← Glossary · Medicare Advantage & Part D
Continuing enrollee
An enrollee whose full claims history from the most recent PBP lets the sponsor tell new from ongoing therapy. Excluded from the NE universe.
If the sponsor has the enrollee's full claims history from the most recent PBP and can tell new therapy from ongoing therapy, the enrollee is a continuing enrollee and is left out of the New Enrollee universe. For Transition testing, CMS samples continuing enrollees' rejected claims tied to cross-year formulary changes, such as formulary deletions. Enrollees with a November or December effective enrollment date should get a full continuing enrollee transition benefit, if applicable.
Source: FA protocol, Universe Table 4 guidance, PDF p. 16; compliance standard 2.1, PDF p. 7.