State Data
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Resources for States Integrating Medicare and Medicaid Data

The Medicare–Medicaid Data Integration (MMDI) program has developed many tools designed to assist state Medicaid agencies (SMAs) with the acquisition, integration, and utilization of Medicare data.

Profiling Substance Use Disorder and Potential Opioid Misuse Among Dual Eligibles
Prescription opioid misuse has emerged as a growing epidemic. To address prescription opioid misuse among dual eligibles, SMAs must understand prescription filling patterns and factors associated with opioid misuse within this population. This use case shows SMAs how to use Part D Prescription Drug Event (PDE) data, with other Medicare and Medicaid data sources, to examine opioid prescription fills among dual-eligible beneficiaries.

Profiling the Provider Role in Opioid Prescribing Among Dual Eligibles
Research shows that excessive and inappropriate prescribing of opioids is a widespread problem among providers and is largely responsible for the observed trends in opioid misuse. This use case will provide guidance to assist SMAs on how to leverage Medicare data to profile providers who prescribe opioids to dual eligibles. This will enhance SMAs' abilities to identify opportunities to implement efforts resulting in safer prescribing analgesic opioids.

Intelligent Assignment
This use case describes how SMAs can utilize current and historic Medicare fee-for-service (FFS) data to identify enrollees’ most frequently used primary care providers or other key Medicare providers, to assign them into a managed care organization (MCO) in which their providers participate (for integrated programs) or that have a companion Medicare Special Needs Plan (SNP) in which their providers participate (for non-integrated programs with the potential for aligned Medicaid and Medicare managed care plans). Assigning enrollees using intelligent assignment can reassure these beneficiaries that they will have continuity of care during the transition to a managed care plan and could reduce the number of beneficiaries opting out of optional programs or switching plans before and after enrollment into a program.

Comparison of Managed Care or Other Program Participants to Non-Participants on Characteristics and Outcomes
This use case describes how SMAs can utilize current and historic Medicare FFS data, Medicaid FFS data, and managed care encounter data to create characteristic profiles for program participants and non-participants to subsequently compare respective outcomes. A "program" could be a Financial Alignment Initiative (FAI) demonstration (or other dual-eligible demonstration), a Medicaid managed care program, a patient-centered medical home, or any alternative to a FFS delivery system designed to improve care coordination for dual eligibles. Examples of characteristics are demographic factors (age, race, gender, and geographic location) and the prevalence of chronic conditions. Examples of outcomes include hospital readmissions, transitions from institutional to home and community-based services (HCBS) settings, and the type of long-term services and supports (LTSS) used when enrollees first start to use LTSS (institutional vs. community-based), among others.

Assessment Data Value and Use
This use case describes how SMAs can use information available in assessments to supplement claims and eligibility data to get a more comprehensive understanding of dual-eligible enrollees’ characteristics and needs. SMAs could use this information to enhance many different aspects of their programs: design, risk stratification, development of effective care coordination (applicable to managed FFS models), performance metrics, and enrollee satisfaction and education. These assessments contain valuable information that cannot generally be found in claims data, such as an enrollee’s level of functional impairment, level of cognitive impairment, and availability of social supports.

Analytics and Dashboard Reporting on Managed Care Program Enrollment and Disenrollment
This use case describes how SMAs can use integrated Medicare and Medicaid data to produce descriptive analyses and timely metrics to better understand the factors associated with enrollment in and disenrollment in managed care programs. It was developed to help SMAs use holistic data to monitor the status of enrollment as a means of improving program design or operations to increase participation in the SMAs' managed care programs targeted at dual-eligible enrollees. Examples include:

  • Chronic conditions and cognitive condition profiles of key groups of interest by enrollment status;
  • Service use profiles of key groups of interest by enrollment status; and
  • Living arrangement profiles of key groups of interest by enrollment status.

Incorporating the HCBS Taxonomy Into Integrated Medicare and Medicaid Data Files
This use case describes how SMAs can incorporate the Centers for Medicare & Medicaid Services’ (CMS) Home and Community-Based Services (HCBS) Taxonomy into their integrated Medicare–Medicaid data files and leverage the Taxonomy in analysis and reporting. Potential application of this analysis include the following examples:

  • The ability for SMAs and CMS to make cross-state comparisons in HCBS coverage and utilization;
  • Examination of changes in use of HCBS in relation to use of Medicare acute and post-acute services; and
  • Examination of characteristics of people using HCBS, such as chronic conditions or limitations in activities of daily living.

Using Integrated Data to Examine Program Integrity in Managed Care
This use case helps SMAs to proactively look for fraud, waste, abuse, and overpayment in managed care programs targeted at dual-eligible enrollees. The MMDI team has identified a number of program integrity analyses that may be particularly relevant to SMAs integrating care for dual-eligible enrollees, including:

  • Capitation payments for ineligible members;
  • Services for ineligible members;
  • Professional visits to residential facilities; and
  • Professional visits to dual-eligible enrollees' homes.

Using Integrated Data to Generate Risk Scores and Chronic Condition Information for Dual-Eligible Enrollees
This use case describes how SMAs can use integrated Medicare-Medicaid data to improve their ability to stratify the dual-eligible population by risk, which should result in more effective care coordination.

Using Integrated Medicare and Medicaid Data to Develop a Profile of the Dual-Eligible Population
SMAs that are developing programs to better coordinate care for dual eligibles need to understand the population's demographic characteristics and service utilization to effectively tailor programs to the population's needs. In this use case, the MMDI team identifies some common profile elements and describe the requisite data sources and methodologies needed to produce them.

Leveraging Integrated Medicare and Medicaid Data to Examine Dual Eligibles’ Prevalence of Behavioral Health Conditions and Differences in Cost and Service Use
Several studies have shown that the dual-eligible population has a high prevalence of mental health conditions and combined mental health and physical health conditions compared to Medicare beneficiaries who do not have Medicaid. The purpose of this use case is to provide SMAs with an understanding of how they can leverage integrated data to: (1) identify the prevalence of seven behavioral health conditions in the dual-eligible population, and (2) examine differences in costs and service utilization for those with and without these conditions.

Leveraging Integrated Medicare and Medicaid Data to Examine Dual Eligibles' Use of Behavioral Health Services
This use case demonstrates how SMAs can leverage integrated Medicare and Medicaid data to describe dual eligibles' utilization of behavioral health services for the treatment of behavioral health disorders. Behavioral health includes substance use disorders and mental health disorders. In particular, this use case provides examples of how SMAs can identify common behavioral health service categories across Medicare and Medicaid programs with different covered services and provider types.

Leveraging Integrated Medicare and Medicaid Data to Examine Dual Eligibles' Quality of Care – Behavioral Health Measures
This use case demonstrates how SMAs can use the Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set 1) with integrated Medicare and Medicaid data to assess the quality of dual eligibles' behavioral health care. We selected two Adult Core Set quality measures that provide information to care coordination as examples: 1) Follow Up After Hospitalization for Mental Health Illness and 2) Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications.

Selecting a Diagnostic Classification System for Assignment of Chronic Conditions to Dual-Eligible Beneficiaries
One of the most notable characteristics of the dual-eligible population is a high prevalence of chronic conditions, including comorbidities. This use case provides a framework to help SMAs choose a diagnostic classification system to identify chronic conditions within the dual-eligible population. To illustrate the framework, we have selected three widely-used diagnostic classification systems: 1) CMS Chronic Conditions Data Warehouse (CCW) chronic conditions algorithms; 2) CMS Hierarchical Condition Category (HCC) risk adjustment model; and 3) the University of California, San Diego (UCSD) Chronic Illness and Disability Payment System (CDPS) diagnostic classification system.

Part D Prescription Drug Event (PDE) Data Overview
Prescription drugs are a significant part of the delivery of health care services to dual eligibles. This use case provides an overview of Medicare Part D Prescription Drug Event (PDE) data and helps SMAs understand how they can use the data, integrated with other sources, to conduct basic analytics to understand dual eligibles' drug utilization.

Part D Prescription Drug Event (PDE) Data and Use
This use case provides examples of analytics SMAs can conduct using PDE data, when integrated with other sources, to understand dual eligibles’ Part D enrollment by plan type, drug utilization, and costs.

Identification of Elderly Dual Eligibles Using High-Risk Medications
The elderly population is at an increased risk for adverse prescription drug reactions as the result of age-related physiologic changes, comorbidities, and polypharmacy. This use case will demonstrate how SMAs can use Medicare PDE data and the publicly available National Committee for Quality Assurance (NCQA) quality measure, the Use of High-Risk Medications (HRMs) in the Elderly, to identify elderly dual eligibles who are using HRMs.

Identifying Elderly Dual-Eligible Beneficiaries for Fall Risk
Falls are the leading cause of fatal and non-fatal injuries among individuals 65 years and older (elderly), with roughly one third of the elderly population estimated to experience a fall each year. This use case was developed to help SMAs identify elderly dual-eligible beneficiaries who are at an increased risk of falling based on the Centers for Disease Control and Prevention (CDC) guidelines.

Emergency Department Utilization Among Dual-Eligible Beneficiaries
Studies have shown that dual-eligible beneficiaries are more likely to use the Emergency Department (ED) than Medicare-only beneficiaries. This use case demonstrates how SMAs can use Medicare data sources to investigate ED utilization patterns in the dual-eligible population.

Rates of Flu Vaccination in the Dual-Eligible Population
The flu vaccine can reduce the risk of contracting a flu virus by 40-60%. This use case helps SMAs identify dual eligible beneficiaires who received a flu vaccination based on the CDC's guidelines, an American Medical Association (AMA) quality measure endorsed by the National Quality Forum (NQF), and guidance from the National Vaccine Program Office (NVPO).

For more information about any of the tools, use cases, or webinars, please contact