1

NUMBER

STATE NOTES/ADDITIONAL
INFORMATION ABOUT THE DATA

1. Total pending applications received between March 1, 2020 and the end of the month prior to the
state's unwinding period (1a + 1b)
1a. Pending MAGI and other non-disability applications
1b. Pending disability-related applications
RENEWALS
2. Total beneficiaries enrolled as of the end of the month prior to the state's unwinding period
STATE'S POLICY FOR COMPLETING RENEWALS
3. State's timeline for the renewal process
MEDICAID FAIR HEARINGS
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
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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 Social Security Act (the Act), 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 8 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.

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OMB Control Number 0938-1148
Expiration date: 3/31/2021

MONTHLY REPORT
NAME OF STATE/TERRITORY:
SUBMISSION DATE: MM/DD/YYYY
REPORTING PERIOD: MM/YYYY
APPLICATION PROCESSING

NUMBER

STATE NOTES/ADDITIONAL
INFORMATION ABOUT THE DATA

NUMBER

STATE NOTES/ADDITIONAL
INFORMATION ABOUT THE DATA

NUMBER

STATE NOTES/ADDITIONAL
INFORMATION ABOUT THE DATA

NUMBER

STATE NOTES/ADDITIONAL
INFORMATION ABOUT THE DATA

1.  Total pending applications received between March 1, 2020 and the end of the month prior to the state's unwinding period (1a + 1b)
1a. Total MAGI and other non-disability applications (2a+3a)
1b. Total disability-related applications (2b+3b)
2.  Of those applications included in Monthly Metric 1, the total number of applications completed as of the last day of the reporting period (2a+2b) 
     2a. Completed MAGI and other non-disability related applications as of the last day of the reporting period
     2b. Completed disability-related applications as of the last day of the reporting period
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 (3a+3b)
     3a. Pending MAGI and other non-disability applications as of the last day of the reporting period
     3b. Pending disability-related applications as of the last day of the reporting period
RENEWALS INITIATED
4. Total beneficiaries for whom a renewal was initiated in the reporting period
RENEWALS AND OUTCOMES
5. Total beneficiaries due for renewal in the reporting period (5a+5b+5c+5d)
5a. Of the beneficiaries included in Metric 5, the number renewed and retained in Medicaid or CHIP (those who remained enrolled) [5a(1) + 5a(2)]
5a(1) Number of beneficiaries renewed on an ex parte basis
5a(2) Number of beneficiaries renewed using a pre-populated renewal form
5b. Of the beneficiaries included in Metric 5, the number determined ineligible for Medicaid or CHIP (and transferred to Marketplace)
5c. Of the beneficiaries included in Metric 5, the number terminated for procedural reasons (i.e. failure to respond)
5d. Of the beneficiaries included in Metric 5, the number whose renewal was not completed
6. Month in which renewals due in the reporting month were initiated
7. Number of beneficiaries due for a renewal since the beginning of the state's unwinding period whose renewal has not yet been completed
MEDICAID FAIR HEARINGS
8. Total number of Medicaid fair hearings pending more than 90 days at the end of the reporting period
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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 Social Security Act (the Act), 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 COVID19 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 17 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 212441850.

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