Remaining Uninsured Data Collection - SAMPLE

Introduction

At the January 2014 CPCA Board and Committee Meetings, the CPCA Board took action to approve and launch a remaining uninsured data initiative. This data initiative is part of a larger multiyear campaign to bring coverage to all Californians. Our overall campaign will only be as strong as the data we have to support it. In the coming months and years we look forward to working with our health centers – their leadership, staff, and patients – on many components of our remaining uninsured campaign. By participating in our remaining uninsured data initiative, you and your health center are playing a critical role and taking an early step, to make sure we have strong data and a strong campaign.

In this brief survey, our goal is to get community clinic and health center information on the populations you serve. Our questions are focused on # Patients by Payer, # Patients by % FPL, and your incredible outreach and enrollment work.

By exchanging quarterly reports, CPCA and the regional consortia will maximize utilization of the data for local, regional, and statewide health policy needs. On a statewide level this data will be used to inform our remaining uninsured efforts, and at local and regional levels, this information can be utilized to impact county dialog on realignment and other issues.

Instructions: Please complete a separate survey for each clinic corporation. We will be collecting the data on a quarterly ongoing basis, so that we may present the findings in real-time.

*** Per UDS, whenever "patients" are counted, it is an un-duplicated count. Each patient is only counted once regardless of the number or scope of visits in the reporting period.

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Question Title

* 1. Member Clinic / Organization Name:

Question Title

* 2. Contact Information:

Name:

Email:

Question Title

* 3. Reporting Time Frame:

Q1: January - March 2014

Q2: April - June 2014

Q3: July - September 2014

Q4: October - December 2014

Question Title

* 4. Total Number of Patients by Income as % of FPL - (per UDS, whenever "patients" are counted, it is an un-duplcated count. Each patient is only counted once regardless of the number of scope of visits during the reported time period):

Below 100%:

100 - 138%:

139 - 200%:

201 - 400%:

Over 400%:

Unknown:

Question Title

* 5. (ALTERNATIVE to question #4: if you are unable to provide data for the ACA aligned FPL levels in question #4, please provide the following information instead.) Total Number of Patients by Income as % of FPL - (per UDS, whenever "patients" are counted, it is an un-duplcated count. Each patient is only counted once regardless of the number of scope of visits during the reported time period):

100% and below:

101 - 150%:

151 - 200%:

Over 200%:

Unknown:

Question Title

* 6. Total Number of Patients by Payor - (per UDS, whenever "patients" are counted, it is an un-duplicated count. Each patient is only counted once regardless of the number or scope of visits in the reporting period):

A.) Medicare:

B.) Medi-Cal (per UDS, this includes individuals who may have "state-only" Medi-Cal.):

C.) Private Insurance (including plans purchased through Covered CA. Per UDS, no special category is used for patients whose insurance may be subsidized through the ACA.):

D.) Other Public Insurance (includes individuals whose visits are covered by county indigent care COVERAGE programs, (e.g. CMSP). Does not include uninsured individuals whose visits are covered by a public source with limited benefits, such as the CCEP, the Early Prevention, Screening, Detection and Treatment Program (EPSDT) or the Breast and Cervical Cancer Control Program (BCCCP), etc.):

E.) None/Uninsured (patients who did not have medical INSURANCE at the time of the last visit. Per UDS, patients whose visits are subsidized through State/Local Government, "indigent care programs" ARE considered to uninsured. Include here, individuals whose services were paid by a public source with limited benefits, such as CCEP, EPSDT, BCCCP, FPACT, etc., and patients charged a sliding scale fee.):

Question Title

* 7. (OPTIONAL) Total Number of None/Uninsured Patients by Income - (per UDS, patients whose visits are subsidized through State/Local Government "indigent care programs" ARE considered to be uninsured. Include here, individuals whose services were paid by a public source with limited benefits, such as CCEP, EPSDT, BCCCP, FACT, etc. and patients charged a sliding scale fee.):

Below 100% FPL:

100 - 138% FPL:

139 - 200% FPL:

201 - 400% FPL:

Over 400% FPL:

Unknown:

Total None/Uninsured (should match None/Uninsured in question #6 above.):