Tip: Identifying Members in Qualified Health Plans, the Arkansas Private Option or Arkansas Works

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07 Feb 2020

30 Dec 2021

Updated Action/Resolution

How to identify members enrolled in qualified health plans (QHP), Arkansas Private Option or Arkansas Works (Medicaid Expansion)

Use the HIOS ID (ME992).  A valid HIOS ID is 16 characters (some submitting entities place values in this field that are not 16 characters wide).   

The presence of a 16 character wide HIOS ID indicates that the member is enrolled in a QHP, Arkansas Private Option, or Arkansas Works plan.   NOTE:  The HIOS ID is not included in a standard data pull.  It is available for an additional fee.

To understand the components of a HIOS ID, see below.  HOIS IDs ending in ‘32’ or ‘36’ represent Arkansas Private Option or Arkansas Works populations.

HIOS ID value component definitions:

• A 16-digit field that serves as a unique plan identifier for a plan and a given variant

• Structured as follows: [HIOS ID][State][Product Iteration][Plan Iteration][Variant]

  • [HIOS ID] = 5-digit HIOS ID

  • [STATE] = 2-digit state code, such as CA, TX, AL, etc. (does include District of Columbia as DC)

  • [Product Iteration] = 3-digit number to indicate a unique product designation

  • [Plan Iteration] = 4-digit number to indicate a unique plan designation

  • [Variant] = 2-digit number to indicate cost-sharing variant and on/off Exchange

    • 00 = Plan sold off the Exchange [Maximum Out of Pocket (MOOP) values not required for these plans]

    • 01-06 = Plan sold on the Exchange in a given CSR variant

    • 31-36 = On-Exchange Medicaid expansion plans (Arkansas and Iowa only)

  • The 14-digit version of this ID is often referred to as the “Standard Component ID” or SCID

To find claims for members enrolled in these plans:

1. Select all members with a HIOS ID (ME992) ending in ‘32’ or ‘36’. 

2. Segment the resulting set using enrollment dates (ME162A and ME163A) to get the correct enrollment period. 

3. Then, join the subset of member data to the medical, pharmacy, or dental claims data using entity ID and member ID:

• ME001 (member/enrollment record entity ID) = MC001 (medical claim entity ID) + ME107 (member/enrollment data Member ID) = MC137 (medical claim member ID)

• ME001 (member/enrollment record entity ID) = PC001 (pharmacy claim entity ID) + ME107 (member/enrollment data Member ID) = PC107 (pharmacy claim member ID)

• ME001 (member/enrollment record entity ID) = DC001 (dental claim entity ID) + ME107 (member/enrollment data Member ID) = DC056 (dental claim member ID)

Members who fall into this group are the Arkansas Medicaid Expansion members. 

There is no member ID or key to link the records across submitting entities. If members must be linked across submitting entities, it is recommended that the Arkansas APCD Unique ID (ME998) and member gender (ME013) be used. 

Arkansas Medicaid member record overlap:

Records for members enrolled in these plans will be present in both the commercial entity member data and the Arkansas Medicaid member data. 

Arkansas Medicaid member records associated with these commercial entity members are identified as:  Submitting Entity ID (ME001) = 99MCD1 and Product ID (ME040) = 06.

It is recommended that the commercial entity enrollment records by used in analytic projects. The Arkansas Medicaid records have duplicative information.

Arkansas Works

QHP

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