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["State-based Exchange Budget"]
["FY 2022 - 2023"]
["FY 2023 - 2024"]
[]
["CCIIO/SMIPG"]
[]
["A.","General Information","Details","Notes (if needed)"]
[null,"State:","Select Your State"]
[null,"State Budget Year (indicate if Calendar or Fiscal):","Fiscal"]
[null,"If State Budget Year is Fiscal, indicate the date range:"]
[null,"Total Current Individual FTEs:"]
[null,"Total Current SHOP FTEs:"]
[null,"Total Marketplace FTE"]
[null,"Does the state require issuers to pay a carrier assessment (user fee)? If yes, is it a broad or market wide assessment?","Yes"]
[null,"Carrier Assessment (User fees) This is carrier assessment for the individual Marketplace and should not include outside of Marketplace values. If a flat dollar amount, please estimate in the notes how it might translate to  a percentage of premiums"]
[null,"General Notes/Comments (if needed):"]
[]
["B.","Marketplace Effectuated Enrollment","2023 Actual","2024 Projected","Notes (if needed)"]
[null,"Total QHP Enrollment for Plan Year"]
[null,"Member Months",0,0]
[]
["B.1","Individual Marketplace Effectuated Enrollment","2022 Actual","2023 Projected","Notes (if needed)"]
[null,"QHP Enrollment for Plan Year"]
[null,"Member Months",0,0]
[]
["B.2","SHOP Marketplace Effectuated Enrollment (if applicable)","2022 Actual","2023 Projected","Notes (if needed)"]
[null,"SHOP QHP Enrollment for Plan Year"]
[null,"Member Months",0,0]
[]
["C.","Revenue",null,"2022 Actual $","2022 Actual $ Revenue Allocated to Individual Expenditures","2022 Actual $ Revenue Allocated to SHOP Expenditures","2023 Projected $","2023 Projected $ Revenue Allocated to Individual Expenditures","2023 Projected $ Revenue Allocated to SHOP Expenditures","Notes (if needed/as requested)"]
[null,"Carrier Assessment (User fees)"," Separate between Inside or Outside Marketplace and between Individual and SHOP plans, if applicable."]
[]
[null,"Total Marketplace Carrier Assessment Collected","Indicate sources in the Notes column."]
[null,"Total Carrier Assessment Inside Individual Marketplace","Indicate sources in the Notes column."]
[null,"Total Carrier Assessment Inside Small Group Marketplace","Indicate sources in the Notes column."]
[null,"Total Carrier Assessment Outside Marketplace Individual Plans","Indicate sources in the Notes column."]
[null,"Total Carrier Assessment Outside Marketplace Small Group Plans","Indicate sources in the Notes column."]
[null,"Other Tax Assessments","Indicate sources in the Notes column."]
[null,"Other Grant Funding","Indicate sources in the Notes column."]
[null,"Revenue or Reimbursement from Medicaid/CHIP","Include Federal and state together."]
[null,"State Revenue/Reimbursement (list sources below)"]
[null,"Other State Revenue Sources (list sources below)"]
{"$rows_empty":9}
[null,"Other Revenue ","Indicate sources in the Notes column."]
[null,"Total $ Revenue",null,0,0,0,0,0,0]
[]
["D.","Marketplace Expenditures (total revenue and expenditures should balance out)","Definition/Details","2022 Actual $","2022 Actual $ Budget Allocated to Individual Expenditures","2022 Actual $ Budget Allocated to SHOP Expenditures","2023 Projected $","2023 Projected $ Budget Allocated to Individual Expenditures","2023 Projected $ Budget Allocated to SHOP Expenditures","Notes (if needed/as requested)"]
[null,"General Totals",null,0,0,0,0,0,0]
[null,"Personnel and Fringe","Officer and director salaries, temporary help, etc. "]
[null,"Indirect Costs","Travel, supplies, etc. "]
[null,"Facility and Other Non-IT Administrative","Rent, utilities, repairs, printing, etc."]
[null,"Other (list items in Notes column)","Vendor costs should be in other sections."]
[null,"External Marketing & Outreach Totals",null,0,0,0,0,0,0]
[null,"Navigators/IPAs","Grants or fees."]
[null,"Direct Marketing & Outreach to Consumers"]
[null,"Education & Outreach to Consumers\n","Consumer facing education, training, outreach activities, and materials."]
[null,"Education & Outreach to Agents/Brokers and Issuers","Agent/broker and issuer facing education, training, outreach activities, and materials ."]
[null,"Paid Media","Paid media."]
[null,"Advertising & Marketing","Efforts dedicated to engaging consumers, alliances, etc."]
[null,"Other (list items in Notes column)","Training Support Materials, Communications, Research, Website, Event Management."]
[null,"% of Total External Marketing & Outreach Allocated to Contractors","Contractor allocation."]
[null,"Call Center Totals",null,0,0,0,0,0,0]
[null,"Maintenance and Operations ","Labor, back office labor, technology, operations, etc."]
[null,"DDI","Efforts associated with development and enhancements."]
[null,"Other (list items in Notes column)","Other."]
[null,"% of Total Call Center Allocated to Contractors","Contractor allocation."]
[null,"IT Platform Totals",null,0,0,0,0,0,0]
[null,"Maintenance and Operations ","Labor, back office labor, technology, operations, etc."]
[null,"DDI","Efforts associated with development and enhancements."]
[null,"Other (list items in Notes column)","Other."]
[null,"% of Total IT Platform Efforts Allocated to Contractors","Contractor allocation."]
[null,"Total $ Expenditures",null,0,0,0,0,0,0]
[]
["E. ","Net Gain/(Loss)",null,"2022 Actual","2023 Projected","Notes (if needed)"]
[null,"Legislative Authority to have a reserve (Select Yes/No from drop-down choices)",null,"Yes","Yes"]
[null,"Total Reserve "]
[null,"Number of Months of Reserve","Number of Months currently available for reserve."]
[null,"Number of Months of Allowable Reserve","Number of Months allowed to have reserve available for."]
[null,"Total $ Net Gain/(Loss) ","Indicate in Notes if reserves/other funding source covers any loss",0,0]
[]
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[]
[null,"PRA Disclosure 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 OMB control number. The valid OMB control number for this information collection is 0938-1119."]
[null,"Note: Information Collection is estimated at 16hrs but may be less with recent streamlining and changes."]