Transcript PowerPoint Slides

Medicaid Analytic eXtract (MAX)
Presentation to the
Academy Health Annual Research
Meeting
San Diego, California
Dave Baugh, CMS/ORDI
June 8, 2004
What is MAX?
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Person-based Medicaid data used for
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Calendar Year (begins 1999, SMRF - prior years)
Event Based
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Research/evaluation
Epidemiology/quality
Statistics/forecasting
Occurrence of eligibility
Dates of service
Final action events (hospital stays, visits, etc.)
Derived from MSIS (7 calendar quarters)
Why Do We Need MAX?
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Eligibility
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Retroactive eligibility in proper chronology
Eligibility codes – verified and improved
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Eligibility data added to each claim
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Services (Claims)
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Final action events (interim claims combined)
Organized by dates of service
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Type of service – verified and regrouped
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Person Summary File
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Calendar year eligibility and summary of claims
Not available from MSIS
MAX Data Sets
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Person Summary File
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Service Files
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Eligibility (annual and monthly)
Managed care enrollment
Utilization and Medicaid payment by type of service
Inpatient hospital
Long term care
Prescription drug
Other Services
Service file records include
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Fee-for-service
Prepaid plans - premium payments and encounters (incomplete)
Medicaid Data Enhancements
Beginning 1999
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More detail Medicaid eligibility
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Dual (Medicare and Medicaid) status
Medicaid case number
Enrollment in prepaid plans
Other eligibility (e.g. TANF, SCHIP)
Services
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More diagnoses and procedures
More data (waiver enrollment, hospital cost centers)
Additional types of service (e.g. DME/supplies, adult
day care)
Maternal delivery indicator
MAX Data Linkages
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To Medicare Enrollment Data Base (EDB)
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To Medi-Span and First Data Bank
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Best way to identify dual eligibles
Begin and end dates of Medicare eligibility
Other Medicare data (e.g. Medicare HIC, date of death)
Prescription drugs
Link on National Drug Code (NDC)
Therapeutic classes (clinical use)
Other FDB data (e.g. generic, OTC or prescribed drug)
Other linkages (Agreement with SSA)
MAX/SMRF Data
Availability
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Who has access?
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Privacy Act and HIPAA regulations apply
Research protocols must be reviewed
A Data Use Agreement (DUA) must be filed
A CMS processing fee may apply
Access to Medi-Span and First Data Bank data restricted
What data are available?
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Years prior to CY 1999 (SMRF)
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1992-1998 – 25-29 states full data
1987-1991 – 5 states, data quality?
Years after CY 1998 (MAX) – all States
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CY 1999 available now
CY 2000 available beginning mid-2004
MAX/SMRF Data
Documentation
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Documentation on the Web via:
www.cms.gov/researchers/max
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Data Dictionaries
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Better descriptions of data elements
Improved source information
Addition of user notes
Data Validation Reports
Data Anomaly Reports
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Valid data, but unexpected results (e.g. broken time series,
new covered service)
Data inconsistencies (can’t be fixed)
Medicaid Data Limitations
MSIS and MAX
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Data not reported
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Incomplete data
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Some desired beneficiary characteristics
Some aggregate payments
Provider characteristics
Periods of ineligibility
Third-party insurance coverage and payments
Services for persons in prepaid plans
Service detail for dual eligibles
Drug payments are prior to rebates
Program and operational variation
Estimates of Dual and
Full Medicaid Benefit Dual
Eligibles
(Using MAX)
Linkage to Medicare (EDB)
Two Steps
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Not available – Name and Address
Not used (initially)
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Step 1 - Linking criteria
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Medicare Health Insurance Claim (HIC)
Medicaid dual status
For Aged - SSN and gender
For Disabled, either
 SSN and date of birth (DOB), or
 SSN, gender and two of three elements in DOB
Step 2 – Linking criteria for step 1 non-links
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Medicaid SSN to EDB claim account number (CAN), plus
Gender and DOB
Setting Dual Eligibility
After the link
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For each linked eligibility record:
Monthly Medicaid eligibility is compared to “spells”
of Medicare eligibility
An dual indicator is set when dates overlap
This indicator “confirms” dual status
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By month
For the year (ever a dual in the year)
Estimating Dual Eligibles
Adjusting for bias
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Estimates adjust for
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Undercounting
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Medicaid-reported duals not linked
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With no SSN
With incorrect/non-matching SSNs
Estimates do not adjust for
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Undercounting
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Medicare-reported duals not linked
Overcounting
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Medicaid persons eligible in more than one state
More than one Medicaid eligible per SSN
Estimating Dual Eligibles
Alternative Estimates
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“Best Estimate” of Duals
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Confirmed duals (linked to EDB), plus
Medicaid eligibles not linked to EDB, but
 Identified as dual eligibles by Medicaid, and
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Had at least one claim in the year where Medicare
copayment and/or deductible was paid by Medicaid
“Upper Bound Estimate” of Duals
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Same as above except for
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Medicaid eligibles not linked to EDB replace “and”
with “and/or”, plus
Estimate not > total aged and disabled eligibles
Full Medicaid Benefit Dual Eligibles
Background on Estimates
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State reporting of dual status in MSIS
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Incomplete at best starting in 1999
For Calendar Year 1999
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11 states reported > 50% unknown type
21 states reported > 20% unknown type
5 states reported no full duals
One state did not report type of dual
Full Medicaid Benefit Dual Eligibles
Methodology
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“Lower Limit” estimate
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By state, allocated unknown type
proportionally
For the six states identified above 
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Produced a combined percent of full benefit to total
dual eligibles for all other states.
Multiplied this percent by the total number of dual
eligibles in the state.
“Best” estimate
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Same as above, except
Allocated all unknown type to full benefit
Dual and Full Medicaid Benefit Dual
Estimates (ever in 1999)
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National estimates (50 states and D.C.)
Dual eligibles
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Confirmed (from EDB) – 6.823 million
Best estimate – 6.881 million
Upper bound estimate – 7.288 million
Full Medicaid Benefit Dual eligibles
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Lower bound estimate – 5.916 million
Best estimate – 6.091 million
“Restricted Benefits” estimate – 6.015 million