The SDRC Team offers state Medicaid agencies advice on how
to use Medicare data for Medicare-Medicaid care coordination and
program integrity activities. In addition to this advice, the
following external websites can provide state Medicaid agencies with detailed
information on the variables and layouts of Medicare data:
- The Chronic Condition Warehouse (CCW) provides
information on Medicare Parts A & B and Assessments (MDS,
OASIS, Swing Bed, and IRF-PAI) data.
Enhancements to the CCW
- The CCW contains Medicare and Medicaid claims,
eligibility, and enrollment data. The CCW also contains
indicators (i.e., "flags") for 27 chronic conditions, which were
originally chosen based on their high prevalence among elderly
Medicare-only beneficiaries. MMCO has expanded these flags for
all years of existing data (2000-2008) to include the following:
1) the Medicaid-only population; 2) identification of individuals
among the Medicare-Medicaid enrollee population with the original
27 conditions for both Medicare and Medicaid claims; rather than
solely their Medicare experience; and 3) additional flags for all
three populations with conditions that are known to affect
Medicare-Medicaid enrollees with disabilities and Medicaid-only
- MMCO developed and has made available CCW flags for 9
mental health conditions, tobacco use, and 15 conditions related
to intellectual, developmental, and physical disability with the
assistance of subject matter experts.
- Coordination of Benefits Agreement (COBA) Companion
COBC’s COBA HIPAA 5010 Companion Guide provides information for preparing and testing HIPAA 5010 COBA
transactions. This guide provides information in understanding
what values will appear in various fields on the outbound 837
Publishing Company (WPC) provides the HIPAA 5010 837-I and 837-P Technical Report Version 3
(TR-3) Guides These comprehensive guides fully lay out the rules
for HIPAA implementation of the 837 claims. There is a charge for
these consolidated guides through WPC.
Medicare-Medicaid Linked Enrollee Analytic
Data Source (MMLEADS) Version 2.0
- MMLEADS is a suite of 2006-2012 linked data files for
Medicare-Medicaid eligibility, enrollment, utilization, and
expenditure data. This data source includes health care
information for all dually eligible Medicare-Medicaid enrollees,
and, for comparison purposes, all Medicare-only beneficiaries and
Medicaid-only beneficiaries with disabilities. MMLEADS provides
utilization and expenditure metrics based on MMCO’s preferred
method of identifying Medicare-Medicaid enrollees (e.g., from the
monthly "State MMA File"), while also keeping the flexibility to
generate metrics according to other user-defined criteria.
MMLEADS contains a linking variable for linking to other data
(e.g., survey, assessment, claims) that are housed in the Chronic
Condition Warehouse (CCW).
SDRC Tip Sheet – Public Use Files (PUFs)
- This tip sheet contains a list of free, publicly available data files that include
Medicare and Medicaid services at the beneficiary and provider levels, data by state, and
data file guides.
MMLEADS Public Use File (PUF)
- The MMLEADS Public Use File (PUF) data are based off MMLEADS, version 2.0.
The 2006-2012 aggregated data include information on full and partial Medicare-Medicaid
enrollees, and also for comparison purposes - Medicare only enrollees and Medicaid only (eligible
via disability) enrollees. The MMLEADS PUF data and User Guide are available for download.
- State-CMS File Exchanges
- Since 2005, state Medicaid agencies have been submitting files at least monthly to CMS to identify
all dually eligible beneficiaries. This includes full-benefit dual-eligible beneficiaries and
partial-benefit dual-eligible beneficiaries (i.e., those who get Medicaid help with Medicare premiums,
and often for cost-sharing). The file is called the "MMA File" (after the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003), but occasionally referred to as the "State Phasedown file."
The MAPD State User Guide has additional information pertinent to the content of multiple monthly files. To access
the user guide, download the following document: MAPD State User Guide
Medicare Modernization Act (MMA) File
State Medicaid agencies ("state") submit files on dual-eligible beneficiaries and partial benefit
dual-eligible beneficiaries (i.e., those who get Medicaid help with Medicare premiums and often for cost-sharing)
to CMS every month. These files are called "MMA Files" (after the Medicare Prescription Drug Improvement and
Modernization Act of 2003") or "State Phasedown Files." Each state sends at least one MMA File (i.e., Request File) to CMS monthly.
More information about MMA Request File Submissions can be found here.
MMA Request Files contain beneficiary names and demographics and information on beneficiary Low-Income Subsidy (LIS),
institutionalization, and Medicaid and Medicare eligibility status. Beneficiary names and demographic information
are used to perform matches between the state beneficiary records and the CMS Medicare Beneficiary Database (MBD).
CMS automatically returns an MMA Response File to the state upon the successful processing of the MMA Request File.
MMA Response Files include a copy of the MMA Request File detail record, error return codes, data from the CMS MBD,
a summary of record validation and matching outcomes, and count by month for each month of enrollment information
on the MMA Request File. For more information on the MMA files, please refer to Sections 4-7 of the MAPD State User Guide.
Territory Beneficiary Query (TBQ) File
- The TBQ process is a data exchange between CMS and the state Medicaid agencies to determine dual status
eligibility and enrollment information as part of the process for LIS enrollment. state Medicaid agencies
can submit TBQ Request Files to obtain batch data submitted through the MMA files, as described above.
The TBQ Response Files contain beneficiary names and demographic information. CMS automatically returns a
TBQ Response File, which contains beneficiary names, residence addresses, demographic information, and
entitlement information for each TBQ Request File. For more information on the TBQ files, please refer to
Section 11.3 of the MAPD State User Guide.
State Medicaid agencies can also download the following data documentation:
Prescription Drug Event (PDE) File Layout
- The PDE File Layout spreadsheet describes both the
structure and variables contained within PDE files.
Part D Netting Explanation
- The Part D Netting Explanation document explains the data
elements that CMS has developed to enable PDE users to identify
and net unique prescription drug claims.
Integrating Monthly Files into Part D Final Action
- The Integrating Monthly Files into Part D Final Action document
explains the additional steps necessary to identify final action
records within the Prescription Drug Event data when incorporating the monthly update files.
For additional technical advice on Medicare data variables and
layouts, contact the SDRC Team by phone at (877) 657-9889 or by
email at SDRC@EconometricaInc.com