CMS-10371 - SBM Metrics

State Based Marketplace Data Collection Template:
Open Enrollment Period Priority and
Expanded End of Open Enrollment Reporting

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

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OMB control number 0938-1119

Table of Exhibits
Exhibit 1: General ........................................................................................................................................................................................................... 1
Exhibit 2: Financial Assistance/Premiums...................................................................................................................................................................... 4
Exhibit 3: Demographics ................................................................................................................................................................................................ 6
Exhibit 4: Operations.................................................................................................................................................................................................... 11
Exhibit 5: Issuers .......................................................................................................................................................................................................... 13
Exhibit 6: Stand-alone Dental Plans ............................................................................................................................................................................. 15
Exhibit 7: Metal Level by Age, Income, Sex, and Race/Ethnicity ................................................................................................................................. 17
Exhibit 8: Consumer Type by Age, Metal Level, Income, Sex, and Race/Ethnicity ...................................................................................................... 38
Exhibit 9: Basic Health Plan Program/Other – only for states with BHP or 1332 plan ................................................................................................ 52
Exhibit 10: Metal Level by Financial (new section) ...................................................................................................................................................... 56
Exhibit 11: Consumer Type by Financial (new section) ............................................................................................................................................... 57
Exhibit 12: Plan Selections by Area (new section) ....................................................................................................................................................... 58

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Exhibit 1: General
Indicator Title
1
Total Plan Selections (net)

2

New Consumers (net)

3

Total Re-enrollees (net)

4

Active Re-enrollees (net)

4.1

Active Re-enrollees who Switched Plans
(net)

4.2
5

Active Re-enrollees who Remained in the
Same Plan or a Crosswalked Plan (net)
Automatic Re-enrollees (net)

6

Number of Submitted Applications (gross)

Description
Count of unique individuals who have selected a Plan Year (PY) 20XX Marketplace
medical plan. Count includes all new and re-enrolling consumers (defined in
Indicators 2 and 3), regardless of whether the consumer has paid the first month
premium. Count does not include plans that were canceled or terminated.
Count of unique individuals who have selected a PY 20XX Marketplace medical
plan, where the consumer did not have PY 20XX Marketplace medical coverage on
or after 11/1/20XX. Count does not include plans that were canceled or
terminated.
Count of unique individuals who have selected a PY 20XX Marketplace medical
plan, where the consumer had non-canceled PY 20XX Marketplace medical
coverage on 11/1/20XX. Count includes consumers who either returned to the
Marketplace and actively selected a PY 20XX Marketplace medical coverage or
were automatically enrolled into a PY 20XX Marketplace medical coverage. Count
does not include plans that were canceled or terminated.
Count of unique individuals who returned to the Marketplace to actively select a
PY 20XX Marketplace medical plan, where the consumer had non-canceled PY
20XX Marketplace medical coverage on or after 11/1/20XX. Count does not include
plans that were canceled or terminated.
Count of active re-enrollees who were crosswalked into an alternate plan and
actively selected another plan than the crosswalked plan for 20XX.
Count of active re-enrollees who were crosswalked into an alternative plan and
actively selected their crosswalked plan.
Count of unique individuals who were automatically re-enrolled into a PY 20XX
Marketplace medical plan, where the consumer had non-canceled PY 20XX
Marketplace medical coverage on or after 11/1/20XX. Count does not include
plans that were canceled or terminated.
Total count of submitted electronic and paper applications. When a consumer is
renewed into a plan, whether automatic or active, that should be counted as an
application submission. Updated applications should not be counted as an
additional application.

1

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Indicator
6.1

Title
Number of Account Transfers (gross)

7

Consumers on Applications Submitted
(gross)

7.1

Consumers on Account Transfers (gross)

8

Consumers Determined or Assessed Eligible
for Medicaid/CHIP (gross)

9

Consumers Eligible for QHP (gross)

9.1

Consumers Eligible for QHP, with Financial
Assistance (gross)

Description
Total count of account transfers received by the Marketplace from Medicaid/CHIP
with at least one applicant determined ineligible for Medicaid or CHIP. This metric
only applies to SBEs that operate an account transfer process with the state
Medicaid/CHIP agency. An account transfer may also be counted as an application,
depending on the Marketplace.
Total count of individuals requesting coverage on submitted applications. Both
new consumers and consumers re-enrolling (automatic and active) in coverage
should be counted.
Total count of individuals on account transfers received by the Marketplace from
Medicaid/CHIP who were determined ineligible for Medicaid or CHIP. This metric
only applies to SBEs that operate an account transfer process with the state
Medicaid/CHIP agency.
Count of individuals on submitted applications who are determined or assessed
eligible for enrollment in Medicaid or CHIP. This includes both new consumers and
consumers re-enrolling (automatic and active) in coverage should be counted. This
count is a subset of Consumers on Applications Submitted (Indicator 7). Eligibility
for Medicaid/CHIP takes precedence over eligibility for a QHP without financial
assistance. Individuals determined eligible for both Medicaid/CHIP and a nonfinancial QHP should be counted, but should not be counted in Indicator 9.
Count of individuals on submitted applications who were determined eligible for
enrollment in a PY 20XX Marketplace medical plan, regardless of whether they
applied for or are eligible for financial assistance. Both new consumers and
consumers re-enrolling (automatic and active) in coverage should be counted. This
count is a subset of Consumers on Applications Submitted (Indicator 7). Eligibility
for Medicaid/CHIP takes precedence over eligibility for a QHP without financial
assistance. Individuals determined eligible for both Medicaid/CHIP and a nonfinancial QHP should not be counted.
Count of individuals on submitted applications who were determined eligible for
enrollment in a PY 20XX Marketplace medical plan and eligible to receive APTC
and/or CSRs. Both new consumers and consumers re-enrolling (automatic and
active) in coverage should be counted. This count is a subset of Consumers Eligible
for QHP (Indicator 9).

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Indicator
11
12

Title
Consumers with a 20XX Plan Selection as of
11/1/20XX
New Consumers without a Previous
Marketplace Application (net)

13

New Consumers with a Prior Application
but No Plan Selection (net)

14

New Consumers with a Prior Plan Selection
but No Coverage on November 1, 20XX
(net)

20

Cancellations and Terminations (gross)

Description
Count of unique individuals with non-canceled PY 20XX Marketplace medical
coverage as of 11/1/20XX.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer did not submit a PY 20XX Marketplace
application.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer submitted a PY 20XX Marketplace application
but did not make a plan selection for PY 20XX Marketplace medical coverage.
Count of unique individual with a non-canceled PY 20XX Marketplace medical plan
selection, where the consumer made a PY 20XX Marketplace medical plan
selection but did not have PY 20XX Marketplace medical coverage on or after
11/1/20XX.
Count of individuals who have canceled their PY 20XX Marketplace medical plan or
had their PY 20XX Marketplace medical plan terminated by the issuer or Exchange
during Open Enrollment. All cancellations and terminations should be counted. For
example, if an individual selects a plan in November and immediately cancels it,
then selects another plan in December and again immediately cancels it, both
cancellations should be counted.

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Exhibit 2: Financial Assistance/Premiums
Indicator Title
21
Number of Plan Selections with Federal
Financial Assistance (net)

21.1

Number of Plan Selections with a ≤ $10
Premium After APTC (net)

21.2

Number of Plan Selections with a $0
Premium After APTC (net)

22

Number of Plan Selections with both CSR
and APTC (net)

23

Number of Plan Selections with APTC only
(net)

24

Number of Plan Selections with CSR only
(net)

24.1

Number of Plan Selections with CSR (net)

24.2

Consumers with 73% Actuarial Value

Description
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer has elected to receive APTC in an amount
greater than $0 and/or receives CSRs. This count includes consumers with APTC
and CSRs (Indicator 22), consumers with only APTC (Indicator 23), and consumers
with only CSRs (Indicator 24).
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer has elected to receive APTC and their monthly
premium after APTC is less than or equal to $10.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer has elected to receive APTC and their monthly
premium after APTC is equal to $0.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer has elected to receive APTC in an amount
greater than $0 and receives CSRs. Count includes consumers with APTC and CSRs.
Consumers with only APTC or with only CSRs should not be counted.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer has elected to receive APTC in an amount
greater than $0. Consumers with CSRs should not be counted.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer receives CSR. Consumers with APTC should
not be counted. Count may include consumers who are eligible to receive APTC
but have elected not to receive APTC.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer receives CSR. Count includes consumers with
only CSRs or with both APTC and CSRs.
Count of consumers with a non-canceled PY 20XX Marketplace medical plan where
the consumer receives CSR and selected a silver plan with an actuarial value of
73% (or the state equivalent).

4

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Indicator
24.3

Title
Consumers with 87% Actuarial Value

Description
Count of consumers with a non-canceled PY 20XX Marketplace medical plan where
the consumer receives CSR and selected a silver plan with an actuarial value of
87% (or the state equivalent).

24.4

Consumers with 94% Actuarial Value

Count of consumers with a non-canceled PY 20XX Marketplace medical plan where
the consumer receives CSR and selected a silver plan with an actuarial value of
94% (or the state equivalent).

24.5

Consumers with CSRs, American
Indian/Alaska Native

Count of consumers who selected a non-canceled PY 20XX Marketplace medical
plan with CSRs reserved for members of federally recognized tribes and Alaska
Native Claims Settlement Act shareholders.

25

Number of Plan Selections without Federal
Financial Assistance (net)

26

Average Premium for All Consumers with a
Plan Selection (net)
Average Premium for all Consumers with a
Plan Selection after APTC (net)

Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer is not eligible to receive APTC, is eligible but
elects not to receive APTC, and/or does not receive CSRs.
The average per person monthly premium for all consumers with a non-canceled
PY 20XX Marketplace medical plan selection, before the application of any APTC.
The average per person monthly premium for all consumers with a non-canceled
PY 20XX Marketplace medical plan selection, after the application of any APTC.
That is, where the consumer receives APTC, the policy premium should be reduced
by the APTC amount before being included in the numerator. The denominator
should be the total covered lives.
The average per person monthly APTC for all consumers with a non-canceled PY
20XX Marketplace medical plan selection, who have elected to receive an APTC
amount greater than $0.
The average per person monthly premium for all consumers with a non-canceled
PY 20XX Marketplace medical plan selection, who have elected to receive an APTC
amount greater than $0, after the application of APTC.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer has elected to receive federal financial
assistance (Indicator 21) and/or financial assistance from a state premium or cost
sharing subsidy program. States with no state subsidy program should mark N/A.

27

28

Average APTC Amount for All Consumers
with a Plan Selection Receiving APTC (net)

29

Average Premium after APTC for All
Consumers with a Plan Selection Receiving
APTC (net)
Number of Plan Selections with Any
Financial Assistance (net)

29.1

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Indicator
29.2

Title
Number of Plan Selections with a ≤ $10
Premium After APTC and State Premium
Subsidy (net)

29.3

Average Premium for all Consumers with a
Plan Selection after APTC and State
Premium Subsidy (net)

29.4

Average Premium after APTC and State
Premium Subsidy for All Consumers with a
Plan Selection Receiving APTC and State
Premium Subsidy (net)
Number of Plan Selections without Any
Financial Assistance (net)

29.5

Exhibit 3: Demographics
Indicator Title
30
Number of Plan Selections where age is 0 17 (net)
31

Number of Plan Selections where age is 18 25 (net)

31.1

Number of Plan Selections where age is 26 34 (net)

Description
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer has elected to receive APTC and/or financial
assistance from a state premium subsidy program, and their monthly premium
after APTC and the state premium subsidy is less than or equal to $10.
The average per person monthly premium for all consumers with a non-canceled
PY 20XX Marketplace medical plan selection, after the application of any APTC and
financial assistance from a state premium subsidy program. That is, where the
consumer receives APTC and/or financial assistance from a state premium subsidy
program, the policy premium should be reduced by the APTC amount and state
subsidy amount before being included in the numerator. The denominator should
be the total covered lives.
The average per person monthly premium for all consumers with a non-canceled
PY 20XX Marketplace medical plan selection, who have elected to receive an APTC
amount greater than $0, and/or financial assistance from a state premium subsidy
program, after the application of APTC and the state subsidy amount.
Count of unique individuals with a non-canceled PY 20XX Marketplace medical
plan selection, where the consumer is not eligible to receive APTC, is eligible but
elects not to receive APTC, does not receive CSRs, and does not receive financial
assistance from a state premium or cost sharing subsidy program. States with no
state subsidy program should mark N/A.

Description
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who are age of 0 - 17. Age represents the recorded
age as of the policy effective coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who age of 18 - 25. Age represents the recorded
age as of the policy effective coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who are age 26 - 34. Age represents the recorded
age as of the policy effective coverage date.

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Indicator
32

Title
Number of Plan Selections where age is 35 44 (net)

32.1

Number of Plan Selections where age is 45 54 (net)

33

Number of Plan Selections where age is 55 64 (net)

33.1

Number of Plan Selections where age is ≥
65 (net)

34

Number of Plan Selections where age is
unknown (net)

35

Number of Plan Selections where sex is
Female (net)
Number of Plan Selections where sex is
Male (net)
Number of Plan Selections where sex is
Unknown (net)
Number of Plan Selections where Ethnicity
is Hispanic or Latino (net)

36
37
38

39

Number of Plan Selections where Race is
White (net)

Description
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who are age of 35 - 44. Age represents the recorded
age as of the policy effective coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who are age 45 - 54. Age represents the recorded
age as of the policy effective coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who are age of 55 - 64. Age represents the recorded
age as of the policy effective coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who are age ≥ 65. Age represents the recorded age
as of the policy effective coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and whose age is unknown. Age represents the
recorded age as of the policy effective coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who attested that they are female.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who attested that they are male.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan whose sex is unknown.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who have indicated they are Mexican, Mexican
American or Chicano/a, Puerto Rican, Cuban, or “other Hispanic or Latino
ethnicity” on their application. Individuals who have indicated that they are
Hispanic or Latino should be counted, regardless of the race selection on their
application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who have indicated they are white on their
application. Individuals who have indicated that they are white should be counted,
regardless of the ethnicity selection on their application.

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Indicator
39.1

Title
Number of Plan Selections where
Race/Ethnicity is White, Non-Hispanic (net)

40

Number of Plan Selections where Race is
African American (net)

40.1

Number of Plan Selections where
Race/Ethnicity is African American, NonHispanic (net)

41

Number of Plan Selections where Race is
Asian (net)

41.1

Number of Plan Selections where
Race/Ethnicity is Asian, Non-Hispanic (net)

42

Number of Plan Selections where Race is
Native Hawaiian/Pacific Islander (net)

Description
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who 1. Indicated that they are white on their
application and 2. Indicated that their ethnicity is not Hispanic or Latino or did not
indicate that their ethnicity is Hispanic or Latino on their application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who have indicated they are black or African
American on their application. Individuals who have indicated that they are black
or African American should be counted, regardless of the ethnicity selection on
their application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who 1. Indicated that they are black or African
American on their application and 2. Indicated that their ethnicity is not Hispanic
or Latino or did not indicate that their ethnicity is Hispanic or Latino on their
application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who have indicated they are Asian Indian, Chinese,
Filipino, Korean, Vietnamese, Japanese, or “other Asian” on their application.
Individuals who have indicated that they are Asian should be counted, regardless
of the ethnicity selection on their application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who 1. Indicated that they are Asian Indian,
Chinese, Filipino, Korean, Vietnamese, Japanese, or “other Asian” on their
application and 2. Indicated that their ethnicity is not Hispanic or Latino or did not
indicate that their ethnicity is Hispanic or Latino on their application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who have indicated they are Guamanian or
Chamorro, Native Hawaiian, Samoan, or “Other Pacific Islander” on their
application. Individuals who have indicated that they are Native Hawaiian or
Pacific Islander should be counted, regardless of the ethnicity selection on their
application.

8

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Indicator
42.1

Title
Number of Plan Selections where
Race/Ethnicity is Native Hawaiian/Pacific
Islander, Non-Hispanic (net)

43

Number of Plan Selections where Race is
American Indian/Alaska Native (net)

43.1

Number of Plan Selections where
Race/Ethnicity is American Indian/Alaska
Native, Non-Hispanic (net)

43.2

Number of Plan Selections where Race is
Middle Eastern/North African (net)

43.3

Number of Plan Selections where Race is
Middle Eastern/North African, NonHispanic (net)

44

Number of Plan Selections where Race is
Multi-Racial (net)

Description
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who 1. Indicated that they are Guamanian or
Chamorro, Native Hawaiian, Samoan, or “other Pacific Islander” on their
application and 2. Indicated that their ethnicity is not Hispanic or Latino or did not
indicate that their ethnicity is Hispanic or Latino on their application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who have indicated they were American Indian or
Alaska Native on their application. Individuals who have indicated that they are
American Indian or Alaska Native should be counted, regardless of the ethnicity
selection on their application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who 1. Indicated that they are American Indian or
Alaska Native on their application and 2. Indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who have indicated they are Lebanese, Iranian,
Egyptian, Syrian, Iraqi, and Israeli, or “other Middle Eastern or North African” on
their application. Individuals who have indicated that they are Middle Eastern or
North African should be counted, regardless of the ethnicity selection on their
application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who 1. Indicated that they are Lebanese, Iranian,
Egyptian, Syrian, Iraqi, and Israeli, or “other Middle Eastern or North African” and
2. Indicated that their ethnicity is not Hispanic or Latino or did not indicate that
their ethnicity is Hispanic or Latino on their application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who have indicated more than one distinct racial:
American Indian / Alaska Native, Asian, Native Hawaiian / Pacific Islander, AfricanAmerican, Middle Eastern / North African, and White on their application.
Individuals who have indicated more than one racial group should be counted,
regardless of the ethnicity selection on their application.

9

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Indicator
44.1

Title
Number of Plan Selections where
Race/Ethnicity is Multi-Racial, Non-Hispanic
(net)

45

Number of Plan Selections where
Race/Ethnicity is Unknown, Non-Hispanic
(net)

45.1

Number of Plan Selections where Race is
Other (net)

45.2

Number of Plan Selections where
Race/Ethnicity is Other, Non-Hispanic (net)

46

Number of Plan Selections where Metal
Level is Platinum (net)
Number of Plan Selections where Metal
Level is Gold (net)
Number of Plan Selections where Metal
Level is Silver (net)
Number of Plan Selections where Metal
Level is Bronze (net)
Number of Plan Selections where Metal
Level is Catastrophic (net)
Consumers with a Plan Selection and
Income < 100%

47
48
49
50
51

Description
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who 1. Have indicated more than one distinct racial
group: American Indian / Alaska Native, Asian, Native Hawaiian / Pacific Islander,
African-American, Middle Eastern / North African, and White, on their application
and 2. Indicated that their ethnicity is not Hispanic or Latino or did not indicate
that their ethnicity is Hispanic or Latino on their application should be counted.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who 1. Did not indicate a race on their application
and 2. Indicated that their ethnicity is not Hispanic or Latino or did not indicate
that their ethnicity is Hispanic or Latino on their application.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who have indicated another race or “Other” on
their application. Individuals should be counted, regardless of the ethnicity
selection on their application. This does not include individuals who are already
counted in indicators 39-45 and indicated other Asian, other Pacific Islander, etc.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who 1. Indicated another race or “Other” on their
application and 2. Indicated that their ethnicity is not Hispanic or Latino or did not
indicate that their ethnicity is Hispanic or Latino on their application. This does not
include individuals who are already counted in indicators 38-45 and indicated
other Hispanic or Latino, other Asian, other Pacific Islander, etc.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan where the metal level is Platinum.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan where the metal level is Gold.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan where the metal level is Silver.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan where the metal level is Bronze.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan where the metal level is Catastrophic.
Count of unique individuals in households with income less than 100% of FPL who
have selected a non-canceled PY 20XX Marketplace medical plan.
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Indicator
52

52.1

53

54

54.1

54.2

54.3

55
55.1
56

Title
Consumers with a Plan Selection and
Income ≥ 100% FPL and ≤ 150% FPL (net)

Description
Count of unique individuals in households with income greater than or equal to
100% and less than or equal to 150% of FPL who have selected a non-canceled PY
20XX Marketplace medical plan.
Consumers with a Plan Selection and
Count of unique individuals in households with income greater than or equal to
Income ≥ 100% FPL and ≤ 138% FPL (net)
100% and less than or equal to 138% of FPL who have selected a non-canceled PY
20XX Marketplace medical plan.
Consumers with a Plan Selection and
Count of unique individuals in households with income greater than 150% and less
Income > 150% FPL and ≤ 200% FPL (net)
than or equal to 200% of FPL who have selected a non-canceled PY 20XX
Marketplace medical plan.
Consumers with a Plan Selection and
Count of unique individuals in households with income greater than 200% and less
Income > 200% FPL and ≤ 250% FPL (net)
than or equal to 250% of FPL who have selected a non-canceled PY 20XX
Marketplace medical plan.
Consumers with a Plan Selection and
Count of unique individuals in households with income greater than 250% and less
Income > 250% FPL and ≤ 300% FPL (net)
than or equal to 300% of FPL who have selected a non-canceled PY 20XX
Marketplace medical plan.
Consumers with a Plan Selection and
Count of unique individuals in households with income greater than 300% and less
Income > 300% FPL and ≤ 350% FPL (net)
than or equal to 350% of FPL who have selected a non-canceled PY 20XX
Marketplace medical plan.
Consumers with a Plan Selection and
Count of unique individuals in households with income greater than 350% and less
Income > 350% FPL and ≤ 400% FPL (net)
than or equal to 400% of FPL who have selected a non-canceled PY 20XX
Marketplace medical plan.
Consumers with a Plan Selections and
Count of unique individuals in households with income greater than 400% who
Income > 400% FPL (net)
have selected a non-canceled PY 20XX Marketplace medical plan.
Consumers with a Plan Selection and
Count of unique individuals in households with income greater than 500% of FPL
Income > 500% FPL (net)
who have selected a non-canceled PY 20XX Marketplace medical plan.
Number of Plan Selections where Income as Count of unique individuals in households with non-reported income and who
a Percent of FPL is Unknown (net)
have selected a non-canceled PY 20XX Marketplace medical plan. Count should
include individuals who do not report income because they are not requesting
financial assistance.

Exhibit 4: Operations

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Indicator
57

Title
Call Center Volume

58

Call Center Wait Time (in seconds)

59

Call Center Calls Abandoned

60

Average Call Handle Time (in seconds)

61

Number of Website Visits

62

Number of Website Unique Visitors

63

Planned Website Downtime

64

Unplanned Website Downtime (gross)

65

Plan Selections with Any Assistance (net)

66

Plan Selections with Agent/Broker
Assistance (net)

Description
The total number of incoming calls received by the call center. Repeat calls from
the same number should be counted separately.
The average wait time, rounded to the nearest second, for each incoming call to
the call center.
The number of incoming calls terminated while waiting to speak to a call center
representative.
The average amount of time, rounded to the nearest second, spent by call center
representatives on each individual call.
The count of webpage and mobile application visits of each IP address that has not
made a webpage or mobile application visit within the last 30 minutes. For
example, if IP address 147.194.0.3 requests the webpage at 12:30 PM and 1:01
PM, that gets counted as 2 visits. If IP address 147.194.0.3 requests the webpage
at 1:24, 1:54, and 1:56, this counts as 1 visit. At 1:24, there was no previous
request within 30 minutes; at 1:54, there was a previous request exactly 30
minutes prior, and at 1:56 there was a previous request at 1:54. A subsequent
request by that same IP address at 3:00 PM would be a new visit.
The count of the unique IP addresses requesting the webpage or mobile
application (e.g. IP 147.194.0.3 requests, gets counted as 1 unique visitor). A single
person using dynamic IP address assignment (identified by login to the same
Exchange account or some other method) should still be counted as two unique
visitors if the IP addresses differ at the time of login.
The amount of planned downtime for the Exchange website, rounded to the
nearest second.
The amount of unplanned downtime for the Exchange website, rounded to the
nearest second.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who received any form of personal assistance with
enrollment. Assistance may have been provided by a navigator, certified
application counselor (CAC), in-person assister, the call center, agent, or broker.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who received personal assistance with enrollment
from an agent or broker. This count should only include individuals who received
assistance from an agent or broker.
12

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
67

Title
Plan Selections with Other Assistance (net)

67.1

Plan Selections with Call Center Assistance
(net)

67.2

Plan Selections with Navigator, In-Person
Assistance (net)

68

Plan Selections with No Assistance (net)

68.1

Plan Selections through Direct Enrollment
Channel

Exhibit 5: Issuers
Indicator Title
Plan Selection by Issuer: Issuer 1
69
Plan Selection by Issuer: Issuer 2
70
Plan Selection by Issuer: Issuer 3
71
Plan Selection by Issuer: Issuer 4
72
Plan Selection by Issuer: Issuer 5
73
Plan Selection by Issuer: Issuer 6
74
Plan Selection by Issuer: Issuer 7
75
Plan Selection by Issuer: Issuer 8
76
Plan Selection by Issuer: Issuer 9
77

Description
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who received personal assistance with enrollment
from someone other than an agent or broker. This count should only include
individuals who received assistance from a source other than an agent or broker.
Such assistance may have been provided by a navigator, certified application
counselor (CAC), the call center, or in-person assister.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who received personal assistance with enrollment
from a call center worker or representative. This count should not include
individuals who received assistance from an agent or broker.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who received personal assistance with enrollment
from a navigator, certified application counselor (CAC) or in-person assister. This
count should not include individuals who received assistance from an agent or
broker.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and who received no personal assistance with
enrollment.
Count of unique individuals who have selected a non-canceled PY 20XX
Marketplace medical plan and whose applications was received through a direct
enrollment channel.

Description
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
13

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
78
79
80
81
82
83
83.1
83.2
83.3
83.4
83.5
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
98.1
98.2
98.3
98.4
98.5

Title
Plan Selection by Issuer: Issuer 10
Plan Selection by Issuer: Issuer 11
Plan Selection by Issuer: Issuer 12
Plan Selection by Issuer: Issuer 13
Plan Selection by Issuer: Issuer 14
Plan Selection by Issuer: Issuer 15
Plan Selection by Issuer: Issuer 16
Plan Selection by Issuer: Issuer 17
Plan Selection by Issuer: Issuer 18
Plan Selection by Issuer: Issuer 19
Plan Selection by Issuer: Issuer 20
Name Issuer 1
Name Issuer 2
Name Issuer 3
Name Issuer 4
Name Issuer 5
Name Issuer 6
Name Issuer 7
Name Issuer 8
Name Issuer 9
Name Issuer 10
Name Issuer 11
Name Issuer 12
Name Issuer 13
Name Issuer 14
Name Issuer 15
Name Issuer 16
Name Issuer 17
Name Issuer 18
Name Issuer 19
Name Issuer 20

Description
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Number of Individuals Selecting a QHP by Issuer.
Name of Issuer 1.
Name of Issuer 2.
Name of Issuer 3.
Name of Issuer 4.
Name of Issuer 5.
Name of Issuer 6.
Name of Issuer 7.
Name of Issuer 8.
Name of Issuer 9.
Name of Issuer 10.
Name of Issuer 11.
Name of Issuer 12.
Name of Issuer 13.
Name of Issuer 14.
Name of Issuer 15.
Name of Issuer 16.
Name of Issuer 17.
Name of Issuer 18.
Name of Issuer 19.
Name of Issuer 20.

14

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Exhibit 6: Stand-alone Dental Plans
Indicator Title
99
Total SADP Plan Selections (net)
100

Number of SADP Plan Selections where age
is 0 - 17 (net)

101

Number of SADP Plan Selections where age
18 - 25 (net)

101.1

Number of SADP Plan Selections where age
is 26 - 34 (net)

102

Number of SADP Plan Selections where age
35 - 44 (net)

102.1

Number of SADP Plan Selections where age
is 45 - 54 (net)

102.2

Number of SADP Plan Selections where age
is 55 - 64 (net)

103

Number of SADP Plan Selections where age
≥65 (net)

104

Number of SADP Plan Selections where age
is unknown (net)

105

Number of SADP Plan Selections where sex
is Female (net)
Number of SADP Plan Selections where sex
is Male (net)
Number of SADP Plan Selections where sex
is unknown (net)

106
107

Description
Count of unique individuals who have selected a PY 20XX SADP. Count does not
include plans that were canceled or terminated.
Count of unique individuals who have selected a non-canceled PY 20XX SADP and
who are age 0 - 17. Age represents the recorded age as of the policy effective
coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX SADP and
who are age 18 - 25. Age represents the recorded age as of the policy effective
coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX SADP and
who are age 26 - 34. Age represents the recorded age as of the policy effective
coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX SADP and
who are age 35 - 44. Age represents the recorded age as of the policy effective
coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX SADP and
who are age 45 - 54. Age represents the recorded age as of the policy effective
coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX SADP and
who are age 55 - 64. Age represents the recorded age as of the policy effective
coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX SADP and
who are age ≥65. Age represents the recorded age as of the policy effective
coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX SADP and
whose age is unknown. Age represents the recorded age as of the policy effective
coverage date.
Count of unique individuals who have selected a non-canceled PY 20XX SADP and
whose sex is Female, according to the selected policy.
Count of unique individuals who have selected a non-canceled PY 20XX SADP and
whose sex is Male, according to the selected policy.
Count of unique individuals who have selected a non-canceled PY 20XX SADP and
whose sex is unknown, according to the selected policy.
15

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

16

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Exhibit 7: Metal Level by Age, Income, Sex, and Race/Ethnicity
Indicator Title
Description
108
Silver plans selected by consumers age 0 Count of individuals who selected a silver medical plan (Indicator 48) and are in
17 (net)
the 0 - 17 age group (Indicator 30).
109
Silver plans selected by consumers age 18 Count of individuals who selected a silver medical plan (Indicator 48) and are in
25 (net)
the 18 - 25 age group (Indicator 31).
109.1
Silver plans selected by consumers age 26 - Count of individuals who selected a silver medical plan (Indicator 48) and are in the
34 (net)
26 - 34 age group (Indicator 31.1).
110
Silver plans selected by consumers age 35 Count of individuals who selected a silver medical plan (Indicator 48) and are in
44 (net)
the 35 - 44 age group (Indicator 32).
110.1
Silver plans selected by consumers age 45 - Count of individuals who selected a silver medical plan (Indicator 48) and are in the
54 (net)
45 - 54 age group (Indicator 32.1).
110.2
Silver plans selected by consumers age 55 - Count of individuals who selected a silver medical plan (Indicator 48) and are in the
64 (net)
55 - 64 age group (Indicator 33).
111
Silver plans selected by consumers age ≥65 Count of individuals who selected a silver medical plan (Indicator 48) and are in the
(net)
≥ 65 age group (Indicator 33.1).
112
Silver plans selected by consumers age is
Count of individuals who selected a silver medical plan (Indicator 48) and whose
unknown (net)
age is unknown (Indicator 34).
113
Bronze plans selected by consumers age 0 - Count of individuals who selected a bronze medical plan (Indicator 49) and are in
17 (net)
the 0 - 17 age group (Indicator 30).
114
Bronze plans selected by consumers age 18 Count of individuals who selected a bronze medical plan (Indicator 49) and are in
- 25 (net)
the 18 - 25 age group (Indicator 31).
114.1
Bronze plans selected by consumers age 26 Count of individuals who selected a bronze medical plan (Indicator 49) and are in
- 34 (net)
the 26 - 34 age group (Indicator 31.1).
115
Bronze plans selected by consumers age 35 Count of individuals who selected a bronze medical plan (Indicator 49) and are in
- 44 (net)
the 35 - 44 age group (Indicator 32).
115.1
Bronze plans selected by consumers age 45 Count of individuals who selected a bronze medical plan (Indicator 49) and are in
- 54 (net)
the 45 - 54 age group (Indicator 32.1).
115.2
Bronze plans selected by consumers age 55 Count of individuals who selected a bronze medical plan (Indicator 49) and are in
- 64 (net)
the 55 - 64 age group (Indicator 33).
116
Bronze plans selected by consumers age
Count of individuals who selected a bronze medical plan (Indicator 49) and are in
≥65 (net)
the ≥ 65 age group (Indicator 33.1).

17

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
117
117.1
117.2
117.3
117.4
117.5
117.6
117.7
117.8
190
191
192
193
194
195
196

Title
Bronze plans selected by consumers age is
unknown (net)
Gold Plans selected by consumers ages 0-17
(net)
Gold Plans selected by consumers ages 1825 (net)
Gold Plans selected by consumers ages 2634 (net)
Gold plans selected by consumers aged 35 –
44 (net)
Gold Plans selected by consumers ages 4554 (net)
Gold Plans selected by consumers ages 5564 (net)
Gold Plans selected by consumers ages ≥ 65
(net)
Gold Plans selected by consumers whose
age is unknown (net)
Platinum Plans selected by consumers ages
0-17 (net)
Platinum Plans selected by consumers ages
18-25 (net)
Platinum Plans selected by consumers ages
26-34 (net)
Platinum plans selected by consumers aged
35 – 44 (net)
Platinum Plans selected by consumers ages
45-54 (net)
Platinum Plans selected by consumers ages
55-64 (net)
Platinum Plans selected by consumers ages
≥ 65 (net)

Description
Count of individuals who selected a bronze medical plan (Indicator 49) and whose
age is unknown (Indicator 34).
Count of individuals who selected a gold medical plan (Indicator 47) and are in the
0 - 17 age group (Indicator 30).
Count of individuals who selected a gold medical plan (Indicator 47) and are in the
18 - 25 age group (Indicator 31).
Count of individuals who selected a gold medical plan (Indicator 47) and are in the
26 - 34 age group (Indicator 31.1).
Count of individuals who selected a gold medical plan (Indicator 47) and are in the
35 - 44 age group (Indicator 32).
Count of individuals who selected a gold medical plan (Indicator 47) and are in the
45 - 54 age group (Indicator 32.1).
Count of individuals who selected a gold medical plan (Indicator 47) and are in the
55 - 64 age group (Indicator 33).
Count of individuals who selected a gold medical plan (Indicator 47) and are in the
≥ 65 age group (Indicator 33.1).
Count of individuals who selected a gold medical plan (Indicator 47) and whose
age is unknown (Indicator 34). ]
Count of individuals who selected a platinum medical plan (Indicator 46) and are in
the 0 - 17 age group (Indicator 30).
Count of individuals who selected a platinum medical plan (Indicator 46) and are in
the 18 - 25 age group (Indicator 31).
Count of individuals who selected a platinum medical plan (Indicator 46) and are in
the 26 - 34 age group (Indicator 31.1).
Count of individuals who selected a platinum medical plan (Indicator 46) and are in
the 35 - 44 age group (Indicator 32).
Count of individuals who selected a platinum medical plan (Indicator 46) and are in
the 45 - 54 age group (Indicator 32.1).
Count of individuals who selected a platinum medical plan (Indicator 46) and are in
the 55 - 64 age group (Indicator 33).
Count of individuals who selected a platinum medical plan (Indicator 46) and are in
the ≥ 65 age group (Indicator 33.1).
18

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
197
198
199
200
201
202
203
204
205
118
118.1

Title
Platinum Plans selected by consumers
whose age is unknown (net)
Catastrophic Plans selected by consumers
ages 0-17 (net)
Catastrophic Plans selected by consumers
ages 18-25 (net)
Catastrophic Plans selected by consumers
ages 26-34 (net)
Catastrophic plans selected by consumers
aged 35 – 44 (net)
Catastrophic Plans selected by consumers
ages 45-54 (net)
Catastrophic Plans selected by consumers
ages 55-64 (net)
Catastrophic Plans selected by consumers
ages ≥ 65 (net)
Catastrophic Plans selected by consumers
whose age is unknown (net)
Silver plans selected by consumers with
income < 100% FPL (net)
Silver plans selected by consumers with
income ≥ 100% FPL and ≤ 138% FPL (net)

119

Silver plans selected by consumers with
income ≥ 100% FPL and ≤ 150% FPL (net)

120

Silver plans selected by consumers with
income > 150% FPL and ≤ 200% FPL (net)

121

Silver plans selected by consumers with
income > 200% FPL and ≤ 250% FPL (net)

Description
Count of individuals who selected a platinum medical plan (Indicator 46) and
whose age is unknown (Indicator 34).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
are in the 0 - 17 age group (Indicator 30).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
are in the 18 - 25 age group (Indicator 31).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
are in the 26 - 34 age group (Indicator 31.1).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
are in the 35 - 44 age group (Indicator 32).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
are in the 45 - 54 age group (Indicator 32.1).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
are in the 55 - 64 age group (Indicator 33).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
are in the ≥ 65 age group (Indicator 33.1).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
whose age is unknown (Indicator 34).
Count of individuals in households with income less than 100% of FPL (Indicator
51) who have selected a silver medical plan (Indicator 48).
Count of individuals in households with income greater than or equal to 100% and
less than or equal to 138% of FPL (Indicator 52.1) who have selected a silver
medical plan (Indicator 48).
Count of individuals in households with income greater than or equal to 100% and
less than or equal to 150% of FPL (Indicator 52) who have selected a silver medical
plan (Indicator 48).
Count of individuals in households with income greater than 150% and less than or
equal to 200% of FPL (Indicator 53) who have selected a silver medical plan
(Indicator 48).
Count of individuals in households with income greater than 200% and less than or
equal to 250% of FPL (Indicator 54) who have selected a silver medical plan
(Indicator 48).
19

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
121.1

Title
Silver plans selected by consumers with
income > 250% PL and ≤ 300% FPL (net)

121.2

Silver plans selected by consumers with
income > 300% FPL and ≤ 350% FPL (net)

121.3

Silver plans selected by consumers with
income > 350% FPL and ≤ 400% FPL (net)

122

Silver plans selected by consumers with
income > 400% (net)
Silver plans selected by consumers with
income > 500% FPL (net)
Silver plans selected by consumers whose
income is unknown (net)
Bronze plans selected by consumers with
income < 100% FPL (net)
Bronze plans selected by consumers with
income ≥ 100% FPL and ≤ 138% FPL (net)

122.1
123
124
124.1

125

Bronze plans selected by consumers with
income ≥ 100% FPL and ≤ 150% FPL (net)

126

Bronze plans selected by consumers with
income > 150% FPL and ≤ 200% FPL (net)

127

Bronze plans selected by consumers with
income > 200% FPL and ≤ 250% FPL (net)

127.1

Bronze plans selected by consumers with
income > 250% FPL and ≤ 300% FPL (net)

Description
Count of individuals in households with income greater than 250% and less than or
equal to 300% of FPL (Indicator 54.1) who have selected a silver medical plan
(Indicator 48).
Count of individuals in households with income greater than 300% and less than or
equal to 350% of FPL (Indicator 54.2) who have selected a silver medical plan
(Indicator 48).
Count of individuals in households with income greater than 350% and less than or
equal to 400% of FPL (Indicator 54.3) who have selected a silver medical plan
(Indicator 48).
Count of individuals in households with income greater than 400% of FPL
(Indicator 55) who have selected a silver medical plan (Indicator 48).
Count of individuals in households with income greater than 500% of FPL
(Indicator 55.1) who have selected a silver medical plan (Indicator 48).
Count of individuals in households whose income is unknown (Indicator 56) and
have selected a silver medical plan (Indicator 48).
Count of individuals in households with income less than 100% of FPL (Indicator
51) who have selected a bronze medical plan (Indicator 49).
Count of individuals in households with income greater than or equal to 100% and
less than or equal to 138% of FPL (Indicator 52.1) who have selected a bronze
medical plan (Indicator 49).
Count of individuals in households with income greater than or equal to 100% and
less than or equal to 150% of FPL (Indicator 52) who have selected a bronze
medical plan (Indicator 49).
Count of individuals in households with income greater than 150% and less than or
equal to 200% of FPL (Indicator 53) who have selected a bronze medical plan
(Indicator 49).
Count of individuals in households with income greater than 200% and less than or
equal to 250% of FPL (Indicator 54) who have selected a bronze medical plan
(Indicator 49).
Count of individuals in households with income greater than 250% and less than or
equal to 300% of FPL (Indicator 54.1) who have selected a bronze medical plan
(Indicator 49).

20

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
127.2

Title
Bronze plans selected by consumers with
income > 300% FPL and ≤ 350% FPL (net)

127.3

Bronze plans selected by consumers with
income > 350% FPL and ≤ 400% FPL (net)

128

Bronze plans selected by consumers with
income > 400% FPL (net)
Bronze plans selected by consumers with
income > 500% FPL (net)
Bronze plans selected by consumers whose
income is unknown (net)
Gold plans selected by consumers with
income < 100% FPL (net)
Gold plans selected by consumers with
income ≥ 100% FPL and ≤ 150% FPL (net)

128.1
129
129.1
129.2

129.3

Gold plans selected by consumers with
income > 150% FPL and ≤ 200% FPL (net)

129.4

Gold plans selected by consumers with
income > 200% FPL and ≤ 250% FPL (net)

129.5

Gold plans selected by consumers with
income > 250% FPL and ≤ 300% FPL (net)

129.6

Gold plans selected by consumers with
income > 300% FPL and ≤ 350% FPL (net)

129.7

Gold plans selected by consumers with
income > 350% FPL and ≤ 400% FPL (net)

Description
Count of individuals in households with income greater than 300% and less than or
equal to 350% of FPL (Indicator 54.2) who have selected a bronze medical plan
(Indicator 49).
Count of individuals in households with income greater than 350% and less than or
equal to 400% of FPL (Indicator 54.3) who have selected a bronze medical plan
(Indicator 49).
Count of individuals in households with income greater than 400% of FPL
(Indicator 55) who have selected a bronze medical plan (Indicator 49).
Count of individuals in households with income greater than 500% of FPL
(Indicator 55.1) who have selected a bronze medical plan (Indicator 49).
Count of individuals in households whose income is unknown (Indicator 56) and
have selected a bronze medical plan (Indicator 49).
Count of individuals in households with income less than 100% of FPL (Indicator
51) who selected a gold medical plan (Indicator 47).
Count of individuals in households with income greater than or equal to 100% and
less than or equal to 150% of FPL (Indicator 52) who have selected a gold medical
plan (Indicator 47).
Count of individuals in households with income greater than 150% and less than or
equal to 200% of FPL (Indicator 53) who selected a gold medical plan (Indicator
47).
Count of individuals in households with income greater than 200% and less than or
equal to 250% of FPL (Indicator 54) who selected a gold medical plan (Indicator
47).
Count of individuals in households with income greater than 250% and less than or
equal to 300% of FPL (Indicator 54.1) who selected a gold medical plan (Indicator
47).
Count of individuals in households with income greater than 300% and less than or
equal to 350% of FPL (Indicator 54.2) who selected a gold medical plan (Indicator
47).
Count of individuals in households with income greater than 350% and less than or
equal to 400% of FPL (Indicator 54.3) who selected a gold medical plan (Indicator
47).

21

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
129.8
129.8.1
129.9
206
207

Title
Gold plans selected by consumers with
income > 400% FPL (net)
Gold plans selected by consumers with
income > 500% FPL (net)
Gold plans selected by consumers whose
income is unknown (net)
Platinum plans selected by consumers with
income < 100% FPL (net)
Platinum plans selected by consumers with
income ≥ 100% FPL and ≤ 150% FPL (net)

208

Platinum plans selected by consumers with
income > 150% FPL and ≤ 200% FPL (net)

209

Platinum plans selected by consumers with
income > 200% FPL and ≤ 250% FPL (net)

210

Platinum plans selected by consumers with
income > 250% FPL and ≤ 300% FPL (net)

211

Platinum plans selected by consumers with
income > 300% FPL and ≤ 350% FPL (net)

212

Platinum plans selected by consumers with
income > 350% FPL and ≤ 400% FPL (net)

213

Platinum plans selected by consumers with
income > 400% FPL (net)
Platinum plans selected by consumers with
income > 500% FPL (net)
Platinum plans selected by consumers
whose income is unknown (net)

214
215

Description
Count of individuals in households with income greater than 400% of FPL
(Indicator 55) who have selected a gold medical plan (Indicator 47).
Count of individuals in households with income greater than 500% of FPL
(Indicator 55.1) who have selected a gold medical plan (Indicator 47).
Count of individuals in households whose income is unknown (Indicator 56) and
have selected a gold medical plan (Indicator 47).
Count of individuals in households with income less than 100% of FPL (Indicator
51) who selected a platinum medical plan (Indicator 46).
Count of individuals in households with income greater than or equal to 100% and
less than or equal to 150% of FPL (Indicator 52) who have selected a platinum
medical plan (Indicator 46).
Count of individuals in households with income greater than 150% and less than or
equal to 200% of FPL (Indicator 53) who selected a platinum medical plan
(Indicator 46).
Count of individuals in households with income greater than 200% and less than or
equal to 250% of FPL (Indicator 54) who selected a platinum medical plan
(Indicator 46).
Count of individuals in households with income greater than 250% and less than or
equal to 300% of FPL (Indicator 54.1) who selected a platinum medical plan
(Indicator 46).
Count of individuals in households with income greater than 300% and less than or
equal to 350% of FPL (Indicator 54.2) who selected a platinum medical plan
(Indicator 46).
Count of individuals in households with income greater than 350% and less than or
equal to 400% of FPL (Indicator 54.3) who selected a platinum medical plan
(Indicator 46).
Count of individuals in households with income greater than 400% of FPL
(Indicator 55) who have selected a platinum medical plan (Indicator 46).
Count of individuals in households with income greater than 500% of FPL
(Indicator 55.1) who have selected a platinum medical plan (Indicator 46).
Count of individuals in households whose income is unknown (Indicator 56) and
have selected a platinum medical plan (Indicator 46).
22

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
216
217

218

219

220

221

222

223
224
225
226
227
228

Title
Catastrophic plans selected by consumers
with income < 100% FPL (net)
Catastrophic plans selected by consumers
with income ≥ 100% FPL and ≤ 150% FPL
(net)
Catastrophic plans selected by consumers
with income > 150% FPL and ≤ 200% FPL
(net)
Catastrophic plans selected by consumers
with income > 200% FPL and ≤ 250% FPL
(net)
Catastrophic plans selected by consumers
with income > 250% FPL and ≤ 300% FPL
(net)
Catastrophic plans selected by consumers
with income > 300% FPL and ≤ 350% FPL
(net)
Catastrophic plans selected by consumers
with income > 350% FPL and ≤ 400% FPL
(net)
Catastrophic plans selected by consumers
with income > 400% FPL (net)
Catastrophic plans selected by consumers
with income > 500% FPL (net)
Catastrophic plans selected by consumers
whose income is unknown (net)
Bronze selected by consumers whose sex is
Female (net)
Silver plans selected by consumers whose
sex is Female (net)
Gold plans selected by consumers whose
sex is Female (net)

Description
Count of individuals in households with income less than 100% of FPL (Indicator
51) who selected a catastrophic medical plan (Indicator 50).
Count of individuals in households with income greater than or equal to 100% and
less than or equal to 150% of FPL (Indicator 52) who have selected a catastrophic
medical plan (Indicator 50).
Count of individuals in households with income greater than 150% and less than or
equal to 200% of FPL (Indicator 53) who selected a catastrophic medical plan
(Indicator 50).
Count of individuals in households with income greater than 200% and less than or
equal to 250% of FPL (Indicator 54) who selected a catastrophic medical plan
(Indicator 50).
Count of individuals in households with income greater than 250% and less than or
equal to 300% of FPL (Indicator 54.1) who selected a catastrophic medical plan
(Indicator 50).
Count of individuals in households with income greater than 300% and less than or
equal to 350% of FPL (Indicator 54.2) who selected a catastrophic medical plan
(Indicator 50).
Count of individuals in households with income greater than 350% and less than or
equal to 400% of FPL (Indicator 54.3) who selected a catastrophic medical plan
(Indicator 50).
Count of individuals in households with income greater than 400% of FPL
(Indicator 55) who have selected a catastrophic medical plan (Indicator 50).
Count of individuals in households with income greater than 500% of FPL
(Indicator 55.1) who have selected a catastrophic medical plan (Indicator 50).
Count of individuals in households whose income is unknown (Indicator 56) and
have selected a catastrophic medical plan (Indicator 50).
Count of individuals who selected a bronze medical plan (Indicator 49) and whose
sex is Female, according to the selected policy (Indicator 35).
Count of individuals who selected a silver medical plan (Indicator 48) and whose
sex is Female, according to the selected policy (Indicator 35).
Count of individuals who selected a gold medical plan (Indicator 47) and whose sex
is Female, according to the selected policy (Indicator 35).
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Indicator
229
230
231
232
233
234
235
236
237
238
239
240
241

Title
Platinum plans selected by consumers
whose sex is Female (net)
Catastrophic plans selected by consumers
whose sex is Female (net)
Bronze plans selected by consumers whose
sex is Male (net)
Silver plans selected by consumers whose
sex is Male (net)
Gold plans selected by consumers whose
sex is Male (net)
Platinum plans selected by consumers
whose sex is Male (net)
Catastrophic plans selected by consumers
whose sex is Male (net)
Bronze plans selected by consumers whose
sex is unknown (net)
Silver plans selected by consumers whose
sex is unknown (net)
Gold plans selected by consumers whose
sex is unknown (net)
Platinum plans selected by consumers
whose sex is unknown (net)
Catastrophic plans selected by consumers
whose sex is unknown (net)
Bronze plans selected by consumers whose
Ethnicity is Hispanic or Latino

Description
Count of individuals who selected a platinum medical plan (Indicator 46) and
whose sex is Female, according to the selected policy (Indicator 35).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
whose sex is Female, according to the selected policy (Indicator 35).
Count of individuals who selected a bronze medical plan (Indicator 49) and whose
sex is Male, according to the selected policy (Indicator 36).
Count of individuals who selected a silver medical plan (Indicator 48) and whose
sex is Male, according to the selected policy (Indicator 36).
Count of individuals who selected a gold medical plan (Indicator 47) and whose sex
is Male, according to the selected policy (Indicator 36).
Count of individuals who selected a platinum medical plan (Indicator 46) and
whose sex is Male, according to the selected policy (Indicator 36).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
whose sex is Male, according to the selected policy (Indicator 36).
Count of individuals who selected a bronze medical plan (Indicator 49) and where
sex is unknown, according to the selected policy (Indicator 37).
Count of individuals who selected a silver medical plan (Indicator 48) and where
sex is unknown, according to the selected policy (Indicator 37).
Count of individuals who selected a gold medical plan (Indicator 47) and where sex
is unknown, according to the selected policy (Indicator 37).
Count of individuals who selected a platinum medical plan (Indicator 46) and
whose sex is unknown, according to the selected policy (Indicator 37).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
whose sex is unknown, according to the selected policy (Indicator 37).
Count of individuals who selected a bronze medical plan (Indicator 49) and have
indicated they are Mexican, Mexican American or Chicano/a, Puerto Rican, Cuban,
or “other Hispanic or Latino ethnicity” on their application. Individuals who have
indicated that they are Hispanic or Latino should be counted, regardless of the
race selection on their application (Indicator 38).

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Indicator
242

Title
Silver plans selected by consumers whose
Ethnicity is Hispanic or Latino

243

Gold plans selected by consumers whose
Ethnicity is Hispanic or Latino

244

Platinum plans selected by consumers
whose Ethnicity is Hispanic or Latino

245

Catastrophic plans selected by consumers
whose Ethnicity is Hispanic or Latino

246

Bronze plans selected by consumers whose
Race is White

247

Silver plans selected by consumers whose
Race is White

248

Gold plans selected by consumers whose
Race is White

Description
Count of individuals who selected a silver medical plan (Indicator 48) and have
indicated they are Mexican, Mexican American or Chicano/a, Puerto Rican, Cuban,
or “other Hispanic or Latino ethnicity” on their application. Individuals who have
indicated that they are Hispanic or Latino should be counted, regardless of the
race selection on their application (Indicator 38).
Count of individuals who selected a gold medical plan (Indicator 47) and have
indicated they are Mexican, Mexican American or Chicano/a, Puerto Rican, Cuban,
or “other Hispanic or Latino ethnicity” on their application. Individuals who have
indicated that they are Hispanic or Latino should be counted, regardless of the
race selection on their application (Indicator 38).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
indicated they are Mexican, Mexican American or Chicano/a, Puerto Rican, Cuban,
or “other Hispanic or Latino ethnicity” on their application. Individuals who have
indicated that they are Hispanic or Latino should be counted, regardless of the
race selection on their application (Indicator 38).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have indicated they are Mexican, Mexican American or Chicano/a, Puerto Rican,
Cuban, or “other Hispanic or Latino ethnicity” on their application. Individuals who
have indicated that they are Hispanic or Latino should be counted, regardless of
the race selection on their application (Indicator 38).
Count of individuals who selected a bronze medical plan (Indicator 49) and have
indicated they are white on their application. Individuals who have indicated that
they are white should be counted, regardless of the ethnicity selection on their
application (Indicator 39).
Count of individuals who selected a silver medical plan (Indicator 48) and have
indicated they are white on their application. Individuals who have indicated that
they are white should be counted, regardless of the ethnicity selection on their
application (Indicator 39).
Count of individuals who selected a gold medical plan (Indicator 47) and have
indicated they are white on their application. Individuals who have indicated that
they are white should be counted, regardless of the ethnicity selection on their
application (Indicator 39).

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Indicator
249

Title
Platinum plans selected by consumers
whose Race is White

250

Catastrophic plans selected by consumers
whose Race is White

251

Bronze plans selected by consumers whose
Race/Ethnicity is White, Non-Hispanic

252

Silver plans selected by consumers whose
Race/Ethnicity is White, Non-Hispanic

253

Gold plans selected by consumers whose
Race/Ethnicity is White, Non-Hispanic

254

Platinum plans selected by consumers
whose Race/Ethnicity is White, NonHispanic

255

Catastrophic plans selected by consumers
whose Race/Ethnicity is White, NonHispanic

256

Bronze plans selected by consumers whose
Race is African American

Description
Count of individuals who selected a platinum medical plan (Indicator 46) and have
indicated they are white on their application. Individuals who have indicated that
they are white should be counted, regardless of the ethnicity selection on their
application (Indicator 39).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have indicated they are white on their application. Individuals who have indicated
that they are white should be counted, regardless of the ethnicity selection on
their application (Indicator 39).
Count of individuals who selected a bronze medical plan (Indicator 49) and have 1.
Indicated that they are white on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application (Indicator 39.1).
Count of individuals who selected a silver medical plan (Indicator 48) and have 1.
Indicated that they are white on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application (Indicator 39.1).
Count of individuals who selected a gold medical plan (Indicator 47) and have 1.
Indicated that they are white on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application (Indicator 39.1).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
1. Indicated that they are white on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application (Indicator 39.1).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have 1. Indicated that they are white on their application and 2. Indicated that
their ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is
Hispanic or Latino on their application (Indicator 39.1).
Count of individuals who selected a bronze medical plan (Indicator 49) and have
indicated they are black or African American on their application. Individuals who
have indicated that they are black or African American should be counted,
regardless of the ethnicity selection on their application (Indicator 40).

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Indicator
257

Title
Silver plans selected by consumers whose
Race is African American

258

Gold plans selected by consumers whose
Race is African American

259

Platinum plans selected by consumers
whose Race is African American

260

Catastrophic plans selected by consumers
whose Race is African American

261

Bronze plans selected by consumers whose
Race/Ethnicity is African American, NonHispanic

262

Silver plans selected by consumers whose
Race/Ethnicity is African American, NonHispanic

263

Gold plans selected by consumers whose
Race/Ethnicity is African American, NonHispanic

264

Platinum plans selected by consumers
whose Race/Ethnicity is African American,
Non-Hispanic

Description
Count of individuals who selected a silver medical plan (Indicator 48) and have
indicated they are black or African American on their application. Individuals who
have indicated that they are black or African American should be counted,
regardless of the ethnicity selection on their application (Indicator 40).
Count of individuals who selected a gold medical plan (Indicator 47) and have
indicated they are black or African American on their application. Individuals who
have indicated that they are black or African American should be counted,
regardless of the ethnicity selection on their application (Indicator 40).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
indicated they are black or African American on their application. Individuals who
have indicated that they are black or African American should be counted,
regardless of the ethnicity selection on their application (Indicator 40).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have indicated they are black or African American on their application. Individuals
who have indicated that they are black or African American should be counted,
regardless of the ethnicity selection on their application (Indicator 40).
Count of individuals who selected a bronze medical plan (Indicator 49) and have 1.
Indicated that they are black or African American on their application and 2.
Indicated that their ethnicity is not Hispanic or Latino or did not indicate that their
ethnicity is Hispanic or Latino on their application (Indicator 40.1).
Count of individuals who selected a silver medical plan (Indicator 48) and have 1.
Indicated that they are black or African American on their application and 2.
Indicated that their ethnicity is not Hispanic or Latino or did not indicate that their
ethnicity is Hispanic or Latino on their application (Indicator 40.1).
Count of individuals who selected a gold medical plan (Indicator 47) and have 1.
Indicated that they are black or African American on their application and 2.
Indicated that their ethnicity is not Hispanic or Latino or did not indicate that their
ethnicity is Hispanic or Latino on their application (Indicator 40.1).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
1. Indicated that they are black or African American on their application and 2.
Indicated that their ethnicity is not Hispanic or Latino or did not indicate that their
ethnicity is Hispanic or Latino on their application (Indicator 40.1).

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Indicator
265

Title
Catastrophic plans selected by consumers
whose Race/Ethnicity is African American,
Non-Hispanic

266

Bronze plans selected by consumers whose
Race is Asian

267

Silver plans selected by consumers whose
Race is Asian

268

Gold plans selected by consumers whose
Race is Asian

269

Platinum plans selected by consumers
whose Race is Asian

270

Catastrophic plans selected by consumers
whose Race is Asian

Description
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have 1. Indicated that they are black or African American on their application and
2. Indicated that their ethnicity is not Hispanic or Latino or did not indicate that
their ethnicity is Hispanic or Latino on their application (Indicator 40.1).
Count of individuals who selected a bronze medical plan (Indicator 49) and have
indicated they are Asian Indian, Chinese, Filipino, Korean, Vietnamese, Japanese,
or “other Asian” on their application. Individuals who have indicated that they are
Asian should be counted, regardless of the ethnicity selection on their application
(Indicator 41).
Count of individuals who selected a silver medical plan (Indicator 48) and have
indicated they are Asian Indian, Chinese, Filipino, Korean, Vietnamese, Japanese,
or “other Asian” on their application. Individuals who have indicated that they are
Asian should be counted, regardless of the ethnicity selection on their application
(Indicator 41).
Count of individuals who selected a gold medical plan (Indicator 47) and have
indicated they are Asian Indian, Chinese, Filipino, Korean, Vietnamese, Japanese,
or “other Asian” on their application. Individuals who have indicated that they are
Asian should be counted, regardless of the ethnicity selection on their application
(Indicator 41).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
indicated they are Asian Indian, Chinese, Filipino, Korean, Vietnamese, Japanese,
or “other Asian” on their application. Individuals who have indicated that they are
Asian should be counted, regardless of the ethnicity selection on their application
(Indicator 41).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have indicated they are Asian Indian, Chinese, Filipino, Korean, Vietnamese,
Japanese, or “other Asian” on their application. Individuals who have indicated
that they are Asian should be counted, regardless of the ethnicity selection on
their application (Indicator 41).

28

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Indicator
271

Title
Bronze plans selected by consumers whose
Race/Ethnicity is Asian, Non-Hispanic

272

Silver plans selected by consumers whose
Race/Ethnicity is Asian, Non-Hispanic

273

Gold plans selected by consumers whose
Race/Ethnicity is Asian, Non-Hispanic

274

Platinum plans selected by consumers
whose Race/Ethnicity is Asian, NonHispanic

275

Catastrophic plans selected by consumers
whose Race/Ethnicity is Asian, NonHispanic

276

Bronze plans selected by consumers whose
Race is Native Hawaiian/Pacific Islander

Description
Count of individuals who selected a bronze medical plan (Indicator 49) and have 1.
Indicated that they are Asian Indian, Chinese, Filipino, Korean, Vietnamese,
Japanese, or “other Asian” on their application and 2. Indicated that their ethnicity
is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino
on their application (Indicator 41.1).
Count of individuals who selected a silver medical plan (Indicator 48) and have 1.
Indicated that they are Asian Indian, Chinese, Filipino, Korean, Vietnamese,
Japanese, or “other Asian” on their application and 2. Indicated that their ethnicity
is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino
on their application (Indicator 41.1).
Count of individuals who selected a gold medical plan (Indicator 47) and have 1.
Indicated that they are Asian Indian, Chinese, Filipino, Korean, Vietnamese,
Japanese, or “other Asian” on their application and 2. Indicated that their ethnicity
is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino
on their application (Indicator 41.1).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
1. Indicated that they are Asian Indian, Chinese, Filipino, Korean, Vietnamese,
Japanese, or “other Asian” on their application and 2. Indicated that their ethnicity
is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino
on their application (Indicator 41.1).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have 1. Indicated that they are Asian Indian, Chinese, Filipino, Korean, Vietnamese,
Japanese, or “other Asian” on their application and 2. Indicated that their ethnicity
is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino
on their application (Indicator 41.1).
Count of individuals who selected a bronze medical plan (Indicator 49) and have
indicated they are Guamanian or Chamorro, Native Hawaiian, Samoan, or “other
Pacific Islander” on their application. Individuals who have indicated that they are
Native Hawaiian or Pacific Islander should be counted, regardless of the ethnicity
selection on their application (Indicator 42).

29

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Indicator
277

Title
Silver plans selected by consumers whose
Race is Native Hawaiian/Pacific Islander

278

Gold plans selected by consumers whose
Race is Native Hawaiian/Pacific Islander

279

Platinum plans selected by consumers
whose Race is Native Hawaiian/Pacific
Islander

280

Catastrophic plans selected by consumers
whose Race is Native Hawaiian/Pacific
Islander

281

Bronze plans selected by consumers whose
Race/Ethnicity is Native Hawaiian/Pacific
Islander, Non-Hispanic

282

Silver plans selected by consumers whose
Race/Ethnicity is Native Hawaiian/Pacific
Islander, Non-Hispanic

Description
Count of individuals who selected a silver medical plan (Indicator 48) and have
indicated they are Guamanian or Chamorro, Native Hawaiian, Samoan, or “other
Pacific Islander” on their application. Individuals who have indicated that they are
Native Hawaiian or Pacific Islander should be counted, regardless of the ethnicity
selection on their application (Indicator 42).
Count of individuals who selected a gold medical plan (Indicator 47) and have
indicated they are Guamanian or Chamorro, Native Hawaiian, Samoan, or “other
Pacific Islander” on their application. Individuals who have indicated that they are
Native Hawaiian or Pacific Islander should be counted, regardless of the ethnicity
selection on their application (Indicator 42).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
indicated they are Guamanian or Chamorro, Native Hawaiian, Samoan, or “other
Pacific Islander” on their application. Individuals who have indicated that they are
Native Hawaiian or Pacific Islander should be counted, regardless of the ethnicity
selection on their application (Indicator 42).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have indicated they are Guamanian or Chamorro, Native Hawaiian, Samoan, or
“other Pacific Islander” on their application. Individuals who have indicated that
they are Native Hawaiian or Pacific Islander should be counted, regardless of the
ethnicity selection on their application (Indicator 42).
Count of individuals who selected a bronze medical plan (Indicator 49) and have 1.
Indicated that they are Guamanian or Chamorro, Native Hawaiian, Samoan, or
“other Pacific Islander” on their application and 2. Indicated that their ethnicity is
not Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino
on their application (Indicator 42.1).
Count of individuals who selected a silver medical plan (Indicator 48) and have 1.
Indicated that they are Guamanian or Chamorro, Native Hawaiian, Samoan, or
“other Pacific Islander” on their application and 2. Indicated that their ethnicity is
not Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino
on their application (Indicator 42.1).

30

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Indicator
283

Title
Gold plans selected by consumers whose
Race/Ethnicity is Native Hawaiian/Pacific
Islander, Non-Hispanic

284

Platinum plans selected by consumers
whose Race/Ethnicity is Native
Hawaiian/Pacific Islander, Non-Hispanic

285

Catastrophic plans selected by consumers
whose Race/Ethnicity is Native
Hawaiian/Pacific Islander, Non-Hispanic

286

Bronze plans selected by consumers whose
Race is American Indian/Alaska Native

287

Silver plans selected by consumers whose
Race is American Indian/Alaska Native

288

Gold plans selected by consumers whose
Race is American Indian/Alaska Native

Description
Count of individuals who selected a gold medical plan (Indicator 47) and have 1.
Indicated that they are Guamanian or Chamorro, Native Hawaiian, Samoan, or
“other Pacific Islander” on their application and 2. Indicated that their ethnicity is
not Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino
on their application (Indicator 42.1).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
1. Indicated that they are Guamanian or Chamorro, Native Hawaiian, Samoan, or
“other Pacific Islander” on their application and 2. Indicated that their ethnicity is
not Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino
on their application (Indicator 42.1).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have 1. Indicated that they are Guamanian or Chamorro, Native Hawaiian,
Samoan, or “other Pacific Islander” on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application (Indicator 42.1).
Count of individuals who selected a bronze medical plan (Indicator 49) and have
indicated they are American Indian or Alaska Native on their application.
Individuals who have indicated that they are American Indian or Alaska Native
should be counted, regardless of the ethnicity selection on their application
(Indicator 43).
Count of individuals who selected a silver medical plan (Indicator 48) and have
indicated they are American Indian or Alaska Native on their application.
Individuals who have indicated that they are American Indian or Alaska Native
should be counted, regardless of the ethnicity selection on their application
(Indicator 43).
Count of individuals who selected a gold medical plan (Indicator 47) and have
indicated they are American Indian or Alaska Native on their application.
Individuals who have indicated that they are American Indian or Alaska Native
should be counted, regardless of the ethnicity selection on their application
(Indicator 43).

31

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Indicator
289

Title
Platinum plans selected by consumers
whose Race is American Indian/Alaska
Native

290

Catastrophic plans selected by consumers
whose Race is American Indian/Alaska
Native

291

Bronze plans selected by consumers whose
Race/Ethnicity is American Indian/Alaska
Native, Non-Hispanic

292

Silver plans selected by consumers whose
Race/Ethnicity is American Indian/Alaska
Native, Non-Hispanic

293

Gold plans selected by consumers whose
Race/Ethnicity is American Indian/Alaska
Native, Non-Hispanic

294

Platinum plans selected by consumers
whose Race/Ethnicity is American
Indian/Alaska Native, Non-Hispanic

295

Catastrophic plans selected by consumers
whose Race/Ethnicity is American
Indian/Alaska Native, Non-Hispanic

Description
Count of individuals who selected a platinum medical plan (Indicator 46) and have
indicated they are American Indian or Alaska Native on their application.
Individuals who have indicated that they are American Indian or Alaska Native
should be counted, regardless of the ethnicity selection on their application
(Indicator 43).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have indicated they are American Indian or Alaska Native on their application.
Individuals who have indicated that they are American Indian or Alaska Native
should be counted, regardless of the ethnicity selection on their application
(Indicator 43).
Count of individuals who selected a bronze medical plan (Indicator 49) and have 1.
Indicated that they are American Indian or Alaska Native on their application and
2. Indicated that their ethnicity is not Hispanic or Latino or did not indicate that
their ethnicity is Hispanic or Latino on their application (Indicator 43.1).
Count of individuals who selected a silver medical plan (Indicator 48) and have 1.
Indicated that they are American Indian or Alaska Native on their application and
2. Indicated that their ethnicity is not Hispanic or Latino or did not indicate that
their ethnicity is Hispanic or Latino on their application (Indicator 43.1).
Count of individuals who selected a gold medical plan (Indicator 47) and have 1.
Indicated that they are American Indian or Alaska Native on their application and
2. Indicated that their ethnicity is not Hispanic or Latino or did not indicate that
their ethnicity is Hispanic or Latino on their application (Indicator 43.1).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
1. Indicated that they are American Indian or Alaska Native on their application
and 2. Indicated that their ethnicity is not Hispanic or Latino or did not indicate
that their ethnicity is Hispanic or Latino on their application (Indicator 43.1).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have 1. Indicated that they are American Indian or Alaska Native on their
application and 2. Indicated that their ethnicity is not Hispanic or Latino or did not
indicate that their ethnicity is Hispanic or Latino on their application (Indicator
43.1).

32

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Indicator
296

Title
Bronze plans selected by consumers whose
Race is Middle Eastern/North African (net)

297

Silver plans selected by consumers whose
Race is Middle Eastern/North African (net)

298

Gold plans selected by consumers whose
Race is Middle Eastern/North African (net)

299

Platinum plans selected by consumers
whose Race is Middle Eastern/North
African (net)

300

Catastrophic plans selected by consumers
whose Race is Middle Eastern/North
African (net)

301

Bronze plans selected by consumers whose
Race/Ethnicity is Middle Eastern/North
African, Non-Hispanic (net)

Description
Count of individuals who selected a bronze medical plan (Indicator 49) and have
indicated they are Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or “other
Middle Eastern or North African” on their application. Individuals who have
indicated that they are Middle Eastern or North African should be counted,
regardless of the ethnicity selection on their application (Indicator 43.2).
Count of individuals who selected a silver medical plan (Indicator 48) and have
indicated they are Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or “other
Middle Eastern or North African” on their application. Individuals who have
indicated that they are Middle Eastern or North African should be counted,
regardless of the ethnicity selection on their application (Indicator 43.2).
Count of individuals who selected a gold medical plan (Indicator 47) and have
indicated they are Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or “other
Middle Eastern or North African” on their application. Individuals who have
indicated that they are Middle Eastern or North African should be counted,
regardless of the ethnicity selection on their application (Indicator 43.2).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
indicated they are Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or “other
Middle Eastern or North African” on their application. Individuals who have
indicated that they are Middle Eastern or North African should be counted,
regardless of the ethnicity selection on their application (Indicator 43.2).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have indicated they are Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or
“other Middle Eastern or North African” on their application. Individuals who have
indicated that they are Middle Eastern or North African should be counted,
regardless of the ethnicity selection on their application (Indicator 43.2).
Count of individuals who selected a bronze medical plan (Indicator 49) and have 1.
Indicated that they are Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or
“other Middle Eastern or North African” and 2. Indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application (43.3).

33

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Indicator
302

Title
Silver plans selected by consumers whose
Race/Ethnicity is Middle Eastern/North
African, Non-Hispanic (net)

303

Gold plans selected by consumers whose
Race/Ethnicity is Middle Eastern/North
African, Non-Hispanic (net)

304

Platinum plans selected by consumers
whose Race/Ethnicity is Middle
Eastern/North African, Non-Hispanic (net)

305

Catastrophic plans selected by consumers
whose Race/Ethnicity is Middle
Eastern/North African, Non-Hispanic (net)

306

Bronze plans selected by consumers whose
Race is Multi-Racial

307

Silver plans selected by consumers whose
Race is Multi-Racial

Description
Count of individuals who selected a silver medical plan (Indicator 48) and have 1.
Indicated that they are Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or
“other Middle Eastern or North African” and 2. Indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application (43.3).
Count of individuals who selected a gold medical plan (Indicator 47) and have 1.
Indicated that they are Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or
“other Middle Eastern or North African” and 2. Indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application (43.3).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
1. Indicated that they are Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or
“other Middle Eastern or North African” and 2. Indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application (43.3).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have 1. Indicated that they are Lebanese, Iranian, Egyptian, Syrian, Iraqi, and
Israeli, or “other Middle Eastern or North African” and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application (43.3).
Count of individuals who selected a bronze medical plan (Indicator 49) and have
indicated more than one distinct racial group: American Indian / Alaska Native,
Asian, Native Hawaiian / Pacific Islander, African-American, Middle Eastern / North
African, and White, on their application. Individuals who have indicated more than
one racial group should be counted, regardless of the ethnicity selection on their
application (Indicator 44).
Count of individuals who selected a silver medical plan (Indicator 48) and have
indicated more than one distinct racial group: American Indian / Alaska Native,
Asian, Native Hawaiian / Pacific Islander, African-American, Middle Eastern / North
African, and White, on their application. Individuals who have indicated more than
one racial group should be counted, regardless of the ethnicity selection on their
application (Indicator 44).

34

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
308

Title
Gold plans selected by consumers whose
Race is Multi-Racial

309

Platinum plans selected by consumers
whose Race is Multi-Racial

310

Catastrophic plans selected by consumers
whose Race is Multi-Racial

311

Bronze plans selected by consumers whose
Race/Ethnicity is Multi-Racial, Non-Hispanic

312

Silver plans selected by consumers whose
Race/Ethnicity is Multi-Racial, Non-Hispanic

Description
Count of individuals who selected a gold medical plan (Indicator 47) and have
indicated more than one distinct racial group: American Indian / Alaska Native,
Asian, Native Hawaiian / Pacific Islander, African-American, Middle Eastern / North
African, and White, on their application. Individuals who have indicated more than
one racial group should be counted, regardless of the ethnicity selection on their
application (Indicator 44).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
indicated more than one distinct racial group: American Indian / Alaska Native,
Asian, Native Hawaiian / Pacific Islander, African-American, Middle Eastern / North
African, and White, on their application. Individuals who have indicated more than
one racial group should be counted, regardless of the ethnicity selection on their
application (Indicator 44).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have indicated more than one distinct racial group: American Indian / Alaska
Native, Asian, Native Hawaiian / Pacific Islander, African-American, Middle Eastern
/ North African, and White, on their application. Individuals who have indicated
more than one racial group should be counted, regardless of the ethnicity
selection on their application (Indicator 44).
Count of individuals who selected a bronze medical plan (Indicator 49) and have 1.
Indicated more than one distinct racial group: American Indian / Alaska Native,
Asian, Native Hawaiian / Pacific Islander, African-American, Middle Eastern / North
African, and White, on their application and 2. Indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application should be counted (Indicator 44.1).
Count of individuals who selected a silver medical plan (Indicator 48) and have 1.
Indicated more than one distinct racial group: American Indian / Alaska Native,
Asian, Native Hawaiian / Pacific Islander, African-American, Middle Eastern / North
African, and White, on their application and 2. Indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application should be counted (Indicator 44.1).

35

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
313

Title
Gold plans selected by consumers whose
Race/Ethnicity is Multi-Racial, Non-Hispanic

314

Platinum plans selected by consumers
whose Race/Ethnicity is Multi-Racial, NonHispanic

315

Catastrophic plans selected by consumers
whose Race/Ethnicity is Multi-Racial, NonHispanic

316

Bronze plans selected by consumers whose
Race/Ethnicity is Unknown, Non-Hispanic

317

Silver plans selected by consumers whose
Race/Ethnicity is Unknown, Non-Hispanic

318

Gold plans selected by consumers whose
Race/Ethnicity is Unknown, Non-Hispanic

Description
Count of individuals who selected a gold medical plan (Indicator 47) and have 1.
Indicated more than one distinct racial group: American Indian / Alaska Native,
Asian, Native Hawaiian / Pacific Islander, African-American, Middle Eastern / North
African, and White, on their application and 2. Indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application should be counted (Indicator 44.1).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
1. Indicated more than one distinct racial group: American Indian / Alaska Native,
Asian, Native Hawaiian / Pacific Islander, African-American, Middle Eastern / North
African, and White, on their application and 2. Indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application should be counted (Indicator 44.1).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have 1. Indicated more than one distinct racial group: American Indian / Alaska
Native, Asian, Native Hawaiian / Pacific Islander, African-American, Middle Eastern
/ North African, and White, on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application should be counted (Indicator 44.1).
Count of individuals who selected a bronze medical plan (Indicator 49) and 1. did
not indicate a race on their application and 2. indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application (Indicator 45).
Count of individuals who selected a silver medical plan (Indicator 48) and 1. did not
indicate a race on their application and 2. indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application (Indicator 45).
Count of individuals who selected a gold medical plan (Indicator 47) and 1. did not
indicate a race on their application and 2. indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application (Indicator 45).

36

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
319

Title
Platinum plans selected by consumers
whose Race/Ethnicity is Unknown, NonHispanic

320

Catastrophic plans selected by consumers
whose Race/Ethnicity is Unknown, NonHispanic

321

Bronze plans selected by consumers whose
Race is Other

322

Silver plans selected by consumers whose
Race is Other

323

Gold plans selected by consumers whose
Race is Other

324

Platinum plans selected by consumers
whose Race is Other

325

Catastrophic plans selected by consumers
whose Race is Other

Description
Count of individuals who selected a platinum medical plan (Indicator 46) and 1. did
not indicate a race on their application and 2. indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application (Indicator 45).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and 1.
did not indicate a race on their application and 2. indicated that their ethnicity is
not Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino
on their application (Indicator 45).
Count of individuals who selected a bronze medical plan (Indicator 49) and have
indicated another race or “Other” on their application. Individuals should be
counted, regardless of the ethnicity selection on their application. This does not
include individuals who are already counted in indicators 39-45 and indicated
other Asian, other Pacific Islander, etc. (Indicator 45.1).
Count of individuals who selected a silver medical plan (Indicator 48) and have
indicated another race or “Other” on their application. Individuals should be
counted, regardless of the ethnicity selection on their application. This does not
include individuals who are already counted in indicators 39-45 and indicated
other Asian, other Pacific Islander, etc. (Indicator 45.1).
Count of individuals who selected a gold medical plan (Indicator 47) and have
indicated another race or “Other” on their application. Individuals should be
counted, regardless of the ethnicity selection on their application. This does not
include individuals who are already counted in indicators 39-45 and indicated
other Asian, other Pacific Islander, etc. (Indicator 45.1).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
indicated another race or “Other” on their application. Individuals should be
counted, regardless of the ethnicity selection on their application. This does not
include individuals who are already counted in indicators 39-45 and indicated
other Asian, other Pacific Islander, etc. (Indicator 45.1).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have indicated another race or “Other” on their application. Individuals should be
counted, regardless of the ethnicity selection on their application. This does not
include individuals who are already counted in indicators 39-45 and indicated
other Asian, other Pacific Islander, etc. (Indicator 45.1).
37

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
326

Title
Bronze plans selected by consumers whose
Race/Ethnicity is Other, Non-Hispanic

327

Silver plans selected by consumers whose
Race/Ethnicity is Other, Non-Hispanic

328

Gold plans selected by consumers whose
Race/Ethnicity is Other, Non-Hispanic

329

Platinum plans selected by consumers
whose Race/Ethnicity is Other, NonHispanic

330

Catastrophic plans selected by consumers
whose Race/Ethnicity is Other, NonHispanic

Description
Count of individuals who selected a bronze medical plan (Indicator 49) and have 1.
Indicated another race or “Other” on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application. This does not include individuals who are already
counted in indicators 38-45 and indicated other Hispanic or Latino, other Asian,
other Pacific Islander, etc. (Indicator 45.2).
Count of individuals who selected a silver medical plan (Indicator 48) and have 1.
Indicated another race or “Other” on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application. This does not include individuals who are already
counted in indicators 38-45 and indicated other Hispanic or Latino, other Asian,
other Pacific Islander, etc. (Indicator 45.2).
Count of individuals who selected a gold medical plan (Indicator 47) and have 1.
Indicated another race or “Other” on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application. This does not include individuals who are already
counted in indicators 38-45 and indicated other Hispanic or Latino, other Asian,
other Pacific Islander, etc. (Indicator 45.2).
Count of individuals who selected a platinum medical plan (Indicator 46) and have
1. Indicated another race or “Other” on their application and 2. Indicated that
their ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is
Hispanic or Latino on their application. This does not include individuals who are
already counted in indicators 38-45 and indicated other Hispanic or Latino, other
Asian, other Pacific Islander, etc. (Indicator 45.2).
Count of individuals who selected a catastrophic medical plan (Indicator 50) and
have 1. Indicated another race or “Other” on their application and 2. Indicated
that their ethnicity is not Hispanic or Latino or did not indicate that their ethnicity
is Hispanic or Latino on their application. This does not include individuals who are
already counted in indicators 38-45 and indicated other Hispanic or Latino, other
Asian, other Pacific Islander, etc. (Indicator 45.2).

Exhibit 8: Consumer Type by Age, Metal Level, Income, Sex, and Race/Ethnicity

38

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
130

Title
New consumers who are age 0 – 17 (net)

131

Active re-enrollees who are age 0 – 17 (net)

132

Automatic re-enrollees who are age 0 – 17
(net)
New consumers who are age 18 - 25 (net)

133
134
135
136
137
138
138.1
138.2

Active re-enrollees who are age 18 - 25
(net)
Automatic re-enrollees who are age 18 – 25
(net)
New consumers who are age 26 - 34 (net)
Active re-enrollees who are age 26 - 34
(net)
Automatic re-enrollees who are age 26 - 34
(net)
New consumers who are age 35 - 44 (net)

138.3

Active re-enrollees who are age 35 - 44
(net)
Automatic re-enrollees who are age 35 - 44

138.4

New consumers who are age 45 - 54 (net)

138.5

Active re-enrollees who are age 45 - 54
(net)
Automatic re-enrollees who are age 45 - 54
(net)
New consumers who are age 55 - 64 (net)

138.6
138.7

Description
Count of new consumers (Indicator 2) who are in the 0 - 17 age group (Indicator
30).
Count of active re-enrollees (Indicator 4) who are in the 0 - 17 age group (Indicator
30).
Count of automatic re-enrollees (Indicator 5) who are in the 0 - 17 age group
(Indicator 30).
Count of new consumers (Indicator 2) who are in the 18 - 25 age group (Indicator
31).
Count of active re-enrollees (Indicator 4) who are in the 18 - 25 age group
(Indicator 31).
Count of automatic re-enrollees (Indicator 5) who are in the 18 - 25 age group
(Indicator 31).
Count of new consumers (Indicator 2) who are in the 26 - 34 age group (Indicator
31.1).
Count of active re-enrollees (Indicator 4) who are in the 26 - 34 age group
(Indicator 31.1).
Count of automatic re-enrollees (Indicator 5) who are in the 26 - 34 age group
(Indicator 31.1).
Count of new consumers (Indicator 2) who are in the 35 - 44 age group (Indicator
32).
Count of active re-enrollees (Indicator 4) who are in the 35 - 44 age group
(Indicator 32).
Count of automatic re-enrollees (Indicator 5) who are in the 35 - 44 age group
(Indicator 32).
Count of new consumers (Indicator 2) who are in the 45 - 54 age group (Indicator
32.1).
Count of active re-enrollees (Indicator 4) who are in the 45 - 54 age group
(Indicator 32.1).
Count of automatic re-enrollees (Indicator 5) who are in the 45 - 54 age group
(Indicator 32.1).
Count of new consumers (Indicator 2) who are in the 55 - 64 age group (Indicator
33).
39

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
138.8

139

Title
Active re-enrollees who are age 55 - 64
(net)
Automatic re-enrollees who are age 55 - 64
(net)
New consumers who are age ≥65 (net)

140

Active re-enrollees who are age ≥65 (net)

141

Automatic re-enrollees who are age
≥65(net)
New consumers whose age is unknown
(net)
Active re-enrollees whose age is unknown
(net)
Automatic re-enrollees whose age is
unknown (net)
New consumers who selected a silver plan
(net)
Active re-enrollees who selected a silver
plan (net)
Automatic re-enrollees who selected a
silver plan (net)
New consumers who selected a bronze plan
(net)
Active re-enrollees who selected a bronze
plan (net)
Automatic re-enrollees who selected a
bronze plan (net)
New consumers who selected a gold plan
(net)
Active re-enrollees who selected a gold
plan (net)

138.9

142
143
144
145
146
147
148
149
150
150.1
150.2

Description
Count of active re-enrollees (Indicator 4) who are in the 55 - 64 age group
(Indicator 33).
Count of automatic re-enrollees (Indicator 5) who are in the 55 - 64 age group
(Indicator 33).
Count of new consumers (Indicator 2) who are in the ≥ 65 age group (Indicator
33.1).
Count of active re-enrollees (Indicator 4) who are in the ≥ 65 age group (Indicator
33.1).
Count of automatic re-enrollees (Indicator 5) who are in the ≥ 65 age group
(Indicator 33.1).
Count of new consumers (Indicator 2) whose age is unknown (Indicator 34).
Count of active re-enrollees (Indicator 4) whose age is unknown (Indicator 34).
Count of automatic re-enrollees (Indicator 5) whose age is unknown (Indicator
34).
Count of new consumers (Indicator 2) who selected a silver plan (Indicator 48).
Count of active re-enrollees (Indicator 4) who selected a silver plan (Indicator 48).
Count of automatic re-enrollees (Indicator 5) who selected a silver plan (Indicator
48).
Count of new consumers (Indicator 2) who selected a bronze plan (Indicator 49).
Count of active re-enrollees (Indicator 4) who selected a bronze plan (Indicator
49).
Count of automatic re-enrollees (Indicator 5) who selected a bronze plan (Indicator
49).
Count of new consumers (Indicator 2) who selected a gold plan (Indicator 47).
Count of active re-enrollees (Indicator 4) who selected a gold plan (Indicator 47).

40

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
150.3
150.4
150.5
150.6
150.7
150.8
150.9
151
152
153
153.1
153.2
153.3
154
155
156

Title
Automatic re-enrollees who selected a gold
plan (net)
New consumers who selected a
catastrophic plan (net)
Active re-enrollees who selected a
catastrophic plan (net)
Automatic re-enrollees who selected a
catastrophic plan (net)
New consumers who selected a platinum
plan (net)
Active re-enrollees who selected a platinum
plan (net)
Automatic re-enrollees who selected a
platinum plan (net)
New consumers whose income is < 100%
FPL (net)
Active re-enrollees whose income is < 100%
FPL (net)
Automatic Re-enrollees whose income is <
100% FPL (net)
New consumers whose income is ≥ 100%
FPL and ≤ 138% FPL (net)
Active re-enrollees whose income is ≥ 100%
FPL and ≤ 138% FPL (net)
Automatic Re-enrollees whose income is ≥
100% FPL and ≤ 138% FPL (net)
New consumers whose income is ≥ 100%
FPL and ≤ 150% FPL (net)
Active re-enrollees whose income is ≥ 100%
FPL and ≤ 150% FPL (net)
Automatic Re-enrollees whose income is ≥
100% FPL and ≤ 150% FPL (net)

Description
Count of automatic re-enrollees (Indicator 5) who selected a gold plan (Indicator
47).
Count of new consumers (Indicator 2) who selected a catastrophic plan (Indicator
50).
Count of active re-enrollees (Indicator 4) who selected a catastrophic plan
(Indicator 50).
Count of automatic re-enrollees (Indicator 5) who selected a catastrophic plan
(Indicator 50).
Count of new consumers (Indicator 2) who selected a platinum plan (Indicator 46).
Count of active re-enrollees (Indicator 4) who selected a platinum plan (Indicator
46).
Count of automatic re-enrollees (Indicator 5) who selected a platinum plan
(Indicator 46).
Count of new consumers (Indicator 2) in households with income less than 100%
of FPL (Indicator 51).
Count of active re-enrollees (Indicator 4) in households with income less than
100% of FPL (Indicator 51).
Count of active re-enrollees (Indicator 5) in households with income less than
100% of FPL (Indicator 51).
Count of new consumers (Indicator 2) in households with income greater than or
equal to 100% of FPL and less than or equal to 138% FPL (Indicator 52.1).
Count of active re-enrollees (Indicator 4) in households with income greater than
or equal to 100% of FPL and less than or equal to 138% FPL (Indicator 52.1).
Count of automatic re-enrollees (Indicator 5) in households with income greater
than or equal to 100% of FPL and less than or equal to 138% FPL (Indicator 52.1).
Count of new consumers (Indicator 2) in households with income greater than or
equal to 100% of FPL and less than or equal to 150% FPL (Indicator 52).
Count of active re-enrollees (Indicator 4) in households with income greater than
or equal to 100% of FPL and less than or equal to 150% FPL (Indicator 52).
Count of automatic re-enrollees (Indicator 5) in households with income greater
than or equal to 100% of FPL and less than or equal to 150% FPL (Indicator 52).
41

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
157
158
159
159.1
159.2
159.3
160
161
162
162.1
162.2
162.3
162.4
162.5
162.6
163

Title
New consumers whose income is > 150%
FPL and ≤ 200% FPL (net)
Active re-enrollees whose income is 150%
FPL and ≤ 200% FPL (net)
Automatic Re-enrollees whose income is >
150% FPL and ≤ 200% FPL (net)
New consumers whose income is > 200%
FPL and ≤ 250% FPL (net)
Active re-enrollees whose income is > 200%
FPL and ≤ 250% FPL (net)
Automatic Re-enrollees whose income is >
200% FPL and ≤ 250% FPL (net)
New consumers whose income is > 250%
FPL and ≤ 300% FPL (net)
Active re-enrollees whose income is > 250%
FPL and ≤ 300% FPL (net)
Automatic Re-enrollees whose income is >
250% FPL and ≤ 300% FPL (net)
New consumers whose income is > 300%
FPL and ≤ 350% FPL (net)
Active re-enrollees whose income is > 300%
FPL and ≤ 350% FPL (net)
Automatic Re-enrollees whose income is >
300% FPL and ≤ 350% FPL (net)
New consumers whose income is > 350%
FPL and ≤ 400% FPL
Active re-enrollees whose income is > 350%
FPL and ≤ 400% FPL (net)
Automatic Re-enrollees whose income is >
350% FPL and ≤ 400% FPL (net)
New consumers whose income is > 400%
FPL (net)

Description
Count of new consumers (Indicator 2) in households with income greater than
150% of FPL and less than or equal to 200% FPL (Indicator 53).
Count of active re-enrollees (Indicator 4) in households with income greater than
150% of FPL and less than or equal to 200% FPL (Indicator 53).
Count of automatic re-enrollees (Indicator 5) in households with income greater
than 150% of FPL and less than or equal to 200% FPL (Indicator 53).
Count of new consumers (Indicator 2) in households with income greater than
200% of FPL and less than or equal to 250% FPL (Indicator 54).
Count of active re-enrollees (Indicator 4) in households with income greater than
200% of FPL and less than or equal to 250% FPL (Indicator 54).
Count of automatic re-enrollees (Indicator 5) in households with income greater
than 200% of FPL and less than or equal to 250% FPL (Indicator 54).
Count of new consumers (Indicator 2) in households with income greater than
250% of FPL and less than or equal to 300% FPL (Indicator 54.1).
Count of active re-enrollees (Indicator 4) in households with income greater than
250% of FPL and less than or equal to 300% FPL (Indicator 54.1).
Count of automatic re-enrollees (Indicator 5) in households with income greater
than 250% of FPL and less than or equal to 300% FPL (Indicator 54.1).
Count of new consumers (Indicator 2) in households with income greater than
300% of FPL and less than or equal to 350% FPL (Indicator 54.2).
Count of active re-enrollees (Indicator 4) in households with income greater than
300% of FPL and less than or equal to 350% FPL (Indicator 54.2).
Count of automatic re-enrollees (Indicator 5) in households with income greater
than 300% of FPL and less than or equal to 350% FPL (Indicator 54.2).
Count of new consumers (Indicator 2) in households with income greater than
350% of FPL and less than or equal to 400% FPL (Indicator 54.3).
Count of active re-enrollees (Indicator 4) in households with income greater than
350% of FPL and less than or equal to 400% FPL (Indicator 54.3).
Count of automatic re-enrollees (Indicator 5) in households with income greater
than 350% of FPL and less than or equal to 400% FPL (Indicator 54.3).
Count of new consumers (Indicator 2) in households with income greater than
400% of FPL (Indicator 55).
42

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
164
165
165.1
165.2
165.3
166
167
168
331
332
333
334
335
336
337
338

Title
Active re-enrollees whose income is > 400%
FPL (net)
Automatic Re-enrollees whose income is >
400% FPL (net)
New consumers whose income is > 500%
FPL (net)
Active re-enrollees whose income is > 500%
FPL (net)
Automatic Re-enrollees whose income is >
500% FPL (net)
New consumers whose income is unknown
(net)
Active re-enrollees whose income is
unknown (net)
Automatic Re-enrollees whose income is
unknown (net)
New consumers whose sex is Female (net)

Description
Count of active re-enrollees (Indicator 4) in households with income greater than
400% of FPL (Indicator 55).
Count of automatic re-enrollees (Indicator 5) in households with income greater
than 400% of FPL (Indicator 55).
Count of new consumers (Indicator 2) in households with income greater than
500% of FPL (Indicator 55.1).
Count of active re-enrollees (Indicator 4) in households with income greater than
500% of FPL (Indicator 55.1).
Count of automatic re-enrollees (Indicator 5) in households with income greater
than 500% of FPL (Indicator 55.1).
Count of new consumers (Indicator 2) in households with income unknown
(Indicator 56).
Count of active re-enrollees (Indicator 4) in households with income unknown
(Indicator 56).
Count of automatic re-enrollees (Indicator 5) in households with income unknown
(Indicator 56).
Count of new consumers (Indicator 2) whose sex is Female, according to the
selected policy (Indicator 35).
Active re-enrollees whose sex is Female
Count of active re-enrollees (Indicator 4) whose sex is Female, according to the
(net)
selected policy (Indicator 35).
Automatic re-enrollees whose sex is Female Count of automatic re-enrollees (Indicator 5) whose sex is Female, according to the
(net)
selected policy (Indicator 35).
New consumers whose sex is Male (net)
Count of new consumers (Indicator 2) whose sex is Male, according to the selected
policy (Indicator 36).
Active re-enrollees whose sex is Male (net) Count of active re-enrollees (Indicator 4) whose sex is Male, according to the
selected policy (Indicator 36).
Automatic re-enrollees whose sex is Male
Count of automatic re-enrollees (Indicator 5) whose sex is Male, according to the
(net)
selected policy (Indicator 36).
New consumers whose sex is unknown
Count of new consumers (Indicator 2) where sex is unknown, according to the
(net)
selected policy (Indicator 37).
Active re-enrollees whose sex is unknown
Count of active re-enrollees (Indicator 4) where sex is unknown, according to the
(net)
selected policy (Indicator 37).
43

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
339
340

Title
Automatic re-enrollees whose sex is
unknown (net)
New consumers whose Ethnicity is Hispanic
or Latino

341

Active re-enrollees whose Ethnicity is
Hispanic or Latino

342

Automatic re-enrollees whose Ethnicity is
Hispanic or Latino

343

New consumers whose Race is White

344

Active re-enrollees whose Race is White

345

Automatic re-enrollees whose Race is
White

346

New consumers whose Race/Ethnicity is
White, Non-Hispanic

Description
Count of automatic re-enrollees (Indicator 5) where sex is unknown, according to
the selected policy (Indicator 37).
Count of new consumers (Indicator 2) who have indicated they are Mexican,
Mexican American or Chicano/a, Puerto Rican, Cuban, or “other Hispanic or Latino
ethnicity” on their application. Individuals who have indicated that they are
Hispanic or Latino should be counted, regardless of the race selection on their
application (Indicator 38).
Count of active re-enrollees (Indicator 4) who have indicated they are Mexican,
Mexican American or Chicano/a, Puerto Rican, Cuban, or “other Hispanic or Latino
ethnicity” on their application. Individuals who have indicated that they are
Hispanic or Latino should be counted, regardless of the race selection on their
application (Indicator 38).
Count of automatic re-enrollees (Indicator 5) who have indicated they are
Mexican, Mexican American or Chicano/a, Puerto Rican, Cuban, or “other Hispanic
or Latino ethnicity” on their application. Individuals who have indicated that they
are Hispanic or Latino should be counted, regardless of the race selection on their
application (Indicator 38).
Count of new consumers (Indicator 2) who have indicated they are white on their
application. Individuals who have indicated that they are white should be counted,
regardless of the ethnicity selection on their application (Indicator 39).
Count of active re-enrollees (Indicator 4) who have indicated they are white on
their application. Individuals who have indicated that they are white should be
counted, regardless of the ethnicity selection on their application (Indicator 39).
Count of automatic re-enrollees (Indicator 5) who have indicated they are white on
their application. Individuals who have indicated that they are white should be
counted, regardless of the ethnicity selection on their application (Indicator 39).
Count of new consumers (Indicator 2) who have 1. Indicated that they are white
on their application and 2. Indicated that their ethnicity is not Hispanic or Latino or
did not indicate that their ethnicity is Hispanic or Latino on their application
(Indicator 39.1).

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OMB control number 0938-1119

Indicator
347

Title
Active re-enrollees whose Race/Ethnicity is
White, Non-Hispanic

348

Automatic re-enrollees whose
Race/Ethnicity is White, Non-Hispanic

349

New consumers whose Race is African
American

350

Active re-enrollees whose Race is African
American

351

Automatic re-enrollees whose Race is
African American

352

New consumers whose Race/Ethnicity is
African American, Non-Hispanic

353

Active re-enrollees whose Race/Ethnicity is
African American, Non-Hispanic

354

Automatic re-enrollees whose
Race/Ethnicity is African American, NonHispanic

Description
Count of active re-enrollees (Indicator 4) who have 1. Indicated that they are white
on their application and 2. Indicated that their ethnicity is not Hispanic or Latino or
did not indicate that their ethnicity is Hispanic or Latino on their application
(Indicator 39.1).
Count of automatic re-enrollees (Indicator 5) who have 1. Indicated that they are
white on their application and 2. Indicated that their ethnicity is not Hispanic or
Latino or did not indicate that their ethnicity is Hispanic or Latino on their
application (Indicator 39.1).
Count of new consumers (Indicator 2) who have indicated they are black or African
American on their application. Individuals who have indicated that they are black
or African American should be counted, regardless of the ethnicity selection on
their application (Indicator 40).
Count of active re-enrollees (Indicator 4) who have indicated they are black or
African American on their application. Individuals who have indicated that they are
black or African American should be counted, regardless of the ethnicity selection
on their application (Indicator 40).
Count of automatic re-enrollees (Indicator 5) who have indicated they are black or
African American on their application. Individuals who have indicated that they are
black or African American should be counted, regardless of the ethnicity selection
on their application (Indicator 40).
Count of new consumers (Indicator 2) who have 1. Indicated that they are black or
African American on their application and 2. Indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application (Indicator 40.1).
Count of active re-enrollees (Indicator 4) who have 1. Indicated that they are black
or African American on their application and 2. Indicated that their ethnicity is not
Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino on
their application (Indicator 40.1).
Count of automatic re-enrollees (Indicator 5) who have 1. Indicated that they are
black or African American on their application and 2. Indicated that their ethnicity
is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic or Latino
on their application (Indicator 40.1).

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Indicator
355

Title
New consumers whose Race is Asian

356

Active re-enrollees whose Race is Asian

357

Automatic re-enrollees whose Race is Asian

358

New consumers whose Race/Ethnicity is
Asian, Non-Hispanic

359

Active re-enrollees whose Race/Ethnicity is
Asian, Non-Hispanic

360

Automatic re-enrollees whose
Race/Ethnicity is Asian, Non-Hispanic

361

New consumers whose Race is Native
Hawaiian/Pacific Islander

Description
Count of new consumers (Indicator 2) who have indicated they are Asian Indian,
Chinese, Filipino, Korean, Vietnamese, Japanese, or “other Asian” on their
application. Individuals who have indicated that they are Asian should be counted,
regardless of the ethnicity selection on their application (Indicator 41).
Count of active re-enrollees (Indicator 4) who have indicated they are Asian Indian,
Chinese, Filipino, Korean, Vietnamese, Japanese, or “other Asian” on their
application. Individuals who have indicated that they are Asian should be counted,
regardless of the ethnicity selection on their application (Indicator 41).
Count of automatic re-enrollees (Indicator 5) who have indicated they are Asian
Indian, Chinese, Filipino, Korean, Vietnamese, Japanese, or “other Asian” on their
application. Individuals who have indicated that they are Asian should be counted,
regardless of the ethnicity selection on their application (Indicator 41).
Count of new consumers (Indicator 2) who have 1. Indicated that they are Asian
Indian, Chinese, Filipino, Korean, Vietnamese, Japanese, or “other Asian” on their
application and 2. Indicated that their ethnicity is not Hispanic or Latino or did not
indicate that their ethnicity is Hispanic or Latino on their application (Indicator
41.1).
Count of active re-enrollees (Indicator 4) who have 1. Indicated that they are Asian
Indian, Chinese, Filipino, Korean, Vietnamese, Japanese, or “other Asian” on their
application and 2. Indicated that their ethnicity is not Hispanic or Latino or did not
indicate that their ethnicity is Hispanic or Latino on their application (Indicator
41.1).
Count of automatic re-enrollees (Indicator 5) who have 1. Indicated that they are
Asian Indian, Chinese, Filipino, Korean, Vietnamese, Japanese, or “other Asian” on
their application and 2. Indicated that their ethnicity is not Hispanic or Latino or
did not indicate that their ethnicity is Hispanic or Latino on their application
(Indicator 41.1).
Count of new consumers (Indicator 2) who have indicated they are Guamanian or
Chamorro, Native Hawaiian, Samoan, or “other Pacific Islander” on their
application. Individuals who have indicated that they are Native Hawaiian or
Pacific Islander should be counted, regardless of the ethnicity selection on their
application (Indicator 42).

46

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OMB control number 0938-1119

Indicator
362

Title
Active re-enrollees whose Race is Native
Hawaiian/Pacific Islander

363

Automatic re-enrollees whose Race is
Native Hawaiian/Pacific Islander

364

New consumers whose Race/Ethnicity is
Native Hawaiian/Pacific Islander, NonHispanic

365

Active re-enrollees whose Race/Ethnicity is
Native Hawaiian/Pacific Islander, NonHispanic

366

Automatic re-enrollees whose
Race/Ethnicity is Native Hawaiian/Pacific
Islander, Non-Hispanic

367

New consumers whose Race is American
Indian/Alaska Native

368

Active re-enrollees whose Race is American
Indian/Alaska Native

Description
Count of active re-enrollees (Indicator 4) who have indicated they are Guamanian
or Chamorro, Native Hawaiian, Samoan, or “other Pacific Islander” on their
application. Individuals who have indicated that they are Native Hawaiian or
Pacific Islander should be counted, regardless of the ethnicity selection on their
application (Indicator 42).
Count of automatic re-enrollees (Indicator 5) who have indicated they are
Guamanian or Chamorro, Native Hawaiian, Samoan, or “other Pacific Islander” on
their application. Individuals who have indicated that they are Native Hawaiian or
Pacific Islander should be counted, regardless of the ethnicity selection on their
application (Indicator 42).
Count of new consumers (Indicator 2) who have 1. Indicated that they are
Guamanian or Chamorro, Native Hawaiian, Samoan, or “other Pacific Islander” on
their application and 2. Indicated that their ethnicity is not Hispanic or Latino or
did not indicate that their ethnicity is Hispanic or Latino on their application
(Indicator 42.1).
Count of active re-enrollees (Indicator 4) who have 1. Indicated that they are
Guamanian or Chamorro, Native Hawaiian, Samoan, or “other Pacific Islander” on
their application and 2. Indicated that their ethnicity is not Hispanic or Latino or
did not indicate that their ethnicity is Hispanic or Latino on their application
(Indicator 42.1).
Count of automatic re-enrollees (Indicator 5) who have 1. Indicated that they are
Guamanian or Chamorro, Native Hawaiian, Samoan, or “other Pacific Islander” on
their application and 2. Indicated that their ethnicity is not Hispanic or Latino or
did not indicate that their ethnicity is Hispanic or Latino on their application
(Indicator 42.1).
Count of new consumers (Indicator 2) who have indicated they are American
Indian or Alaska Native on their application. Individuals who have indicated that
they are American Indian or Alaska Native should be counted, regardless of the
ethnicity selection on their application (Indicator 43).
Count of active re-enrollees (Indicator 4) who have indicated they are American
Indian or Alaska Native on their application. Individuals who have indicated that
they are American Indian or Alaska Native should be counted, regardless of the
ethnicity selection on their application (Indicator 43).
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Indicator
369

Title
Automatic re-enrollees whose Race is
American Indian/Alaska Native

370

New consumers whose Race/Ethnicity is
American Indian/Alaska Native, NonHispanic

371

Active re-enrollees whose Race/Ethnicity is
American Indian/Alaska Native, NonHispanic

372

Automatic re-enrollees whose
Race/Ethnicity is American Indian/Alaska
Native, Non-Hispanic

373

New consumers whose Race is Middle
Eastern/North African

374

Active re-enrollees whose Race is Middle
Eastern/North African

375

Automatic re-enrollees whose Race is
Middle Eastern/North African

Description
Count of automatic re-enrollees (Indicator 5) who have indicated they are
American Indian or Alaska Native on their application. Individuals who have
indicated that they are American Indian or Alaska Native should be counted,
regardless of the ethnicity selection on their application (Indicator 43).
Count of new consumers (Indicator 2) who have 1. Indicated that they are
American Indian or Alaska Native on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application (Indicator 43.1).
Count of active re-enrollees (Indicator 4) who have 1. Indicated that they are
American Indian or Alaska Native on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application (Indicator 43.1).
Count of automatic re-enrollees (Indicator 5) who have 1. Indicated that they are
American Indian or Alaska Native on their application and 2. Indicated that their
ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is Hispanic
or Latino on their application (Indicator 43.1).
Count of new consumers (Indicator 2) who have indicated they are Lebanese,
Iranian, Egyptian, Syrian, Iraqi, and Israeli, or “other Middle Eastern or North
African” on their application. Individuals who have indicated that they are Middle
Eastern or North African should be counted, regardless of the ethnicity selection
on their application (Indicator 43.2).
Count of active re-enrollees (Indicator 4) who have indicated they are Lebanese,
Iranian, Egyptian, Syrian, Iraqi, and Israeli, or “other Middle Eastern or North
African” on their application. Individuals who have indicated that they are Middle
Eastern or North African should be counted, regardless of the ethnicity selection
on their application (Indicator 43.2).
Count of automatic re-enrollees (Indicator 5) who have indicated they are
Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or “other Middle Eastern or
North African” on their application. Individuals who have indicated that they are
Middle Eastern or North African should be counted, regardless of the ethnicity
selection on their application (Indicator 43.2).

48

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OMB control number 0938-1119

Indicator
376

Title
New consumers whose Race/Ethnicity is
Middle Eastern/North African, NonHispanic

377

Active re-enrollees whose Race/Ethnicity is
Middle Eastern/North African, NonHispanic

378

Automatic re-enrollees whose
Race/Ethnicity is Middle Eastern/North
African, Non-Hispanic

379

New consumers whose Race is Multi-Racial

380

Active re-enrollees whose Race is MultiRacial

381

Automatic re-enrollees whose Race is
Multi-Racial

Description
Count of new consumers (Indicator 2) who have 1. Indicated that they are
Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or “other Middle Eastern or
North African” and 2. Indicated that their ethnicity is not Hispanic or Latino or did
not indicate that their ethnicity is Hispanic or Latino on their application (Indicator
43.3).
Count of active re-enrollees (Indicator 4) who have 1. Indicated that they are
Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or “other Middle Eastern or
North African” and 2. Indicated that their ethnicity is not Hispanic or Latino or did
not indicate that their ethnicity is Hispanic or Latino on their application (Indicator
43.3).
Count of automatic re-enrollees (Indicator 5) who have 1. Indicated that they are
Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli, or “other Middle Eastern or
North African” and 2. Indicated that their ethnicity is not Hispanic or Latino or did
not indicate that their ethnicity is Hispanic or Latino on their application (Indicator
43.3).
Count of new consumers (Indicator 2) who have indicated more than one distinct
racial group: American Indian / Alaska Native, Asian, Native Hawaiian / Pacific
Islander, African-American, Middle Eastern / North African, and White, on their
application. Individuals who have indicated more than one racial group should be
counted, regardless of the ethnicity selection on their application (Indicator 44).
Count of active re-enrollees (Indicator 4) who have indicated more than one
distinct racial group: American Indian / Alaska Native, Asian, Native Hawaiian /
Pacific Islander, African-American, Middle Eastern / North African, and White, on
their application. Individuals who have indicated more than one racial group
should be counted, regardless of the ethnicity selection on their application
(Indicator 44).
Count of automatic re-enrollees (Indicator 5) who have indicated more than one
distinct racial group: American Indian / Alaska Native, Asian, Native Hawaiian /
Pacific Islander, African-American, Middle Eastern / North African, and White, on
their application. Individuals who have indicated more than one racial group
should be counted, regardless of the ethnicity selection on their application
(Indicator 44).
49

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
382

Title
New consumers whose Race/Ethnicity is
Multi-Racial, Non-Hispanic

383

Active re-enrollees whose Race/Ethnicity is
Multi-Racial, Non-Hispanic

384

Automatic re-enrollees whose
Race/Ethnicity is Multi-Racial, Non-Hispanic

385

New consumers whose Race/Ethnicity is
Unknown, Non-Hispanic

386

Active re-enrollees whose Race/Ethnicity is
Unknown, Non-Hispanic

387

Automatic re-enrollees whose
Race/Ethnicity is Unknown, Non-Hispanic

388

New consumers whose Race is Other

Description
Count of new consumers (Indicator 2) who have 1. Indicated more than one
distinct racial group: American Indian / Alaska Native, Asian, Native Hawaiian /
Pacific Islander, African-American, Middle Eastern / North African, and White, on
their application and 2. Indicated that their ethnicity is not Hispanic or Latino or
did not indicate that their ethnicity is Hispanic or Latino on their application should
be counted (Indicator 44.1).
Count of active re-enrollees (Indicator 4) who have 1. Indicated more than one
distinct racial group: American Indian / Alaska Native, Asian, Native Hawaiian /
Pacific Islander, African-American, Middle Eastern / North African, and White, on
their application and 2. Indicated that their ethnicity is not Hispanic or Latino or
did not indicate that their ethnicity is Hispanic or Latino on their application should
be counted (Indicator 44.1).
Count of automatic re-enrollees (Indicator 5) who have 1. Indicated more than one
distinct racial group: American Indian / Alaska Native, Asian, Native Hawaiian /
Pacific Islander, African-American, Middle Eastern / North African, and White, on
their application and 2. Indicated that their ethnicity is not Hispanic or Latino or
did not indicate that their ethnicity is Hispanic or Latino on their application should
be counted (Indicator 44.1).
Count of new consumers (Indicator 2) who 1. did not indicate a race on their
application and 2. indicated that their ethnicity is not Hispanic or Latino or did not
indicate that their ethnicity is Hispanic or Latino on their application (Indicator 45).
Count of active re-enrollees (Indicator 4) who 1. did not indicate a race on their
application and 2. indicated that their ethnicity is not Hispanic or Latino or did not
indicate that their ethnicity is Hispanic or Latino on their application (Indicator 45).
Count of automatic re-enrollees (Indicator 5) who 1. did not indicate a race on
their application and 2. indicated that their ethnicity is not Hispanic or Latino or
did not indicate that their ethnicity is Hispanic or Latino on their application
(Indicator 45).
Count of new consumers (Indicator 2) who have indicated another race or “Other”
on their application. Individuals should be counted, regardless of the ethnicity
selection on their application. This does not include individuals who are already
counted in indicators 39-45 and indicated other Asian, other Pacific Islander, etc.
(Indicator 45.1).
50

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OMB control number 0938-1119

Indicator
389

390

391

392

393

Title
Active re-enrollees whose Race is Other

Description
Count of active re-enrollees (Indicator 4) who have indicated another race or
“Other” on their application. Individuals should be counted, regardless of the
ethnicity selection on their application. This does not include individuals who are
already counted in indicators 39-45 and indicated other Asian, other Pacific
Islander, etc. (Indicator 45.1).
Automatic re-enrollees whose Race is Other Count of automatic re-enrollees (Indicator 5) who have indicated another race or
“Other” on their application. Individuals should be counted, regardless of the
ethnicity selection on their application. This does not include individuals who are
already counted in indicators 39-45 and indicated other Asian, other Pacific
Islander, etc. (Indicator 45.1).
New consumers whose Race/Ethnicity is
Count of new consumers (Indicator 2) who have 1. Indicated another race or
Other, Non-Hispanic
“Other” on their application and 2. Indicated that their ethnicity is not Hispanic or
Latino or did not indicate that their ethnicity is Hispanic or Latino on their
application. This does not include individuals who are already counted in indicators
38-45 and indicated other Hispanic or Latino, other Asian, other Pacific Islander,
etc. (Indicator 45.2).
Active re-enrollees whose Race/Ethnicity is Count of active re-enrollees (Indicator 4) who have 1. Indicated another race or
Other, Non-Hispanic
“Other” on their application and 2. Indicated that their ethnicity is not Hispanic or
Latino or did not indicate that their ethnicity is Hispanic or Latino on their
application. This does not include individuals who are already counted in indicators
38-45 and indicated other Hispanic or Latino, other Asian, other Pacific Islander,
etc. (Indicator 45.2).
Automatic re-enrollees whose
Count of automatic re-enrollees (Indicator 5) who have 1. Indicated another race
Race/Ethnicity is Other, Non-Hispanic
or “Other” on their application and 2. Indicated that their ethnicity is not Hispanic
or Latino or did not indicate that their ethnicity is Hispanic or Latino on their
application. This does not include individuals who are already counted in indicators
38-45 and indicated other Hispanic or Latino, other Asian, other Pacific Islander,
etc. (Indicator 45.2).

51

Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Exhibit 9: Basic Health Plan Program/Other – only for states with BHP or 1332 plan
Indicator Title
Description
169
Total BHP Enrollees/Other (net)
Count of unique individuals who have enrolled in BHP or other related programs.
Count does not include enrollments that were canceled or terminated, or
individuals enrolled in Medicaid/CHIP programs that are not BHP.
170
New BHP/Other Enrollees (New Enrollees)
Count of unique individuals who have enrolled in BHP or other related programs
(net)
who were not enrolled in an exchange-facilitated program (i.e. BHP, QHP, or any
other integrated programs, like Medicaid) immediately prior to this BHP
enrollment.
171
BHP/Other Re-enrollees (net)
Count of unique individuals who have enrolled in BHP or other related programs
who were enrolled in an exchange-facilitated program (i.e. BHP, QHP, or any other
integrated programs, like Medicaid) immediately prior to this BHP enrollment.
172
Consumers Eligible for BHP/Other (net)
Count of all individuals determined or assessed eligible for BHP or other related
programs. Only individuals on submitted applications and requesting coverage are
included. Count all individuals determined/assessed eligible even if the individual
does not subsequently enroll in coverage.
173
Consumers enrolled in BHP/Other as of
Count of unique individuals with non-canceled BHP or other related program
11/1/20XX (ONE TIME)
coverage ending as of 11/1/20XX .
174
Number of BHP/Other Enrollees where age Count of unique individuals who have non-canceled BHP or other related program
is 0 - 17 (net)
coverage and who are age 0 - 17. Age represents the recorded age as of the policy
effective coverage date.
175
Number of BHP/Other Enrollees where age Count of unique individuals who have non-canceled BHP or other related program
18 - 25 (net)
coverage and who are age 18 - 25. Age represents the recorded age as of the
policy effective coverage date.
175.1
Number of BHP/Other Enrollees where age Count of unique individuals who have non-canceled BHP or other related program
is 26 - 34 (net)
coverage and who are age 26 - 34. Age represents the recorded age as of the
policy effective coverage date.
176
Number BHP/Other Enrollees where age 35 Count of unique individuals who have non-canceled BHP or other related program
- 44 (net)
coverage and who are age 35 - 44. Age represents the recorded age as of the
policy effective coverage date.
176.1
Number of BHP/Other Enrollees where age Count of unique individuals who have non-canceled BHP or other related program
is 45 - 54 (net)
coverage and who are age 45 - 54. Age represents the recorded age as of the
policy effective coverage date.
52

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OMB control number 0938-1119

Indicator
177

Title
Number of BHP/Other Enrollees where age
≥55 (net)

178

Number of BHP/Other Enrollees where age
is unknown (net)

179

Number of BHP/Other Enrollees where sex
is Female (net)
Number of BHP/Other Enrollees where sex
is Male (net)
Number of BHP Enrollees where sex is
unknown (net)
Number of BHP/Other Enrollees where
Ethnicity is Hispanic or Latino (net)

180
181
182

183

Number of BHP/Other Enrollees where
Race is White (net)

183.1

Number of BHP/Other Enrollees where
Race/Ethnicity is White, Non-Hispanic (net)

184

Number of BHP/Other Enrollees where
Race is African American (net)

184.1

Number of BHP/Other Enrollees where
Race/Ethnicity is African American, NonHispanic (net)

Description
Count of unique individuals who have non-canceled BHP or other related program
coverage and who are age ≥55. Age represents the recorded age as of the policy
effective coverage date.
Count of unique individuals who have non-canceled BHP or other related program
coverage and whose age is unknown. Age represents the recorded age as of the
policy effective coverage date.
Count of unique individuals who have non-canceled BHP or other related program
coverage and whose sex is Female, according to the selected policy.
Count of unique individuals who have non-canceled BHP or other related program
coverage and whose sex is Male, according to the selected policy.
Count of unique individuals who have non-canceled BHP or other related program
coverage and whose sex is unknown, according to the selected policy.
Count of unique individuals who have non-canceled BHP or other related program
other related program coverage and who have indicated they are Mexican,
Mexican American or Chicano/a, Puerto Rican, Cuban, or “other Hispanic or Latino
ethnicity” on their application. Hispanic or Latino ethnicity should be counted,
regardless of the race selection on their application.
Count of unique individuals who have non-canceled BHP or other related program
coverage and who have indicated they are white on their application. Individuals
who have indicated that they are white should be counted, regardless of the
ethnicity selection on their application.
Count of unique individuals who have non-canceled BHP or other related program
coverage and who 1. Indicated that they are white on their application and 2.
Indicated that their ethnicity is not Hispanic or Latino or did not indicate that their
ethnicity is Hispanic or Latino on their application.
Count of unique individuals who have non-canceled BHP or other related program
coverage and who have indicated they are black or African American on their
application. Individuals who have indicated that they are black or African American
should be counted, regardless of the ethnicity selection on their application.
Count of unique individuals who have non-canceled BHP or other related program
coverage and who 1. Indicated that they are black or African American on their
application and 2. Indicated that their ethnicity is not Hispanic or Latino or did not
indicate that their ethnicity is Hispanic or Latino on their application.
53

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Indicator
185

185.1

186

186.1

187

187.1

Title
Number of BHP/Other Enrollees where
Race is Asian (net)

Description
Count of unique individuals who have non-canceled BHP or other related program
coverage and who have indicated they are Asian Indian, Chinese, Filipino, Korean,
Vietnamese, Japanese, or "other Asian" on their application. Individuals who have
indicated that they are Asian should be counted, regardless of the ethnicity
selection on their application.
Number of BHP/Other Enrollees where
Count of unique individuals who have non-canceled BHP or other related program
Race/Ethnicity is Asian, Non-Hispanic (net)
coverage and who 1. Indicated that they are Asian Indian, Chinese, Filipino,
Korean, Vietnamese, Japanese, or “other Asian” on their application and 2.
Indicated that their ethnicity is not Hispanic or Latino or did not indicate that their
ethnicity is Hispanic or Latino on their application.
Number of BHP/Other Enrollees where
Count of unique individuals who have non-canceled BHP or other related program
Race is Native Hawaiian/Pacific Islander
coverage and who have indicated they are Guamanian or Chamorro, Native
(net)
Hawaiian, Samoan, or Other Pacific Islander on their application. Individuals who
have indicated that they are Native Hawaiian or Pacific Islander should be counted,
regardless of the ethnicity selection on their application.
Number of BHP/Other Enrollees where
Count of unique individuals who have non-canceled BHP or other related program
Race/Ethnicity is Native Hawaiian/Pacific
coverage and who 1. Indicated that they are Guamanian or Chamorro, Native
Islander, Non-Hispanic (net)
Hawaiian, Samoan, or “other Pacific Islander” on their application and 2. Indicated
that their ethnicity is not Hispanic or Latino or did not indicate that their ethnicity
is Hispanic or Latino on their application.
Number of BHP/Other Enrollees where
Count of unique individuals who have non-canceled BHP or other related program
Race is American Indian/Alaska Native (net) coverage and who have indicated they are American Indian or Alaska Native on
their application. Individuals who have indicated that they are American Indian or
Alaska Native should be counted, regardless of the ethnicity selection on their
application.
Number of BHP/Other Enrollees where
Count of unique individuals who have non-canceled BHP or other related program
Race/Ethnicity is American Indian/Alaska
coverage and who 1. Indicated that they are American Indian or Alaska Native on
Native, Non-Hispanic (net)
their application and 2. Indicated that their ethnicity is not Hispanic or Latino or
did not indicate that their ethnicity is Hispanic or Latino on their application.

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Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
187.2

Title
Number of BHP/Other Enrollees where
Race is Middle Eastern/North African (net)

187.3

Number of BHP/Other Enrollees where
Race is Middle Eastern/North African, NonHispanic (net)

188

Number of BHP/Other Enrollees where
Race is Multi-Racial (net)

188.1

Number of BHP/Other Enrollees where
Race/Ethnicity is Multi-Racial, Non-Hispanic
(net)

189

Number of BHP/Other Enrollees where
Race/Ethnicity is Unknown, Non-Hispanic
(net)

189.1

Number of BHP/Other Enrollees where
Race is Other (net)

Description
Count of unique individuals who have non-canceled BHP or other related program
coverage and who have indicated they are Lebanese, Iranian, Egyptian, Syrian,
Iraqi, and Israeli, or “other Middle Eastern or North African” on their application.
Individuals who have indicated that they are Middle Eastern or North African
should be counted, regardless of the ethnicity selection on their application.
Count of unique individuals who have non-canceled BHP or other related program
coverage and who 1. Indicated that they are Lebanese, Iranian, Egyptian, Syrian,
Iraqi, and Israeli, or “other Middle Eastern or North African” and 2. Indicated that
their ethnicity is not Hispanic or Latino or did not indicate that their ethnicity is
Hispanic or Latino on their application.
Count of unique individuals who have non-canceled BHP or other related program
coverage and who have indicated more than one distinct racial group as defined
above: American Indian / Alaska Native, Asian, Native Hawaiian / Pacific Islander,
African-American, Middle Eastern / North African, and White, on their application.
Individuals who have indicated more than one racial group should be counted,
regardless of the ethnicity selection on their application.
Count of unique individuals who have non-canceled BHP or other related program
coverage and who 1. Have indicated more than one distinct racial group: American
Indian / Alaska Native, Asian, Native Hawaiian / Pacific Islander, African-American,
Middle Eastern / North African, and White, on their application and 2. Indicated
that their ethnicity is not Hispanic or Latino or did not indicate that their ethnicity
is Hispanic or Latino on their application should be counted.
Count of unique individuals who 1. Have non-canceled BHP or other related
program coverage and who did not indicate a race on their application and 2.
Indicated that their ethnicity is not Hispanic or Latino or did not indicate that their
ethnicity is Hispanic or Latino on their application.
Count of unique individuals who have non-canceled BHP or other related program
coverage and who have indicated another race or “Other” on their application.
Individuals should be counted, regardless of the ethnicity selection on their
application. This does not include individuals who are already counted in indicators
183-189 and indicated other Asian, other Pacific Islander, etc.

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Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
189.2

Title
Number of BHP/Other Enrollees where
Race/Ethnicity is Other, Non-Hispanic (net)

Exhibit 10: Metal Level by Financial (new section)
Indicator Title
394
Bronze plans selected by consumers who
receive both CSR and APTC

395

Silver plans selected by consumers who
receive both APTC and CSR

396

Gold plans selected by consumers who
receive both APTC and CSR

397

Bronze plans selected by consumers who
receive APTC only

398

Silver plans selected by consumers who
receive APTC only

399

Gold plans selected by consumers who
receive APTC only

400

Bronze plans selected by consumers who
receive CSR only

Description
Count of unique individuals who have non-canceled BHP or other related program
coverage and who 1. Indicated another race or “Other” on their application and 2.
Indicated that their ethnicity is not Hispanic or Latino or did not indicate that their
ethnicity is Hispanic or Latino on their application. This does not include individuals
who are already counted in indicators 182-189 and indicated other Hispanic or
Latino, other Asian, other Pacific Islander, etc.

Description
Count of individuals who selected a bronze medical plan (Indicator 49) and have
elected to receive APTC in an amount greater than $0 and receives CSR. Count
includes consumers with APTC and CSRs. Consumers with only APTC or with only
CSRs should not be counted.
Count of individuals who selected a silver medical plan (Indicator 48) and have
elected to receive APTC in an amount greater than $0 and receives CSR. Count
includes consumers with APTC and CSRs. Consumers with only APTC or with only
CSRs should not be counted.
Count of individuals who selected a gold medical plan (Indicator 49) and have
elected to receive APTC in an amount greater than $0 and receives CSR. Count
includes consumers with APTC and CSRs. Consumers with only APTC or with only
CSRs should not be counted.
Count of individuals who selected a bronze medical plan (Indicator 49) and have
elected to receive APTC in an amount greater than $0. Consumers with CSRs
should not be counted.
Count of individuals who selected a silver medical plan (Indicator 48) and have
elected to receive APTC in an amount greater than $0. Consumers with CSRs
should not be counted.
Count of individuals who selected a gold medical plan (Indicator 49) and have
elected to receive APTC in an amount greater than $0. Consumers with CSRs
should not be counted.
Count of individuals who selected a bronze medical plan (Indicator 49) and
receives CSR in an amount greater than $0. Count may include consumers who are
eligible to receive APTC but have elected not to receive APTC.
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Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Indicator
401

Title
Silver plans selected by consumers who
receive CSR only

402

Gold plans selected by consumers who
receive CSR only

Exhibit 11: Consumer Type by Financial (new section)
Indicator Title
403
New consumers who receive both APTC
and CSR
404

Active re-enrollees who receive both APTC
and CSR

405

Automatic re-enrollees who receive both
APTC and CSR

406

New consumers who receive APTC only

407

Active re-enrollees who receive APTC only

408
409

Automatic re-enrollees who receive APTC
only
New consumers who receive CSR only

410

Active re-enrollees who receive CSR only

411

Automatic re-enrollees who receive CSR
only

Description
Count of individuals who selected a silver medical plan (Indicator 48) and receives
CSR in an amount greater than $0. Count may include consumers who are eligible
to receive APTC but have elected not to receive APTC.
Count of individuals who selected a gold medical plan (Indicator 49) and receives
CSR in an amount greater than $0. Count may include consumers who are eligible
to receive APTC but have elected not to receive APTC.

Description
Count of new consumers (Indicator 2) who have elected to receive APTC in an
amount greater than $0 and receives CSR. Count includes consumers with APTC
and CSRs. Consumers with only APTC or with only CSRs should not be counted
Count of Active re-enrollees (Indicator 4) who have elected to receive APTC in an
amount greater than $0 and receives CSR. Count includes consumers with APTC
and CSRs. Consumers with only APTC or with only CSRs should not be counted
Count of Automatic re-enrollees (Indicator 5) who have elected to receive APTC in
an amount greater than $0 and receives CSR. Count includes consumers with APTC
and CSRs. Consumers with only APTC or with only CSRs should not be counted
Count of new consumers (Indicator 2) who have elected to receive APTC in an
amount greater than $0. Consumers with CSRs should not be counted.
Count of Active re-enrollees (Indicator 4) who have elected to receive APTC in an
amount greater than $0. Consumers with CSRs should not be counted.
Count of Automatic re-enrollees (Indicator 5) who have elected to receive APTC in
an amount greater than $0. Consumers with CSRs should not be counted.
Count of new consumers (Indicator 2) who receive CSR in an amount greater than
$0. Count may include consumers who are eligible to receive APTC but have
elected not to receive APTC.
Count of Active re-enrollees (Indicator 4) who receive CSR in an amount greater
than $0. Count may include consumers who are eligible to receive APTC but have
elected not to receive APTC.
Count of Automatic re-enrollees (Indicator 5) who receive CSR in an amount
greater than $0. Count may include consumers who are eligible to receive APTC
but have elected not to receive APTC.
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Expiration date. XX/XX/XXXX
OMB control number 0938-1119

Exhibit 12: Plan Selections by Area (new section)
Indicator Title
412
Plan Selections by Consumers in Rural
Locations
413
Plan Selections by Consumers in Non-Rural
Locations
420
Plan Selections by Consumers in Counties

430

DMIs Generated - Annual Income (gross)

436

DMIs Generated - Total (gross)

Description
Count of unique consumers in rural locations based on ZIP code and county, as
defined by the Health Resources and Services Administration (HRSA).
Count of unique consumers in non-rural locations based on ZIP code and county,
as defined by the Health Resources and Services Administration (HRSA).
Count of unique individuals who have selected a Plan Year PY 20XX Marketplace
medical plan by county. Count includes all new and re-enrolling consumers
(defined in Indicators 2 and 3), regardless of whether the consumer has paid the
first month premium. Count does not include plans that were canceled or
terminated.
Count of households that were subjected to a data matching inconsistency (DMI)
based on Annual Household Income.
Sum of households that were subjected to Annual Household Income data
matching inconsistency (DMI) and individuals who were subjected to any data
matching inconsistency of all other DMI types. Note this metric should be the sum
of the number of Annual Income DMIs at the household level and the number of
individuals with DMIs of all other types.

Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1119. The time
required to complete this information collection is estimated to average 16 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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