The Medicare Master Beneficiary Summary File

Transcription

1 The Medicare Master Beneficiary Summary File THE OLD AND NEW INFORMATION IT CONTAINS Marshall McBean, M.D., M.Sc. Principle Investigator and Director, ResDAC Professor, University of Minnesota

2 Beneficiary-Level Part D Information Enrollment or denominator information this presentation Utilization or numerator information later presentations Prescription Drug Event (PDE) information Characteristics files 2

3 Acronyms in this Presentation BSF Beneficiary Summary File CCW Chronic Condition Warehouse EDB Enrollment Database RTI Research Triangle Institute CAHPS - Consumer Assessment of Healthcare Providers and System PDE Prescription Drug Event QMB Qualified Medicare Beneficiary 3

4 Acronyms in this Presentation SLMB Specified Low-income Medicare Beneficiary QI Qualifying Individuals QDWI Qualified Disabled and Working Individuals PACE Program of All-Inclusive Care for the Elderly LIS Low Income Subsidy PDP Prescription Drug Plan MA-PD Medicare Advantage Prescription Drug Plan 4

5 History of Enrollment or Denominator Information for use in Part D studies Until recently there was a single Denominator File created originally to work with Part A and Part B data; thin (80 columns), and we suggested that everyone get a copy of it for every study. Now different denominator files may be mentioned: The old Denominator File is no longer available The Part D Denominator short lived Beneficiary Summary File (BSF) the next one Master Beneficiary Summary File (MBSF) -- this is it! (for now) 5

6 Master Beneficiary Summary File Segments There are 4 segments to the Master Beneficiary Summary File Beneficiary Summary File or Medicare Enrollment (A/B/C/D information) Chronic Conditions Cost & Utilization NDI Death Information (includes ICD-10 Cause of Death) ; through This presentation is about the Beneficiary Summary File (BSF) segment; sometimes shown as Part A/B or Part A/B/D 6

7 Beneficiary Summary File (BSF) Segment of the MBSF Similar to the traditional Medicare Denominator File 100% of all Medicare beneficiaries enrolled in that year Annual, calendar year file one record per beneficiary Information is what is known by CMS as of 12/31/20XX Traditional denominator information available by end of summer of 20XX+1 in what is now called the Beneficiary Summary File (BSF) segment of the MBSF Part D denominator information added in January or February/March 20XX+2, also, to the BSF segment of the MBSF So, you could have received the BSF segment for one year in 1 or 2 pieces depending on when you request data. May not be true in 2013 and forward. 7

8 Traditional Demographic and Enrollment Information in BSF Segment of MBSF Unique beneficiary identification number Demographics Medicare Part A, Part B, and Medicare Advantage Plan enrollment information by month and annually Information about death Died during that year (yes/no) Date the person died Whether the beneficiary is in the 5% CCW random sample or the enhanced 5% CCW random sample Note: Part D data, unless otherwise specified in the Data Use Agreement (DUA) will be on the 5% samples 8

9 Identification Number and Demographic Information A beneficiary identification number: encrypted BENE_ID is unique to each Data Use Agreement (DUA); created by CCW/Buccaneer Date of birth and Age as of 12/31/20XX Gender Race/ethnicity a one column field Place of residence state, county and zip code 9

10 Agreement Between Demographic Information in BSF and in Claims Files All demographic information in BSF and claims files comes from the Enrollment Database (EDB) maintained at CMS Data Center As claims are processed, the demographic information known to CMS at that time overwrites any demographic information in the claim Therefore, there is agreement between BSF and claims unless change in status during the year essentially talking about change in residency PDE File gender and date of birth variables from a different source; therefore, recommend linking PDE and BSF for all demographic information. 10

11 Residency in BSF State, county and ZIP code of residence are the mailing address for official correspondence Some persons have their mail sent to another person (e.g., son, daughter, guardian) Because residency in BSF is based on the information available at the end of the calendar year, there may be some mismatch with residence on a claim from earlier in year. No residency variables in PDE or other Part D data files. 11

12 Traditional Enrollment Information A variable for each month and one indicting the total number of months enrolled in that year Enrolled in Medicare Part A Enrolled in Medicare Part B State buy-in did a state pay Medicare for beneficiary s Part B coverage in traditional Medicaid Program or in a Medicare Savings Program (QMB, SLMB, QI) Enrolled in Medicare Advantage (Part C); a.k.a. managed care, HMO 12

13 Medicare Savings Programs opic=counselor&page=script&slide_id=390 and link to the individual state requirements New York state (see handout in this tab) - /update/savingsprogram/medicaresavingsprogram.htm QMB Qualified Medicare Beneficiary SLIMB Specified Low-income Medicare Beneficiary QI Qualifying Individuals QDWI Qualified Disabled and Working Individuals 13

14 State Buy-in Variable Values 0 = NOT ENTITLED 1 = PART A ONLY 2 = PART B ONLY 3 = PART A AND PART B A = PART A, STATE BUY-IN B = PART B, STATE BUY-IN C = PARTS A AND B, STATE BUY-IN 14

15 State Buy-In Indicator Values, June % Sample, all ages State Buy-In Frequency Percent 0 = Not entitled (Why?) 126, = Part A only 164, = Part B only 3, = Part A and Part B 1,913, A = Part A, State Buy-in B = Part B, State Buy-in 13, C = Parts A & B, State Buy-in 396,

16 How ResDAC Recommends You Use the State Buy-In Variable 1. Use it to select those with both Part A and Part B coverage State Buy-in Variable values of 3 and C Do all of your studies on those who have both Part A and Part B coverage. Why? see next slide» Those with Part A only have lower rates of utilization (of hospitalization, e.g.» Not many beneficiaries with only Part B, and probably have different health utilization patterns 2. To identify those with less resources (will discuss in Segments C and D of this workshop) 16

17 Hospitalization rates by type of Medicare coverage (per 100 enrollees) supports the conclusion that persons with A-only coverage probably have incomplete claims, even for Part A services A+B A only

18 Part D-related Denominator and Enrollment Information in the BSF Segment of the MBSF Types of information RTI race variable (RTI = Research Triangle Institute) Additional enrollment information Information for linking with the Part D Characteristics Files Enrollment information is presented in 2 different ways For each month of the year; therefore, 12 variables Number of months (0-12), 1 variable 18

19 Race A One Column Variable Hispanic ethnicity not asked nor coded separately Originally, race coded as: white, black, other, unknown Effective 1994, race codes were expanded to: white, black, Asian, Hispanic, Native American, other, unknown the old race variable. New RTI Race Code variable is available in the Beneficiary Summary File segment of the Master Beneficiary Summary File (The old race code information is available, also.) Was in the Part D sub-segment, but now in the Part A/B subsegment. 19

20 Traditional Medicare Race Variable Accuracy and agreement between race variable in the Enrollment Database (EDB) and SELFRACE, self-reported race, from Medicare CAHPS Surveys of RACE/ Ethnicity Sensitivity Specificity Positive predictive value Kappa White Black Hispanic Asian/P.I Am. Indian/ Ak.Native Other/Unk

21 Information Used in Algorithm Improving the Identification of Hispanics and Asian/Pacific Islanders Language preference for materials requested from CMS and Social Security Administration Source of the race/ethnicity code (survey, Indian Health Service, other) State of residence (PR or HI) Hispanic and Asian/Pacific Islander surname lists from U.S. Census Bureau 21

22 Accuracy and Agreement Measures for RTI Race and EDB Race Compared with SELFRACE in the CAHPS Surveys Race/ Ethnicity Sensitivity Specificity Positive predictive value Kappa Hispanic Asian/PI

23 Percentage Distribution of Medicare Enrollees by Race, 2008 BSF Race Code versus RTI Race Code 1.84% Other 2.49% Hispanic 1.86% Asian 0.43% N America n Native 2.43% Asian/Pl 7.80% Hispanic 0.42% American Indian/Alask a Native 10.12% Black 1.19% Other 9.77% Black 83.11% White 77.64% White 23

24 Part D-Related Enrollment Information Encrypted Plan Contract ID very important; next occurs 12 times unique to each plan tells what type of plan: MA-PD or PDP Cost Share Group (occurs 12 times) information about low income subsidy State Reported Dual Eligible Status Code (occurs 12 times) Beneficiary Dual Status Eligibility Months (0-12) On/Off Creditable Coverage Switch - little use Retiree Drug Subsidy Indicators (occurs 12 times) and number of months little use 24

25 Encrypted Plan Contract ID Variable Name = PTD_CONTRACT_ID Values for 1 st column of 5 column variable H: local MA-PD, PACE*, Cost Plans and Demonstrations; have PDE data R: Regional MA-PD; have PDE data S: PDP (prescription drug plan); have PDE data N: Not Part D enrolled; No data E: Employee-sponsored plans (beginning in 2007); have PDE data; But most often do not have Plan Characteristics Data; historically, very few plans/beneficiaires, but the number increasing * PACE = Program of All-Inclusive Care for the Elderly; see 25

26 Percent Distribution of PTD_CONTRACT_ID June 2008, 5% Sample, all ages First Column of PTD_CONTRACT_ID Percent 0 - Not enrolled in Medicare that month 4.8 N Not Part D enrolled 40.4 H - Local MA-PD 17.2 R Regional MA-PD 0.6 S PDP 36.7 E Employer-sponsored plan

27 Extra help Low Income Subsidy (LIS) Benefits Help paying Medicare drug plan s monthly premium, any yearly deductible, coinsurance, and/or copayments No coverage gap liability No late enrollment penalty Major Effort on the part of CMS and advocacy groups to inform beneficiaries about the Low Income Subsidy available to them to help pay for Part D services. Low Income Subsidy (LIS) only relates to Part D services, but this information is known for all beneficiaries 27

28 Extra Help Low Income Subsidy - Repeat Repeat: Major Effort on the part of CMS and advocacy groups to inform beneficiaries with incomes and/or assets above levels that would qualify them for the above programs about the subsidy(ies) available to beneficiaries to help pay for Part D services Medicare & You National Council on Aging See handout at end of this tab for next 2 slides 28

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32 Medicare Part D Enrollment, % 10% 14% No creditable coverage Primary coverage through FEHB, TRICARE, or active worker Covered by employers who receive RDS Other creditable coverage 21% 13% Non-LIS in MA-PD LIS in MA-PD Non-LIS in PDP 4% 17% 3% LIS in PDP 32

33 The Variable that Describes the Low Income is the Cost Share Group Variable Values for Cost Share Group variable 00 = Not Medicare enrolled for the month XX = Enrolled in Medicare A and/or B, but no MIIR record for the month Enrolled in Medicare A and/or B and enrolled in Part D and: 01 = Bene is deemed with 100% premium-subsidy and no copayment 02 = Bene is deemed with 100% premium-subsidy and low copayment 03 = Bene is deemed with 100% premium-subsidy and high copayment 04 = Bene with LIS, 100% premium-subsidy and high copayment 05 = Bene with LIS, 100% premium-subsidy and 15% copayment 06 = Bene with LIS, 75% premium-subsidy and 15% copayment 07 = Bene with LIS, 50% premium-subsidy and 15% copayment 08 = Bene with LIS, 25% premium-subsidy and 15% copayment 09 = No premium subsidy nor cost sharing = not LIS = not in Part D 33

34 Frequency of Cost Share Group Values Among All Medicare Beneficiaries June, 2008, 5% Sample Cost Share Group Frequency Percent 00 = Not Medicare enrolled for the month 126, = Bene deemed; 100% premium subsidy; no copayment 68, = Bene deemed; 100% premium subsidy; low copayment 273, = Bene deemed; 100% premium subsidy; high copayment 112, = Bene with LIS; 100% premium subsidy; high copayment 55, = Bene with LIS; 100% premium subsidy; 15% copayment 5, = Bene with LIS; 75% premium subsidy; 15% copayment 6, = Bene with LIS; 50% premium subsidy; 15% copayment 6, = Bene with LIS; 25% premium subsidy; 15% copayment 5, = Not LIS, but in Part D 901, = Not Part D 367, = Not Part D 313, = Not Part D 375, XX = Enrolled in Medicare A &/or B; no MIIR record for month 1,

35 Summary: LIS and Non-LIS Beneficiaries in Medicare Population June 2008 Percent of Total Medicare Population Percent of Part D Enrollees Enrolled in Part D Low Income Subsidy (LIS) Deemed to be LIS Not deemed; therefore, applied for LIS

36 Frequency of Cost Share Group Values June 2008, 5% Sample, All Ages Cost Share Group Frequency Percent of LIS 01 = Bene deemed; 100% premium subsidy; no copayment 68, = Bene deemed; 100% premium subsidy; low copayment 273, = Bene deemed; 100% premium subsidy; high copayment 112, = Bene with LIS; 100% premium subsidy; high copayment 55, = Bene with LIS; 100% premium subsidy; 15% copayment 5, = Bene with LIS; 75% premium subsidy; 15% copayment 6, = Bene with LIS; 50% premium subsidy; 15% copayment 6, = Bene with LIS; 25% premium subsidy; 15% copayment 5,

37 Percent Distribution of LIS Beneficiaries, June 2008 PS = Premium Subsidy Deemed; 100% PS; no copay Deemed; 100% PS; low copay Deemed; 100% PS; high copay Other LIS; 100% PS; high copay Other LIS; 100% PS; 15% copay Other LIS; 75% PS; 15% copay Other LIS; 50% PS; 15% copay Other LIS; 25% PS; 15% copay 37

38 Collapsed Values for Cost Share Group Variable Those who receive Low Income Subsidy (LIS) Deemed eligible (01, 02, 03) Those who apply for LIS (04, 05, 06, 07, 08) How useful is this information? 38

39 Percent Distribution of LIS Beneficiaries, June 2008 Deemed (85.3%) Other LIS (14.7%) 39

40 State Reported Dual Status Eligible Code Variable Occurs 12 times Can finally tell who has traditional Medicaid versus one of the Medicare Savings Programs (QMB, SLMB, QI, QDWI). As described earlier, formerly, the Medicare Denominator File and the BSF only had a State buy-in variable that lumped together Medicaid recipients and those in Medicare Savings Programs (QMB, SLMB, QI, QDWI). 40

41 State Reported Dual Eligible Status Code Variable Values 00 = Not Medicare enrolled for the month XX = Enrolled in Medicare A and/or B, but no MIIR record for the month NA = Non-Medicaid 01 = QMB only 02 = QMB and Medicaid coverage including RX 03 = SLMB only 04 = SLMB and Medicaid coverage including RX 05 = QDWI 06 = Qualified Individuals 08 = Other Dual Eligibles (Non-QMB, SLMB, QWDI, or QI) w/medicaid coverage including RX 09 = Other Dual Eligibles but without Medicaid coverage 99 = Unknown 41

42 State Reported Dual Status Eligible Code Variable JUNE 2008, 5% sample, all ages Frequency Percent 00 = Not Medicare enrolled that month 126, = QMB only 44, = QMB + Medicaid coverage inc. Rx 238, = SLMB only 33, = SLMB + Medicaid coverage inc. Rx 11, = QDWI < = Qualified individuals 19, = Other Dual Eligibles (non-qmb, SLMB, QDWI or QI) 83, = Other duals without Medicaid coverage 14, = Unknown NA = Non Medicaid 2,045, XX = Enrolled in A and/or B, no MIIR record 1,

43 Dual Eligible Medicare and Medicaid Beneficiaries -- Discuss So, who are the duals? 01 = QMB only 02 = QMB and Medicaid coverage including RX 03 = SLMB only 04 = SLMB and Medicaid coverage including RX 05 = QDWI 06 = Qualified Individuals 08 = Other Dual Eligibles (Non-QMB, SLMB, QWDI, or QI) w/medicaid coverage including RX 09 = Other Dual Eligibles but without Medicaid coverage 43

44 Full Duals, Partial Duals, And to be Decided 01 = QMB only 02 = QMB and Medicaid coverage including RX 03 = SLMB only 04 = SLMB and Medicaid coverage including RX 05 = QDWI 06 = Qualified Individuals 08 = Other Dual Eligibles (Non-QMB, SLMB, QWDI, or QI) w/medicaid coverage including RX 09 = Other Dual Eligibles but without Medicaid coverage 44

45 Full Duals, Partial Duals, Undecided, and Others June 2008, 5% Sample, All Ages Frequency Percent 00 = Not Medicare enrolled that month 126, = QMB only 44, = QMB + Medicaid coverage inc. Rx 238, = SLMB only 33, = SLMB + Medicaid coverage inc. Rx 11, = QDWI < = Qualified individuals 19, = Other Dual Eligibles (non-qmb, SLMB, QDWI or QI) 83, = Other duals without Medicaid coverage 14, = Unknown NA = Non Medicaid 2,045, XX = Enrolled in A and/or B, no MIIR record 1,

46 Full Duals, Partial Duals, and Undecided June 2008, 5% Sample, All Ages Frequency Percent of Duals Full Duals 333, Partial Duals 97, Undecided 14,

47 Additional Variable in BSF Segment of MBSF Beneficiary Dual Status Eligibility Months Sum of the monthly State Reported Dual Eligible Status Code codes 01 through 09 47

48 Linking with the Characteristics Files 3 variables in BSF segment of MBSF used to link to the Characteristics Files: Encrypted Contract ID Encrypted Plan Benefit Package ID Encrypted Segment (market area) ID The Characteristics Files will be explained later in Workshop Plan Characteristics File Provider (Pharmacy) Characteristics File Prescriber Characteristics File Drug Characteristics File (actually appended to the PDE file) 48