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? Person-based Medicaid data used for Research/evaluation Epidemiology/quality Statistics/forecasting Calendar Year (begins 1999, SMRF - prior years) Event Based Occurrence of eligibility Dates of service Final action events (hospital stays, visits, etc.) Derived from MSIS (7 calendar quarters)

Why Do We Need MAX? Eligibility Retroactive eligibility in proper chronology Eligibility codes – verified and improved Eligibility data added to each claim Services (Claims) Final action events (interim claims combined) Organized by dates of service Type of service – verified and regrouped Person Summary File Calendar year eligibility and summary of claims Not available from MSIS

MAX Data Sets Person Summary File Eligibility (annual and monthly) Managed care enrollment Utilization and Medicaid payment by type of service Service Files Inpatient hospital Long term care Prescription drug Other Services Service file records include Fee-for-service Prepaid plans - premium payments and encounters (incomplete)

Medicaid Data Enhancements Beginning 1999 More detail Medicaid eligibility Dual (Medicare and Medicaid) status Medicaid case number Enrollment in prepaid plans Other eligibility (e.g. TANF, SCHIP) Services 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 To Medicare Enrollment Data Base (EDB) Best way to identify dual eligibles Begin and end dates of Medicare eligibility Other Medicare data (e.g. Medicare HIC, date of death) To Medi-Span and First Data Bank 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 Who has access? 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? Years prior to CY 1999 (SMRF) – states full data – 5 states, data quality? Years after CY 1998 (MAX) – all States CY 1999 available now CY 2000 available beginning mid-2004

MAX/SMRF Data Documentation Documentation on the Web via: Data Dictionaries Better descriptions of data elements Improved source information Addition of user notes Data Validation Reports Data Anomaly Reports 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 Data not reported Some desired beneficiary characteristics Some aggregate payments Provider characteristics Incomplete data 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 Not available – Name and Address Not used (initially) Medicare Health Insurance Claim (HIC) Medicaid dual status Step 1 - Linking criteria 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 Medicaid SSN to EDB claim account number (CAN), plus Gender and DOB

Setting Dual Eligibility After the link 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 By month For the year (ever a dual in the year)

Estimating Dual Eligibles Adjusting for bias Estimates adjust for Undercounting Medicaid -reported duals not linked With no SSN With incorrect/non-matching SSNs Estimates do not adjust for Undercounting Medicare-reported duals not linked Overcounting Medicaid persons eligible in more than one state More than one Medicaid eligible per SSN

Estimating Dual Eligibles Alternative Estimates “Best Estimate” of Duals Confirmed duals (linked to EDB), plus Medicaid eligibles not linked to EDB, but Identified as dual eligibles by Medicaid, and Had at least one claim in the year where Medicare copayment and/or deductible was paid by Medicaid “Upper Bound Estimate” of Duals Same as above except for 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 State reporting of dual status in MSIS Incomplete at best starting in 1999 For Calendar Year 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 “Lower Limit” estimate By state, allocated unknown type proportionally For the six states identified above - 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 Same as above, except Allocated all unknown type to full benefit

Dual and Full Medicaid Benefit Dual Estimates (ever in 1999) National estimates (50 states and D.C.) Dual eligibles Confirmed (from EDB) – million Best estimate – million Upper bound estimate – million Full Medicaid Benefit Dual eligibles Lower bound estimate – million Best estimate – million “Restricted Benefits” estimate – million