Field Definitions

The following fields are included in the latest available full Excel worksheet of DHP, available in In-App Downloads. Some fields may not be available in the online searchable database. See Glossary and Enrollment Field Hierarchy for additional explanations.

State — Indicates the state for which the enrollment data in the record is applicable. “National” indicates that the enrollment data represent total nationwide figures for the listed insurer.

MCO ID — Unique key identifier, automatically generated, to distinguish each health insurer record. Used for linking to other AIS databases, and for tracking companies on a year-over-year basis.

Insurer — aka MCO Name, the name by which the entity wishes to be known, as of the latest survey by AIS researchers.

Commercial Risk? — Indicates whether the listed entity participates in the commercial risk market sector.

Managed Medicaid? — Indicates whether the listed entity participates in the managed Medicaid market sector.

Medicare Advantage? — Indicates whether the listed entity participates in the managed Medicare market sector.

Provider-Sponsored? — Indicates whether the listed entity is owned or affiliated with a provider entity, such that it is designated as a provider-sponsored plan. Provider-based plans are any plan that is owned by, or owns, in whole or in part, a segment of its provider network, and leverages that relationship to gain efficiency in coverage and treatment of its insured population.

BCBS Affiliate? — Indicates whether the listed entity is licensed to sell insurance products under the Blue Cross and Blue Shield Association brand.

Note — Notes on any caveats or additional explanations required to fully understand the data presented in this record.

Mailing Address — Business mailing address of the insurer as listed in AIS's Directory of Health Plans.

Website — Website URL to learn more about the listed company or its products.

Private/Public — Indicates whether the company is privately owned or publicly traded on a major stock exchange.

Stock Symbol — Stock symbol by which the company, or parent company, is traded on a major stock exchange.

Tax Status — Indicates whether the company is not-for-profit or for-profit, per tax status designation.

Parent/Owner — Name of parent company or owner of the company, where applicable.

Behavioral Health Vendor(s) — Name(s) of entities that perform behavioral health management services for the insurer. May include owned subsidiaries or internal departments as well as contracted private vendors and community-based resources.

Pharmacy Benefit Manager(s) — aka PBM. Name(s) of entities that perform pharmacy benefit management and formulary decision-making functions for the insurer.

Specialty Pharmacy Provider(s) — aka SPP. Name(s) of specialty pharmacy provider(s) contracted by the company to manage specialty pharmacy utilization and spend for one or more drug products.

Total Medical Enrollment — All enrollees in primary medical insurance plans and ASO plans offered by this entity.

Total Risk — All enrollees in either commercial or public-sector risk-based primary medical insurance plans.

Individual — Primary medical insurance plan purchased commercially by an individual or family, not through a group, employer, or government entitlement. Enrollment should not include enrollment in student, short-term or limited benefit plans, SCHIP programs or Medicare Supplement.

Small Group — Employer-based group risk membership in group size deemed “small” by the reporting entity--Typically groups of 2-50 people.

Large Group — Employer-based group risk membership in group size deemed “large” by the reporting entity--Typically groups of 51+ people.

Total Group Risk — Employer-based group risk membership. Employers include government entities, unions and private sector employers.

Commercial Risk — Employer-based group or individual health plan enrollment in insured (risk) plans.

Total Non-Risk/ASO — aka, Self-Funded. Enrollment in self-funded, administrative services only (ASO), or non-risk medical plans. Covers only membership of self-funded employers or other groups that are not listed elsewhere in this database.

Medicare Advantage — All membership under Medicare Part C managed care plans. Does include MA-PDs; does not include Medicare FFS. This category includes Medicare CCPs, Medicare Cost plans and Medicare PFFS plans.

Medicare FFS (CMS) — Members in the traditional FFS (non-managed) Medicare program, not enrolled in an HMO or managed care plan operated by an insurance company. These members are likely to overlap the Medicare PDP and Medicare Supplemental plan enrollment found in the insurer records in this database.

Medicaid HMO National — All membership in Medicaid HMOs, plans contracted with state Medicaid agencies to cover Medicaid beneficiaries.

Dual-Eligibles — Indicates members that are designated by AIS as Dual-Eligibles. These plans serve people that are eligible for both Medicare and Medicaid under CMS-designated initiatives, such as Dual-Eligible Special Needs Plans (D-SNPs) and CMS's duals demonstration programs. Does NOT overlap Medicare Advantage or Medicaid HMO categories, but may overlap Special Needs Plans or PACE Plans (because D-SNPs and PACE plans serve dual-eligibles).

SCHIP — Membership in the State Children's Health Insurance Program (SCHIP).

Medicaid FFS — All Medicaid membership in a state that is not contracted to Medicaid HMOs, funded directly by state. This includes Medicaid FFS lives that are administered by an MCO and represented in an MCO record, but are still funded directly by the state and not in an HMO contract. This also includes members of Primary Care Case Management (PCCM) programs, a method of care delivery in which a primary care provider or provider group closely coordinates enrollees’ health services, and is reimbursed through the state, plus an additional fee for their services.

Total Public Sector — Total of all enrollment in government entitlement programs. Includes Medicare Advantage and FFS, Medicaid HMO and FFS, Dual-Eligibles and SCHIP categories.

FEHBP Enrollment — Enrollment in the Federal Employees Health Benefit Program, aka FEP, this is a SUBSET of the Total Medical Enrollment field—this typically overlaps the Total Fully Insured/Commercial Risk/Group Risk/Large Group Risk Enrollment.

Public Exchange Enrollment — Members that enrolled in Individual or Small Group plans via public exchanges for the current plan year, including low-income programs such as those in New York and Massachusetts. Public exchange enrollment is a subset of the Commercial Risk category, which is comprised of Large-Group/Small-Group/Individual. Note: In most cases, exchange enrollment refers to members enrolled in Individual plans, but a small number of MCOs include SHOP enrollment in their submissions, resulting in the public exchange figure exceeding the Individual figure..

Medicare Supplement — Medical insurance supplemental plan, aka Medigap plan, purchased by an individual whose primary medical insurance is traditional FFS Medicare. Because this is an optional rider on top of a primary medical plan, these members duplicate some members in the Medicare FFS enrollment and also some Medicare Advantage lives.

PDP Enrollment — Enrollment in stand-alone PDP plans under Medicare Part D. Since this is pharmacy benefit enrollment, not medical enrollment, it is not a subset of the total and does not factor into the total medical enrollment at all.

Total in State — Total enrollees identified as being in this state.

Risk in State — Enrollees in either commercial or public-sector risk-based primary medical insurance plans attributed to the state indicated.

Individual in State — Individual (non-group) members identified as being in the state.

Small Grp in State — Small-group membership attributed to the state.

Large Grp in State — Large-group membership attributed to the state.

Group Members in State — Total number of commercial group members attributed to the state.

Med Sup in State — Number of members in Medicare Supplement plans attributed to the state for this insurer. Note: Medicare Supplement plans are also sold by other types of entities not covered by DHP, so totals in DHP do not represent all members nationally. This is because Medicare Supplement plans are not a primary medical insurance product, but are a specialty product that overlaps primary medical insurance, i.e., traditional fee-for-service Medicare coverage.

Commercial Risk in State — Total number of commercial group and individual members attributed to the state.

ASO in State — Total number of ASO/self-funded/non-risk members attributed to the state.

Medicare in State — Total number of Medicare Advantage plan members attributed to the state.

SCHIP in State — Total number of SCHIP members attributed to the state.

Medicaid HMO in State — Total number of Medicaid HMO members attributed to the state.

Medicaid FFS — Total number of Medicaid FFS members attributed to the state.

Part D in State — Number of members in Medicare Part D (PDP) plans attributed to the state for this insurer. Note: PDP plans are also sold by other types of entities not covered by DHP (such as PBMs). Therefore, total Part D members counted in DHP do not represent all members nationally. This is because Part D plans are not a primary medical insurance product, but are a specialty product that overlaps primary medical insurance, i.e., traditional fee-for-service Medicare coverage.

State Postal Abbreviations: — AL, AR, AK, etc. indicate the total medical enrollment attributed to that state. FN=foreign enrollment outside of the U.S. or Puerto Rico.

Notes About State-Level Enrollment FieldsState-level enrollment may indicate members that actually live in the state, or members of a group that is headquartered within the state — this varies by insurer. Not all members can be attributed to a specific state. In particular, members in some nationally contracted ASO plans are not associated with a particular state. Ideally all states will add up to total medical enrollment, but comprehensive state breakdown may not be available for all records. If there is discrepancy it should be explained in the Publication Note field, available in the View Details report for the record in question. Membership within a state does not guarantee that the state is in the health plan’s service area. Even if the state is within the health plan’s service area, it does not mean that the health plan serves all counties/regions in that state. Many plans are small and serve only selected counties/regions.