Identifying Medicare Managed Care Beneficiaries from the Master Beneficiary Summary or Denominator Files

Identifying Medicare Managed Care Beneficiaries from the Master Beneficiary Summary or Denominator Files

Current Version Date: 
12/28/2017
Purpose: 

The purpose of this article is to describe how to use the Medicare managed care enrollment information found in the Medicare Beneficiary Summary File (MBSF) Research Identifiable File (RIF) or Denominator in the Limited Data Set (LDS). Medicare managed care is sometimes also called Medicare Advantage, Medicare Part C or Medicare + Choice.

Background

Managed care organizations do not submit all claims for health care utilization to the Centers for Medicare and Medicare Services (CMS); therefore Medicare utilization files are only considered complete for fee-for-service beneficiaries. In most cases, researchers will want to exclude beneficiaries enrolled in Medicare managed care in order to accurately characterize the receipt of care for each beneficiary. The information below describes how to create a binary indicator of Managed Care enrollment.

Two situations for which CMS does receive information about services received for those enrolled in managed care are: (1) hospice care, which is administered as a “carve out” of managed care; and (2) “information only” claims submitted by facilities for calculation of disproportionate share (DSH), indirect medical education (IME) and graduate medical education (GME) payments. Researchers interested in hospice use or DSH, IME or GME payments may not want to exclude beneficiaries enrolled in Medicare managed care from their cohort.

Identifying Medicare Managed Care Enrollees

Researchers often wish to exclude beneficiaries that were ever enrolled in managed care during the study period.

The variable “HMO indicator” (HMOIND01- HMOIND12 in the MBSF, HMO_INDICATOR1- HMO_INDICATOR12 in the LDS Denominator) is a monthly indicator that identifies whether a beneficiary was enrolled in a Fee-for-Service (FFS) or managed care plan. (Please note that CMS uses the terms “HMO” and “GHO” to indicate a managed care plan.)   In general, HMOINDxx values (‘0’,’4’) indicate fee-for-service beneficiaries, while values (‘1’,’2’,’A’,’B’,’C’) indicate managed care enrollees (Table 1).

 

Table 1. Frequency of the HMO Indicator Variable by Year (Rounded up to the nearest 1,000)

 

Code Value

Code Description

2005

2007

2009

2011

2013

2015

FFS

0

Not a member of HMO

38,937,000 (87%)

37,759,000 (81%)

37,661,000 (77%)

39,217,000 (76%)

40,268,000 (73%)

40,310,000 (69%)

MC

1

Non lock-in, CMS to process provider claims

390,000

(1%)

349,000 (1%)

321,000

(1%)

413,000

(1%)

498,000

(1%)

611,000

(1%)

MC

2

Non lock-in, GHO to process in-plan Part A and in-area Part B claims

38,000

(0%)

39,000

(0%)

37,000

(0%)

14,000

(0%)

4,000

(0%)

<1,000

(0%)

FFS*

4

Fee-for-service participant in case or disease management demonstration projects (effective 2005 forward)

14,000

(0%)

116,000

(0%)

22,000

(0%)

7,000

(0%)

<1,000

 (0%)

<1,000

(0%)

MC

A

Lock-in, CMS to process provider claims

0

0

0

0

0

0

MC

B

Lock-in, GHO to process in-plan Part A and in-area Part B claims

0

0

0

0

0

0

MC

C

Lock-in, GHO to process all provider claims

5,391,000

(12%)

8,432,208 (18%)

10,885,000

(22%)

12,068,000

(23%)

14,509,000

(26%)

17,244,000

(30%)

 

 

TOTAL

44,770,000

46,695,000

48,923,000

51,718,000

55,278,000

58,165,000

Based on HMOIND07 (July) 100% MBSF RIF
Non Lock-in: Participants are allowed to switch managed care plans or move to FFS as desired
Lock-in: Participants are required to remain enrolled in the managed care plan for a certain period of time.
FFS=Fee-for-Service, MC=Managed Care
*researchers interested in chronic conditions from 2005-2009, especially in states where the demonstration projects were active, may wish to exclude these beneficiaries from their analyses (see below for information)


The HMO_Indicator value ‘4’ was established in 2005 for the purpose of identifying beneficiaries participating in a case or disease management demonstration program (CMS Change Request 3410) that is administered by a managed care plan. Claims related to the case or disease management demonstration program will not appear in the claims files, but all other Medicare FFS utilization will be present.  There are few participants in these programs (Table 1) especially after 2009. Researchers studying chronic condition care during these years, especially in those states where the demonstration projects were active, may wish to examine any differences in these groups more carefully.

The HMO_Indicator values ‘1’ and ‘A’ include in their description that CMS is to process provider claims; however, the monthly rate of claims for those with a value of ‘1’, especially for Part B services is much lower than the rate for FFS beneficiaries.  These beneficiaries should be excluded with along with other managed care beneficiaries due to concern that we do not observe all claims.

Acknowledgments: 
ResDAC would also like to acknowledge Xuanzi (Shirley) Qin, Research Assistant for her analytical assistance with this article.
Article Number: 
114
This work was performed under CMS Contract Number HHSM-500-2005-00027I.
Related Data File Families: 

Disclaimer

The process and materials mentioned as part of this KnowledgeBase article are current, as of the publication date on the article, to the best of our knowledge. The examples provided are correct in the aggregate but may not apply to every subgroup or circumstance that a researcher may wish to study. It is up to the researcher to conduct analysis and confirm that the patterns described in this KnowledgeBase article apply to his/her particular study. If your research findings appear to contradict the advice provided, please contact ResDAC at resdac@umn.edu.