Improving the accuracy and reliability of service-level managed care data should be a priority for federal oversight (MACPAC 2013). Data reported by states and managed care plans provide important information for answering key policy and program accountability questions; data are necessary to monitor trends and make projections on spending, service use, and the quality and appropriateness of care. However, data submitted by managed care plans to states and by states to CMS have varied in their consistency, availability, and timeliness (OIG 2009). This variability creates challenges for analyzing and monitoring managed care programs and limits the ability to compare states.
Managed care encounter data
States are required to collect encounter data from managed care organizations (MCOs)—that is, information relating to the receipt of any items or services by an enrollee under the MCO contract— and to submit these data to CMS. States use encounter data to support a variety of data-driven activities and analyses including rate setting, risk adjustment, quality measurement, value-based purchasing, program integrity, and policy development. The federal government uses encounter data to measure state and plan performance, monitor compliance with federal rules, support program integrity efforts, and facilitate comparisons across states and between fee for service and managed care.
The federal government has numerous statutory authorities that require the collection and submission of these data, including:
- Section 1902(a)(4) of the Social Security Act, which allows the Secretary to request the data needed to ensure the proper and efficient operation of the state plan;
- Section 1903(m)(2)(A)(xi) of the Act, which specifies that an MCO must report encounter data to the state in a timeframe and level of detail specified by CMS; and
- Section 1903(i)(25) of the Act, which mandates that federal matching payments to the states must not be made for individuals for whom the state does not report enrollee encounter data to CMS.
Federal regulations require additional specificity regarding the accuracy and completeness of data that must be submitted to CMS for purposes of federal oversight. For example, 42 CFR 438.818(a) describes detailed encounter data-reporting standards that states must meet in order to receive federal matching payments, including a requirement that states validate the data for accuracy and completeness. Further, states must conduct an independent audit at least every three years of the accuracy and completeness of the encounter data submitted by MCOs (42 CFR 438.602(e)).
Federal regulations also address the health information systems that MCOs must maintain in order to submit the data necessary for states to comply with the encounter data submission requirements (42 CFR 438.242). State contracts with MCOs must ensure that each MCO maintains a system capable of collecting and maintaining enrollee encounter data and submitting these data to the state at the frequency and level of detail specified by CMS and the state in order to support program administration, oversight, and program integrity. A state may withhold a percentage of the capitation payment to penalize a managed care plan that does not submit timely enrollee encounter data (42 CFR 438.6(b)(3)), or impose a civil monetary penalty as an intermediate sanction (42 CFR 438.702).
Transformed Medicaid Statistical Information System (T-MSIS)
Since 1999, CMS has required states to provide detailed eligibility and claims information on a quarterly basis through a central system known as the Medicaid Statistical Information System (MSIS). This system collected only limited information on managed care. Further, encounter records provided in MSIS generally did not include a payment amount and many states failed to routinely include these records in their MSIS submissions, which precluded CMS from using these data to perform policy analyses or answer program accountability questions.
CMS updated the MSIS data requirements and developed a new data set referred to as the Transformed Medicaid Statistical Information System (T-MSIS). The T-MSIS data set, which is submitted monthly by each state, contains enhanced information about beneficiary eligibility, beneficiary and provider enrollment, service utilization, claims and managed care data, and expenditure data. As noted above, states are required to ensure that MCOs maintain systems capable of collecting and submitting encounter data that meets state and federal standards for timeliness and completeness. The T-MSIS data specifications, which describe the data elements and standardized formats for encounter data files, serve as the federal standards that MCOs must meet to demonstrate compliance with this federal regulation.
Quality information
State Medicaid programs collect a variety of quality information from MCOs to monitor and measure performance. Commonly used tools for monitoring quality in Medicaid managed care include the Healthcare Effectiveness Data and Information Set (HEDIS) measures and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.
- HEDIS. HEDIS is a set of quality, access, and effectiveness-of-care measures developed by the National Committee for Quality Assurance (NCQA) for use by commercial, Medicare, and Medicaid health plans. HEDIS measures address many common indicators of health use and quality including immunization status, asthma medication use, breast cancer screening, and anti-depression medication management. Because many states require participating MCOs to collect and report data using HEDIS measures, the data can be used to make comparisons among plans and potentially across programs and across states. HEDIS is a registered trademark of NCQA.
- CAHPS. CAHPS is a set of beneficiary surveys designed for children and adults that covers a range of topics, including access to care and use of services, wait times, appointment scheduling, access to specialty care, and satisfaction with providers. For Medicaid programs, CAHPS is an important quality improvement tool used by states and managed care plans to measure performance, determine where to focus improvement efforts, and track improvements over time. Some state Medicaid agencies use CAHPS and similar measures to gauge member satisfaction with Medicaid managed care arrangements. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality, which oversees the survey.
Managed care program information
CMS periodically collects and reports program-level information on Medicaid managed care programs. These include:
- state profiles summarizing the state managed care programs, authorities, covered populations, geographic areas, benefits, participating plans, plan selection process, rate setting, and quality and performance incentives; and
- annual enrollment reports indicating managed care enrollment by state, type of program, and program and plan.
