Narrative Report Format. Title Line One - (Name of Individual State Program) Title Line Two - Section 1115 Quarterly Report Demonstration/Quarter Reporting Period: Example: Demonstration Year: year # and dates
Narrative Report Format. Title Line One – Michigan Medicaid Nonpregnant Childless Adults Waiver (Adult Benefits Waiver) Section 1115 Demonstration Title Line Two - Section 1115 Quarterly Report Demonstration/Quarter Reporting Period: Example: Demonstration Year: 1 (01/01/10-09/30/10) Federal Fiscal Quarter: 2/2010 (01/01/10 – 03/31/10) Introduction Information describing the goal of the Demonstration, what it does, and key dates of approval/operation. (This should be the same for each report.) Enrollment Information Please complete the following table that outlines all enrollment activity under the Demonstration. The State should indicate “N/A” where appropriate. If there was no activity under a particular enrollment category, the State should indicate that by “0.” Enrollment Count Note: Enrollment counts should be person counts, not member months. Demonstration Populations (as hard-coded in the CMS-64) Current Enrollment (last day of quarter) Newly Enrolled in Current Quarter Disenrolled in Current Quarter Childless Adults
Narrative Report Format. TITLE Title Line One – Arizona Health Care Cost Containment System -- AHCCCS, A Statewide Approach of Cost Effective Health Care Financing Title Line Two - Section 1115 Quarterly Report Demonstration/Quarter Reporting Period: Example: Demonstration Year: 5 (5/01/04 - 4/30/05) Federal Fiscal Quarter: 4/2004 (7/04 - 9/04) INTRODUCTION: Information describing the goal of the Demonstration, what it does, and key dates of approval /operation. (This should be the same for each report.) ENROLLMENT INFORMATION: Please complete the following table that outlines all enrollment activity under the Demonstration. The State should indicate “N/A” where appropriate. If there was no activity under a particular enrollment category, the State should indicate that by “0”. Note: Enrollment counts should be person counts, not participant months. Population Groups (as hard coded in the CMS 64) Current Enrollees (to date) No. Voluntary Disenrolled in current Quarter No. Involuntary Disenrolled in current Quarter Population 1 – AFDC / SOBRA Population 2 - SSI Population 3 – ALTCS DD Etcetera Voluntary Disenrollments: Cumulative Number of Voluntary Disenrollments Within Current Demonstration Year: Reasons for Voluntary Disenrollments: Involuntary Disenrollments: Cumulative Number of Involuntary Disenrollments Within Current Demonstration Year: Reasons for Involuntary Disenrollments: Outreach/Innovative Activities: Summarize outreach activities and/or promising practices for the current quarter. Operational/Policy Developments/Issues: Identify all significant program developments/issues/problems that have occurred in the current quarter. Financial/Budget Neutrality Developments/Issues: Identify all significant developments/issues/problems with financial accounting, budget neutrality, and CMS 64 reporting for the current quarter. Identify the State’s actions to address these issues. Consumer Issues: A summary of the types of complaints or problems consumers identified about the program in the current quarter. Include any trends discovered, the resolution of complaints, and any actions taken, or to be taken, to prevent other occurrences. Quality Assurance/Monitoring Activity: Identify any quality assurance/monitoring activity in current quarter. ESI Issues: Identify all significant program developments/issues/problems that have occurred in the current quarter. Family Planning Extension Program: Identify all significant program developments/issues/problems that have occurred in the cur...
Narrative Report Format. TITLE Title Line One – State of Louisiana (Greater New Orleans Community Health Connection Demonstration 11-W-00252/6) Title Line Two - Section 1115 Quarterly Report Demonstration Reporting Period: Example: Demonstration Year: 1 (October 1, 2010 – September 30, 2011) Introduction: Information describing the goal of the Demonstration, what it does, and key dates of approval /operation. (This should be the same for each report.) Enrollment Information: Please complete the following table that outlines current enrollment in each GNOCHC program under the Demonstration. The State should indicate “N/A” where appropriate. Note: Enrollment counts should be person counts, not participant months. GNOCHC Programs Current Enrollees (to date) Outreach/Innovative Activities: Summarize outreach activities and/or promising practices for the current quarter. Operational/Policy Developments/Issues: Identify all significant program developments/issues/problems that have occurred in the current quarter.
