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

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

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

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

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)

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Master Beneficiary Summary File

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 2008.

This presentation is about the Beneficiary Summary File (BSF) segment; sometimes shown as Part A/B or Part A/B/D

Segments

6

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.

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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

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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

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

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.

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Traditional Enrollment Information

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

A variable for each month and one indicting the total

number of months enrolled in that year

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Medicare Savings Programs

http://www.medicareinteractive.org/page2.php?topic=counselor&page=script&slide_id=390 and link to the individual state requirements

New York state (see handout in this tab) -http://www.health.ny.gov/health_care/medicaid/program/update/savingsprogram/medicaresavingsprogram.htm

QMB – Qualified Medicare Beneficiary

SLIMB – Specified Low-income Medicare Beneficiary

QI – Qualifying Individuals

QDWI – Qualified Disabled and Working Individuals

http://www.medicare.gov/publications/pubs/pdf/10126.pdf

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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

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State Buy-In Indicator Values, June 2008 5% Sample, all ages

State Buy-In Frequency Percent

0 = Not entitled (Why?) 126,068 4.82

1 = Part A only 164,463 6.28

2 = Part B only 3,826 0.15

3 = Part A and Part B 1,913,210 73.07

A = Part A, State Buy-in 58 0.00

B = Part B, State Buy-in 13,603 0.52

C = Parts A & B, State Buy-in 396,942 15.16

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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

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

0

5

10

15

20

25

30

35

65-74 75-84 85+

A+B

A only

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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

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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 sub-segment.

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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 2000 - 02

RACE/

Ethnicity Sensitivity Specificity

Positive

predictive

value

Kappa

White 99.3 61.7 91.7 0.71

Black 97.4 98.8 86.3 0.91

Hispanic 29.5 99.9 92.7 0.43

Asian/P.I. 54.7 99.8 84.5 0.66

Am. Indian/

Ak.Native 35.7 99.9 59.9 0.45

Other/Unk. 1.7 98.8 4.9 0.01 20

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

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 79.2 29.5 99.7 99.9 81.5 92.7 0.80 0.43

Asian/PI 76.6 54.7 99.2 99.8 84.5 84.5 0.79 0.66

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Percentage Distribution of Medicare Enrollees by Race, 2008 BSF Race Code versus RTI Race Code

83.11% White

10.12% Black

1.84% Other

1.86% Asian

2.49% Hispanic

0.43% N American Native

77.64% White

9.77% Black

1.19% Other

2.43% Asian/Pl

7.80% Hispanic

0.42% American

Indian/Alaska Native

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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

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Encrypted Plan Contract ID Variable Name = PTD_CONTRACT_ID Values for 1st 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 http://www.medicare.gov/publications/pubs/pdf/11341.pdf

25

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 0.3 26

“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

“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 2013 - http://www.medicare.gov/pubs/pdf/10050.pdf

National Council on Aging - http://www.ncoa.org/assets/files/pdf/center-for-benefits/part-d-lis-eligibility-and-coverage.pdf

http://www.ncoa.org/assets/files/pdf/center-for-benefits/part-d-lis-eligibility-and-benefits-chart.pdf

See handout at end of this tab for next 2 slides

28

29

30

31

10%

14%

13%

3%

17%

4%

21%

17%

Medicare Part D Enrollment, 2010

No creditable coverage

Primary coverage throughFEHB, TRICARE, or activeworkerCovered by employers whoreceive RDS

Other creditable coverage

Non-LIS in MA-PD

LIS in MA-PD

Non-LIS in PDP

LIS in PDP32

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

10 -13 = not in Part D 33

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 126,016 4.81

01 = Bene deemed; 100% premium subsidy; no copayment 68,521 2.62

02 = Bene deemed; 100% premium subsidy; low copayment 273,292 10.44

03 = Bene deemed; 100% premium subsidy; high copayment 112,178 4.28

04 = Bene with LIS; 100% premium subsidy; high copayment 55,327 2.11

05 = Bene with LIS; 100% premium subsidy; 15% copayment 5,341 0.20

06 = Bene with LIS; 75% premium subsidy; 15% copayment 6,419 0.25

07 = Bene with LIS; 50% premium subsidy; 15% copayment 6,230 0.24

08 = Bene with LIS; 25% premium subsidy; 15% copayment 5,002 0.19

09 = Not LIS, but in Part D 901,153 34.42

10 = Not Part D 367,827 14.05

11 = Not Part D 313,768 11.98

12 = Not Part D 375,206 14.33

XX = Enrolled in Medicare A &/or B; no MIIR record for month 1,890 0.07 34

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 54.8 100

Low Income Subsidy (LIS) 20.3 37.1

Deemed to be LIS 17.3 31.7

Not deemed; therefore, applied

for LIS 3.0 5.5

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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 68,521 12.87

02 = Bene deemed; 100% premium subsidy; low copayment 273,292 51.34

03 = Bene deemed; 100% premium subsidy; high copayment 112,178 21.07

04 = Bene with LIS; 100% premium subsidy; high copayment 55,327 10.39

05 = Bene with LIS; 100% premium subsidy; 15% copayment 5,341 1.00

06 = Bene with LIS; 75% premium subsidy; 15% copayment 6,419 1.21

07 = Bene with LIS; 50% premium subsidy; 15% copayment 6,230 1.17

08 = Bene with LIS; 25% premium subsidy; 15% copayment 5,002 0.94

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Percent Distribution of LIS Beneficiaries, June 2008 PS = Premium Subsidy

12.9

51.3

21.1

10.4

1.0 1.2 1.2 0.9

Deemed; 100% PS; nocopay

Deemed; 100% PS; lowcopay

Deemed; 100% PS; highcopay

Other LIS; 100% PS; highcopay

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

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

Percent Distribution of LIS Beneficiaries, June 2008

Deemed(85.3%)

Other LIS(14.7%)

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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

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

State Reported Dual Status Eligible Code Variable JUNE 2008, 5% sample, all ages

Frequency Percent

00 = Not Medicare enrolled that month 126,016 4.81

01 = QMB only 44,594 1.70

02 = QMB + Medicaid coverage inc. Rx 238,071 9.09 03 = SLMB only 33,604 1.28

04 = SLMB + Medicaid coverage inc. Rx 11,846 0.45

05 = QDWI <11 0.00

06 = Qualified individuals 19,057 0.73 08 = Other Dual Eligibles (non-QMB, SLMB, QDWI or QI) 83,447 3.19

09 = Other duals without Medicaid coverage 14,403 0.55

99 = Unknown 17 0.00

NA = Non Medicaid 2,045,220 78.12

XX = Enrolled in A and/or B, no MIIR record 1,890 0.07 42

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

Dual Eligible Medicare and Medicaid Beneficiaries -- Discuss So, who are the duals?

43

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

Full Duals, Partial Duals, Undecided, and Others June 2008, 5% Sample, All Ages

Frequency Percent

00 = Not Medicare enrolled that month 126,016 4.81

01 = QMB only 44,594 1.70

02 = QMB + Medicaid coverage inc. Rx 238,071 9.09 03 = SLMB only 33,604 1.28

04 = SLMB + Medicaid coverage inc. Rx 11,846 0.45

05 = QDWI <11 0.00

06 = Qualified individuals 19,057 0.73 08 = Other Dual Eligibles (non-QMB, SLMB, QDWI or QI) 83,447 3.19

09 = Other duals without Medicaid coverage 14,403 0.55

99 = Unknown 17 0.00

NA = Non Medicaid 2,045,220 78.12

XX = Enrolled in A and/or B, no MIIR record 1,890 0.07 45

Full Duals, Partial Duals, and Undecided June 2008, 5% Sample, All Ages

Frequency Percent of

Duals

Full Duals 333,364 74.9

Partial Duals 97,255 21.8

Undecided 14,403 3.2

46

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

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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)

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