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An Introduction to Medicaid and CHIP Eligibility and Enrollment Performance Measures

Appendix A: Overview of Medicaid and CHIP Eligibility and Enrollment Performance Indicators

Call center operations. CMS established three measures for call center operations: call volume, average wait times for a call to be answered, and the rate at which calls are abandoned. These measures will provide insight into consumers’ level of demand for call center assistance.1 Average wait times and call abandonment rates will also inform high-level assessments of the extent to which the call centers manage call volume efficiently and effectively. These measures do not provide information on the types of assistance consumers seek through the call centers or their levels of satisfaction with the assistance they receive.  States may define “call center” as any call center, hotline, or combination of hotlines that take a significant number of calls regarding applying for or enrolling in Medicaid or CHIP, so the data may not be comparable across states. The measures will not reflect calls related to Medicaid and CHIP that are received by call centers overseen or operated by the Marketplaces.

Numbers of applications, transfers, and renewals. The total number of Medicaid and CHIP applications received and accounts up for renewal will indicate the overall volume of traffic to Medicaid and CHIP eligibility and enrollment systems, informing assessments of overall Medicaid/CHIP agency workload and the demand for coverage. This demand may fluctuate for a variety of reasons, including due to responses to outreach campaigns, changing economic conditions, or state policy choices. States will also report the total number of Medicaid and CHIP cases transferred from Marketplaces. This measure will provide an indication of what share of total Medicaid and CHIP applications are initiated through the Marketplaces as well as of the volume of coordination occurring between the Medicaid/CHIP agency and the Marketplace. The measure will not provide significant insight into how well or seamlessly that coordination is occurring, since there are no measures to indicate whether any transfers are unsuccessful or whether individuals experience any gaps or disruptions in coverage. Additionally, states will report the number of applications consumers submit online, by mail, in person, or by phone, providing insight into consumers’ preferred mode of application submission. The share of initiated applications that are completed and overall consumer experiences with the application process are not being measured.

Eligibility determinations. The total number of individuals determined eligible or ineligible for Medicaid or CHIP during the reporting period will provide information into the outcome of submitted applications. 2 In reporting the number of individuals determined ineligible for Medicaid and CHIP, CMS has requested that states separately report the number determined ineligible and those denied due to lack of necessary information. This will enable analysis of how many and what proportion of negative determinations that are made due to difficulties obtaining necessary information.3 States will also separately report administrative eligibility determinations that states make using data from other programs like SNAP. As of December 2013, five states are enrolling eligible individuals in Medicaid based on data available through SNAP and three are enrolling eligible parents based on existing Medicaid and CHIP enrollment data for their children 4

Application processing times and pending applications. Beginning in 2014, states will also report application processing times and the number of applications still pending as of the last date of the reporting period. These indicators will provide information on the efficiency of application processing through the system, and can help states and CMS identify potential delays or problems with processing. 5

Total enrollment. States will report total enrollment of all individuals in Medicaid and CHIP as of the last day of the reporting period.  Enrollment will be reported separately for children and adults and for individuals determined eligible based on Modified Adjusted Gross Income (MAGI) as well as those determined eligible under other standards. This measure will provide insight into overall trends in enrollment over time and allow for comparisons between these groups. The data will not separately identify enrollment among individuals made newly eligible by the Medicaid expansion for low-income adults, making it difficult to draw conclusions about the impact of the Medicaid expansion using this data.

Appendix B: Definitions of Medicaid and CHIP Eligibility and Enrollment Performance Indicators

Measure Definition
Call Center Operations
Call Volume1,3 Total number of calls received by call centers (including helplines or hotlines) that receive a significant number of calls about applying for or enrolling in Medicaid and CHIP.  Excludes SBM call centers but includes call centers that receive calls about applying for other programs like SNAP.  The types of calls include calls from individuals applying over the phone, calls with eligibility questions, and calls about enrolling in Medicaid/CHIP managed care.  CMS also asked states to describe the call centers, helplines, and hotlines.
Average Caller Wait Time1,3 Average time that a caller waits before being connected to an agent (reported by call center and as a weighted average across call centers).
Rate of Abandoned Calls 1,3 Percentage of all calls abandoned by callers (reported by call center and as a weighted average across call centers).
Applications, Transfers and Renewals
Number of Applications Received Each Week/Month2 Total number of Medicaid and CHIP applications received in previous week/month, including any received by an SBM. Applications transferred from FFM are excluded. Applications are reported by source agency and by means of submission (online, mail, in-person, phone, other).
Number of Electronic Account Transfers From Marketplaces to Medicaid/CHIP1,2 Number of electronic accounts transferred from the FFM (or an SBM that does not have an integrated eligibility system) to state Medicaid agencies. In both assessments and determinations will be reported, as well as cases in which an individual assessed as ineligible requests a full determination by a state agency.  Medicaid and CHIP agencies will report the number of cases they transfer to CHIP or Marketplaces for those programs to make eligibility determinations.
Number of Renewals2 Number of accounts up for annual renewal of eligibility. (Renewals that take place due to a change in beneficiaries’ circumstances are not included). Renewals are reported by CHIP and MAGI and non-MAGI Medicaid applications.
 Determinations
Number of Individuals Determined Eligible1,2 Number of individuals determined eligible for Medicaid or CHIP at application or renewal. Includes all determinations of eligibility made by Medicaid agencies, CHIP agencies, and SBMs, but does not include determinations made by FFMs.  Determinations are reported by MAGI and non-MAGI populations and by application type (application, renewal, administrative determination, or other).  Some individuals may be both MAGI and non-MAGI eligible; such individuals may be reported as having two eligibility determinations.
Number of Individuals Determined Ineligible1,2 Number of individuals determined ineligible for Medicaid or CHIP through application or renewal. Includes all determinations of ineligibility made by Medicaid agencies, CHIP agencies, and SBMs, but does not include determinations made by FFMs. Determinations are reported by application type (application, renewal, or administrative determination). States also report the number of cases determined ineligible due inadequate documentation or lack of follow up. (Individuals who request disenrollment or are disenrolled after not paying premiums, as well as children who are eligible but not enrolled due to being subject to a waiting period or premium lock-out, are not included.)
Application Processing Efficiency
Pending Applications and Renewals2 Number of applications and redeterminations for Medicaid and CHIP pending as of the last day of the reporting period, regardless of the date of application or the date for renewal. This indicator measures the time between when a Medicaid and CHIP agency receives an application and when the agency makes a decision on that application.
Application Processing Time2 Processing times before determination for all applicants who received a determination during the reporting period, regardless of the date of application. States will report  medians and distribution of processing times for both MAGI and non-MAGI populations and break down processing times by the source of the application (i.e., whether it is a direct application or a transfer from another program).
Enrollment
Total Enrollment1,2 The total number of individuals enrolled in Medicaid and CHIP coverage as of the last day of the reporting period.  (Individuals with retroactive, conditional, and presumptive eligibility are included; CHIP children subject to a waiting period or premium lock-out period are considered eligible but not enrolled and are excluded.)  Enrollment is reported for children and adults and MAGI and non-MAGI populations.  It will include people who are eligible for comprehensive Medicaid coverage (this measure excludes enrollment in limited benefit coverage such as family planning).

Measures with this note are collected by CMS weekly during open enrollment (October 1, 2013 to March 31, 2014)

Measures with this note are collected by CMS monthly. 
Measures with this note are collected by CMS monthly outside open enrollment (April 1, 2014 and after).

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