FAQ Data Descriptions Enrollment and Eligibility 

There are a number of terms that are important to both the Solicitation document and to the data sets that have somewhat different meanings in the context of each environment.

For this Solicitation, this includes most terms describing eligibility and enrollment. For example, the Solicitation defines enrollment in relation to recipients’ future enrollments in Coordinated Care Entities (CCEs) and Managed Care Community Networks (MCCNs).

The data sets refer to other enrollments: a recipient can be enrolled in a particular benefit program, for example. The same person may enroll in a CCE or a MCCN, by a process distinct from enrollment in any other program.

A similar issue arises regarding the multiple contexts in which eligibility may be assessed. Additionally, the term ‘eligibility’ is sometimes used incorrectly as a matter of habit. For example, a ‘dual eligible’ recipient is in fact dually enrolled in Medicare and Medicaid. (A similar misuse can occur for any enrolled person.)

Any proposal using the terms ‘eligibility’ and ‘enrollment’ must clarify what the term means in the various contexts in which they appear. Please consult the Glossary, Solicitation Definition List, and data dictionary for more information on these terms.

We have included an eligibility indicator for Seniors and (adult) Persons with Disabilities (SPDs), the priority population for the Solicitation. A value of 1 indicates that the recipient is a Senior or Person with Disabilities as of the anchor date. A value of 0 indicates that the recipient is not a Senior or Person with Disabilities and is therefore a non-priority recipient.

The Seniors and Persons with Disabilities (SPD) indicator is set according to the recipient’s age as of the anchor date (if the person is over 65 years of age) or his or her disability status as of his or her most recent full benefit eligibility date within the experience period (if the person is 19 to 64 years of age). SPD indicators are applied to all recipients in the data set, irrespective of current eligibility.

Likewise, the Medicare dual eligibility indicator is according to the recipient’s most recent full benefit eligibility date within the experience date. The data user can therefore clearly differentiate priority and non-priority, dual and non-dual recipients, even for those recipients not currently eligible.

The data Current Eligibility refers to full benefit eligibility as of the anchor date. Recipients are included in the data if they were eligible for full benefits (and enrolled in one or more programs) any time during the year. The Current Eligibility flag is 1 if they were still eligible on the anchor date; otherwise, it is 0. Recipients are included in the data if they were eligible for full benefits (and enrolled in one or more programs) any time during the year.

Eligibility flags are included in the data sets for Primary Care Case Management (PCCM) eligibility. These are marked if a recipient was eligible at any point during the experience period.

Finally, a categorical item denotes the Enrollment Program Group as of the last day of the experience period. For definitions of eligibility and enrollment, please see the Glossary.

For further information on these vocabulary terms, please consult the ‘Solicitation and Policy Details’ section of the FAQ.

The data sets include enrollment flags for Primary Care Case Management (PCCM). (Please note that PCCM enrollment does match PCCM eligibility, due in part to enrollment process lag time and in part due to recipients’ selection of voluntary Health Maintenance Organization (HMO) in place of PCCM enrollment.)

We also provide an indicator for Management Care Organization (MCO) enrollment at any time during the year. This category combines recipients who enrolled in a Voluntary Health Maintenance Organization (HMO), a single current Managed Care Community Network (MCCN), and Reaching Elderly across Chicago’s Horizon (REACH). The MCO category is mutually exclusive with the Fee for Service (FFS) category, which is also flagged in the data set. The distinction between MCO and FFS recipients is highly significant for Type of Service data; please see our Type of Service documentation for further information.

Number of Enrolled Days indicates how many days a recipient was enrolled during the experience period; it will be less than 365 for recipients who are not currently eligible and for those who enrolled after the start of the experience period.

Yes. Primary Care Case Management (PCCM) eligibility is determined using current eligibility files which describe what a client’s eligibility status was on December 31, 2010, (the anchor date). Some factors that affect whether or not a client is eligible for the PCCM program can be updated retroactively. In some cases, this results in a client appearing ineligible for the program when they were enrolled on the anchor date. In other cases, it will appear that a client was eligible on the anchor date but not enrolled.

Generally speaking, benefits programs allow for retroactive enrollment, under which Healthcare and Family Services (HFS) will pay for services that the newly enrolled recipient used in the 90 days prior to their enrollment. This makes HFS responsible for paying claims during a period when management of the recipient’s care was impossible.

Please inform us. We have attempted to distill multiple eligibility and enrollment layers into a simple recipient-level summary. Eligibility and enrollment can change for each recipient over the course of the experience period. We are open to suggestions on how to better meet your needs.

The data sets include enrollment flags for Primary Care Case Management (PCCM). (Please note that PCCM enrollment does match PCCM eligibility, due in part to enrollment process lag time and in part due to recipients’ selection of voluntary Health Maintenance Organization (HMO) in place of PCCM enrollment.)

We also provide an indicator for Management Care Organization (MCO) enrollment at any time during the year. This category combines recipients who enrolled in Voluntary Health Maintenance Organization (HMO), a single current Managed Care Community Networks (MCCN), and Reaching Elderly Across Chicago’s Horizon (REACH). The MCO category is mutually exclusive with the Fee for Service (FFS) category, which is also flagged in the data set. The distinction between MCO and FFS recipients is highly significant for Type of Service data; please see our Type of Service documentation for further information.

The data set also includes information on recipient’s waiver enrollment. There are nine categories of waivers and a number of waiver-like programs, all of which allow for selected recipients to receive services beyond the standard Medicaid benefits. We supply three waiver enrollment data points for each waiver program: enrollment as of the anchor date, enrollment anytime during the experience period, and claims. We have an additional field that contains information on long-term care institutionalization as of the anchor date, as well as three fields for Money Follows the Person (MFP): enrollment as of the anchor date, enrollment at any point during the experience period, and claims. For more information on the justification for these multiple indicators, please read our FAQ item on waivers below.

Number of Enrolled Days indicates how many days they were enrolled during the experience period; it will be less than 365 for recipients who are not currently eligible.

Please inform us. We have attempted to distill multiple eligibility and enrollment layers into a simple recipient-level summary. Eligibility and enrollment can change for each recipient over the course of the experience period. We are open to suggestions on how to better meet your needs.