Form CMS-10333 Appendix 3

Appendix 3
Template for the Annual Report
Consumer Savings
I.

Total amount of savings on behalf of consumers: $________
a. Of the total amount of consumer savings, note the amount of savings involving appeals
and grievances: $________
b. If the total amount of savings includes savings other than appeals-related recovered
benefits, provide examples:

How CAP has Addressed CLAS
Provide a brief summary of how the program has provided assistance that is culturally and linguistically
appropriate. Include information about translation services provided by the CAP, including but not
limited to the translation of materials that were developed by the CAP. Refer to the Office of Minority
Health’s website for the national standards on culturally and linguistically appropriate services
(http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15).

Lessons Learned
Provide a description of the lessons the program has learned that could inform the actions your program
takes in the future or that could be helpful to other programs.

Major Accomplishments
Provide a description of the accomplishments your program has made as a result of the grant.

Policy Changes Implemented
Provide a description of policy changes implemented as a result of, or that were informed by, information
collected by your program.

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Illustrative Examples
Provide at least one, but not more than three, examples of how your CAP helped a consumer obtain or
maintain coverage under a provision added by the ACA, or where a consumer’s case was referred for
enforcement and enforcement action was taken. (Note that under no circumstances should any personally
identifiable information (PII) be reported to CCIIO.)

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Instructions for the Annual Report Template
Consumer Savings
I.

Total amount of savings on behalf of consumers – Enter the dollar amount of benefits recovered
with the assistance of the CAP on behalf of consumers. This number should include benefits
recovered as a result of the appeals and grievances process, as well as benefits recovered not related
to an appeal.
a. Of the total amount of consumer savings, note the amount of savings involving
appeals and grievances – Enter the dollar amount of benefits recovered with the
assistance of the CAP on behalf of consumers related to the appeals and grievances
process. Typically, consumer savings represent the costs of healthcare services,
procedures, and claims that would have been the responsibility of the consumer had the
CAP grantee not intervened on the consumer’s behalf. This number should be a portion
of the number entered in Section I. above.
Consider the following information when completing this section:
You may use the dollar amount information found on the explanation of benefits
(EOB) or a bill from a provider that the consumer received to determine the
amount of recovered benefits if the consumer’s appeal or complaint outcome is
successful.
A reduction in the dollar amount paid by the consumer as a result of the
program’s intervention can be considered a recovered benefit. For example, if
the consumer receives services from an out-of-network provider and the issuer
later determines that the consumer is only responsible for in-network costs, the
recovered benefit amount would be the out-of-network costs less the in-network
costs.
Typically, cost-sharing, deductibles, and co-pay amounts are excluded from the
recovered benefit amount, as those amounts are the consumer’s responsibility.
For example, if a consumer is denied coverage for a service that costs $3000, the
consumer has an unmet deductible of $1000, and the program assists the
consumer in getting the $3000 service covered; the recovered benefit amount
would be the cost of the service less the cost of the unmet deductible ($3000 $1000 = $2000).
b. If the total amount of savings includes savings other than appeals-related recovered
benefits, provide examples – If the number entered in Section I. above is greater than
the number entered in Section a. above, please provide examples of what types of
consumer savings are included in the amount entered in Section I. above.

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How CAP has Addressed CLAS
Provide a brief summary of how the program has provided assistance that is culturally and
linguistically appropriate. Include information about translation services provided by the CAP,
including but not limited to the translation of materials that were developed by the CAP. Refer to
the Office of Minority Health’s website for the national standards on culturally and linguistically
appropriate services (http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15). –
Describe how the CAP was able to provide consumer assistance that was culturally and linguistically
appropriate, noting specific examples of how consumers benefitted from these efforts. In providing this
description, under no circumstances should any personally identifiable information be reported to CCIIO.

Lessons Learned
Provide a description of the lessons the program has learned that could inform the actions your
program takes in the future or that could be helpful to other programs. – Describe instances where
the CAP was able to learn lessons from activities undertaken that will inform the CAP’s approach to those
or similar activities in the future, and which could provide guidance to other programs when they
encounter similar situations.

Major Accomplishments
Provide a description of the accomplishments your program has made as a result of the grant. –
Describe the CAP’s major accomplishments, including but not limited to those related to operations,
communication and relationship-building, direct consumer assistance, training, expansion of services, and
public education, that were achieved as a result of receiving the grant.

Policy Changes Implemented
Provide a description of policy changes implemented as a result of, or that were informed by,
information collected by your program. – Describe policy changes implemented in your State that were
in reaction to or supported by information collected by your CAP.

Illustrative Examples
Provide at least one, but not more than three, examples of how your CAP helped a consumer obtain
or maintain coverage under a provision added by the ACA, or where a consumer’s case was
referred for enforcement and enforcement action was taken. (Note that under no circumstances
should any personally identifiable information (PII) be reported to CCIIO.) – Provide at least one,
but not more than three, examples of how a consumer’s situation was positively impacted by the

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assistance provided by or involvement of the CAP, including situations when a provision of the ACA
assisted a consumer in obtaining or maintaining coverage, or when a consumer’s case was referred for
enforcement.
Under no circumstances should any personally identifiable information (PII) be reported to CCIIO. The
basic pieces of PII to avoid that could identify a consumer are the following: the consumer’s name
(instead refer to the consumer as “consumer,” “caller,” “writer,” etc. as appropriate) and the consumer’s
contact information. In some instances, what would otherwise not be considered PII may become PII
based on the consumer’s circumstances. For example if the consumer has a rare health condition, the
consumer’s health condition could be considered PII and should not be included by name in the consumer
story. Below please find an example of a de-identified consumer story.
Illustrative Example:
The consumer was successfully treated for lung cancer in 2008 and has follow-up
appointments every 6 months to check for recurrence. He is uninsured and seeking
coverage for follow up appointments and the peace of mind that treatment would be
covered in the case of recurrence. He works for a hospital and a community clinic as a
nurse; neither employer offers coverage. He is eligible to enroll in the guaranteed issue
individual market plan, but the $1,500/month premium is unaffordable and he would face
a pre-existing condition exclusion period. The CAP helped the consumer determine that
he was eligible for the Pre-existing Condition Insurance Plan (PCIP), and helped him
enroll. The $561 monthly PCIP premium will be a financial challenge, but he was able
to adjust his budget to allow for the added expense.

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