Medicaid Analytic eXtract Data: Identification of Medicaid Managed Care Beneficiaries

Using the MAX Personal Summary file variables to identify Managed Care and Fee-For-Service Beneficiaries

Medicaid Analytic eXtract Data: Identification of Medicaid Managed Care Beneficiaries

Current Version Date: 
01/26/2018
Purpose: 

This article describes three variable groups that can be used to identify managed care enrollment for Medicaid beneficiaries. Codes for the variables are also given that identify beneficiaries who received their comprehensive medical care under the Fee-For-Service (FFS) payment system.

The CMS Medicaid Analytic eXtract (MAX) data include enrollment information for all Medicaid enrollees within a state, regardless of whether the beneficiary receives all services under FFS or is enrolled in managed care organizations (MCOs). All FFS utilization and any reported MCO utilization is also included in MAX files.

Medicaid beneficiaries can be enrolled in several different types of MCOs at the same time. For example, a beneficiary may be enrolled in one managed care plan for dental care and another managed care plan for behavioral health, while also receiving their medical care under FFS. Another beneficiary could receive all of their care through a comprehensive MCO.

The MAX Personal Summary (PS) includes three groups of variables that identify MCO enrollees.

The most detailed information is in this group:

  1. Pre-Paid Plan Enrollment Group

Summarized enrollment information is in each of these two variable groups:

  1. Pre-Paid Plan Months Count Group
  2. Medicaid Managed Care Combination Group

Each group includes several variables and/or repeating variables.

1.     Pre-Paid Plan Enrollment Group

This group includes two different variables:

                -Eligible Pre-Paid Plan Type

                -Eligible Pre-Paid Plan Identifier

The PS file can include up to four different type/identifier pairs in each month of the file year. Using the Eligible Pre-Paid Plan Identifier variable, it is possible to determine the exact name of the plan by using the CMS downloadable crosswalk files that are available on the CMS web site for each calendar year of MAX data.

Researchers can use the Eligible Pre-Paid Plan Type variable to identify Medicaid beneficiaries with comprehensive FFS coverage. When the value of this variable is 02, 03, 07 or 88, beneficiaries’ medical claims for non-pregnancy services were paid FFS.

2.     Pre-Paid Months Count Group

This group includes seven variables that each provide a month count for a type of plan. The seven variables are:

-Prepaid plan months (comprehensive plans)

-Prepaid plan months (dental managed care plans)

-Prepaid plan months (behavioral managed care plans)

-Prepaid plan months (prenatal/delivery managed care plans)

-Prepaid plan months (long term care managed care plans)

-Prepaid plan months (all-inclusive care for the elderly (PACE) plans)

-Prepaid plan months (primary care case management (PCCM) plans)

 

The month count variable only provides a count of the total months of enrollment for each of these specific plan types in the file year.

Medicaid beneficiaries whose medical care for non-pregnancy related services were paid FFS, will have a month count of zero for comprehensive, long term care and PACE plans.

3.     Medicaid Managed Care Combination Group

This group includes one variable that repeats for each month of the calendar year of the file. The variable is:

                -Manged Care Combinations

The Managed Care Combinations are created during MAX production by re-coding the data available in any of the four occurrences of Eligible Pre-Paid Plan Type. The combinations represent groupings that are frequently used by researchers. The variable documentation describes how the data from the Eligible Pre-Paid Plan Type maps to each value of the Managed Care Combinations.

Beneficiaries who received comprehensive medical services under the FFS payment system are identified in each month by Managed Care Combination values of 02, 03, 04, 10, 11, 13, 14 and 16.

Article Number: 
46
Author(s): 
This work was performed under CMS Contract Number HHSM-500-2015-00558G
Related Data File Families: 
Related Data Files: 

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.