Medicaid Analytic Extract Files

Transcription

1 Medicaid Analytic Extract Files DEVELOPMENT AND STRUCTURE Gerri Barosso, RD, MPH, MS Senior Technical Advisor University of Minnesota

2 Overview Source of CMS Medicaid data CMS MAX: Medicaid Analytic Extract Where does the information come from? Why does it matter? How can this help if you have state data? 2

3 CMS Medicaid Research Files CMS Medicaid Research Files pre-1999 data files:» State Medicaid Research Files (SMRF) 1999 and forward:» Medicaid Analytic Extract (MAX) State files used by some researchers may include some or all of the MAX source files Limitations of source files brought forward Particular concern if you are working with these MAX sources as state data Matters even with MAX, since production can t overcome all state variation. 3

4 Overview of Data Systems MSIS MSIS statistical reports MAX 4

5 MSIS DATA SOURCES State MMIS: Eligibility files and FFS claims MSIS MAX 5

6 MMIS MMIS Medicaid Management Information System Primary purpose: administrative Information on the population and services» Beneficiary, provider enrollment» Utilization records Historically fee-for-service claims payment Managed care encounters» Included where MMIS updated» Required by the ACA by 2014 Not developed for research 6

7 MMIS (CONT) MMIS characteristics Flexibility in system design after meeting federal minimums Variables, definitions, file structures, data quality procedures vary by state Administered by various contractors or the state» 2016 (most recent report): 17 by one contractor, 12 state adm, 11 by second contractor, remainder across other contractors» Report includes CMS Regional Office (RO) contact 7

8 MMIS (CONT) MMIS characteristics Utilization and payment data in MMIS files:» Based on date of adjudication» Separate records for adjustments & interim hospital bills» Potentially long lag between date of service and adjudication» Utilization data sources can vary: national or statespecific claims forms or electronic systems 8

9 MMIS (CONT) MMIS characteristics If used for research consider effects of:» State processing system» State specific codes for eligibility and services» Missing services Other state agencies providing services with Medicaid dollars May/may not include capitated managed care utilization 9

10 MSIS DATA SOURCES State MMIS: Eligibility files and FFS claims Encounter Data Systems MSIS MAX 10

11 MSIS Data Sources State MMIS: Eligibility files and FFS claims Encounter Data Systems MSIS MAX 11

12 ENCOUNTER DATA Federally mandated beginning in 1999 Historically poor state compliance ACA mandates encounter submission or FMAP withheld Potential data inconsistencies Record variables or edits can vary from fee-for-service Systems may vary state-to-state August, 2015 (most current report) evaluation of usability » IP 21-6 states, OT 23-16, RX 18-12» Best for child and adult eligibility groups Improvement over time 12

13 NON-MMIS DATA SOURCES State MMIS: Eligibility files and FFS claims Encounter Data Systems Non-MMIS Medicaid Utilization files MSIS MAX 13

14 NON-MSIS DATA SOURCES Services paid under specific state programs using Medicaid dollars Past examples from some states: EPSDT (Early Periodic Screening, Diagnosis, and Treatment), mental health services Not processed through MMIS Potentially missing from MSIS If occurred, noted in anomaly tables. Does not seem to be a current issue 14

15 MSIS DATA SOURCES State MMIS: Eligibility files and FFS claims Encounter Data Systems Non-MSIS Medicaid Utilization files MSIS MAX 15

16 MSIS Medicaid Statistical Information System (MSIS) Again, not research data collection system Federal Fiscal Year, Quarterly files» Adjustments, interim bills included» Filed by date of payment, not service» Enrollment data by processing date Retroactive eligibility is out of chronological order» Many quarters to get one calendar year of data 16

17 Update: evolving MAX production Data from state system(s) MSIS Transformed-MSIS T-MSIS MAX or differently named CMS research file 17

18 MAX Source is MSIS (for now, then T-MSIS) Enhancements create Research friendly files Addition of CMS-created variables Additional quality review in MAX creation Data documentation includes» Variable values and definitions» Limitations and anomalies» Data validation tables» Waiver crosswalks for descriptions, ID numbers 18

19 MAX (Enhancements Continued) Organized by calendar year of service Final action events Any retroactive eligibility placed in proper chronology Individual state eligibility/service mapping» reviewed and edited» uniform coding across states Linkage to Medicare Enrollment Database completed Cross reference files applied for changes in MSIS IDs 19

20 MAX Data Files (cont) MAX Data Set Contents Five file types, per calendar year, per state Enrollment and summary utilization:» Personal Summary File (PS) Utilization» Inpatient (IP)» Long Term Care (LT)» Prescription Drug (RX)» Other Therapy (OT) 20

21 MAX Data Files (cont) Link between files at beneficiary level Bene_ID as released by CCW» Cross referenced between states, across years» Same ID in Medicare, assessment data and MAX data MSIS_ID as released by CMS in the past» State-specific ID» Link within state, across files and years» Should remain constant for one individual across time Some variables differ across years Values refined for same variable New variables or definitions added 2005, 2006, 2007, 2008, 2011, 2012» Record layouts/data dictionaries Most current on CMS web site Match year of data to year of layout 21

22 MAX Data Files (cont) Personal Summary File (PS) Unique beneficiary identifier Demographics Eligibility» Waiver enrollment» Detailed managed care enrollment» Dual eligibility for Medicare and Medicaid» Medicare Enrollment Database variables Linked by SSN provided by state HIC, date of death, Medicare eligibility, SSA language Summary of charges and payments 22

23 MAX Data Files (cont) Utilization Files 4 claim types: IP, LT, RX, OT All claim types include limited enrollment variables pulled from the PS Some fields vary by claim type in number, availability ICD diagnosis codes CPT-4, ICD, NDC, HCPCS, state specific procedure codes Type of record varies across files IP stay records LT monthly/variable OT, RX service or line item records 23

24 MAX Data Files (cont) Inpatient Claim File (IP) Utilization Bene_ID 123, 123, 123 Bene_ID 456 No claims Bene_ID 789 Other Therapy File (OT) Utilization Bene_ID 123 Bene_ID 456,456, 456, 456 Bene_ID 789, 789 Personal Summary File (PS) Enrollment Bene_ID 123 Bene_ID 456 Bene_ID 789 Long Term Care File (LT) Utilization No claims Bene_ID 123 Bene_ID 456 No claims Bene_ID 789 Prescription Drug File (RX) Utilization Bene_ID 123, 123, 123, 123 Bene_ID 456,456, 456, 456 Bene_ID 789,

25 Medicaid Analytic Extract Files DEVELOPMENT AND STRUCTURE Questions? 25