Medicare

Medicare is a health insurance program, administered by the United States government, for people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other special criteria like the End Stage Renal Disease program (ESRD).

Standardized Patient Assessment Data Elements (SPADE)

The Standardized Patient Assessment Data Elements (SPADE) file includes standardized data elements developed by CMS to meet the requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The IMPACT Act requires the reporting of standardized patient assessment data with regard to quality measures and SPADE. In addition, the IMPACT Act requires assessment data to be standardized and interoperable to allow for exchange of the data among post-acute providers and other providers. The Act intends for standardized post-acute care data to improve Medicare beneficiary outcomes through shared-decision making, care coordination, and enhanced discharge planning. The data elements in the SPADE data set address care in the following post-acute settings: Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, Skilled Nursing Facilities and Home Health Agencies.

This file includes (variable highlights):

  • Special services, treatments, and interventions
    • For example: ventilator use, dialysis, chemotherapy, central line placement, total parenteral nutrition, high risk drugs
  • Medical conditions and co-morbidities
  • Cognitive function
  • Mental status including depression and dementia
  • Ability to communicate

Special considerations:

  • This is a standalone file and cannot be linked to any other RIF data.

Skilled Nursing Facility (Encounter)

The Medicare Skilled Nursing Facility (Encounter) file includes Medicare Advantage plan records for skilled nursing facility stays. Skilled nursing care is the only level of nursing home care that is covered by the Medicare program.

 This file includes:

  • Diagnosis codes (ICD diagnosis)
  • Procedure codes (ICD procedure)
  • Resource Utilization Group codes (RUGs)
  • Admission/discharge dates
  • Organization NPI number only
  • No payment variables
  • Part C/Medicare Advantage benefit package and contract number

Special considerations:

  • Many Medicare Advantage Plans offer extra coverage in addition to services covered under traditional fee-for-service Medicare (e.g., vision, hearing, dental, and/or health and wellness programs). Encounter data may include records for some of these additional items and services provided under the plan.

Outpatient (Encounter)

The Medicare Outpatient (Encounter) file contains Medicare Advantage plan records from a variety of outpatient providers. Examples of institutional outpatient providers include hospital outpatient departments, rural health clinics, renal dialysis facilities, outpatient rehabilitation facilities, comprehensive outpatient rehabilitation facilities, Federally Qualified Health Centers and community mental health centers.

This file includes (variable highlights):

  • Diagnosis (ICD diagnosis) codes
  • HCPCS code
  • Revenue center codes, dates, unit counts
  • Part C Benefit Package and Contract number
  • Organization NPI number
  • No payment information

Special considerations:

  • Many Medicare Advantage Plans offer extra coverage in addition to services covered under traditional fee-for-service Medicare (e.g., vision, hearing, dental, and/or health and wellness programs). Encounter data may include records for some of these additional items and services provided under the plan.

Inpatient (Encounter)

The Medicare Inpatient (Encounter) file contains Medicare Advantage plan records for inpatient hospital stays.

This file includes (variable highlights):

  • Admission, discharge dates
  • Diagnosis (ICD diagnosis) codes
  • Procedure (ICD procedure) codes
  • Diagnostic related group (DRG) codes
  • Patient discharge status code
  • Organization NPI
  • Part C/Medicare Advantage benefit package and contract number
  • Revenue center codes, dates, unit counts
  • No payment variables are available

Special considerations:

  • Many Medicare Advantage Plans offer extra coverage in addition to services covered under traditional fee-for-service Medicare (e.g., vision, hearing, dental, and/or health and wellness programs). Encounter data may include records for some of these additional items and services provided under the plan.

Home Health Agency (Encounter)

The Medicare Home Health Agency (Encounter) file includes Medicare Advantage (MA) plan records for home health agency services.

This file includes (variable highlights):

  • Part C Benefit Package and Contract number
  • Diagnosis (ICD diagnosis) codes
  • HCPCS code
  • Revenue center codes, dates, unit counts
  • Organization NPI
  • NPI for line rendering physician
  • Patient discharge status code
  • No payment variables

Special considerations:

  • Many Medicare Advantage Plans offer extra coverage in addition to services covered under traditional fee-for-service Medicare (e.g., vision, hearing, dental, and/or health and wellness programs). Encounter data may include records for some of these additional items and services provided under the plan.

Durable Medical Equipment (Encounter)

The Medicare Durable Medical Equipment (Encounter) file includes Medicare Advantage plans records for medical supplies.

This file includes (variable highlights):

  • Part C Benefit Package and Contract number
  • Diagnosis (ICD diagnosis)
  • HCPCS code
  • Organization NPI
  • NPI for line supplier
  • Date of service (line date)

Special considerations:

  • Many Medicare Advantage Plans offer extra coverage in addition to services covered under traditional fee-for-service Medicare (e.g., vision, hearing, dental, and/or health and wellness programs). Encounter data may include records for some of these additional items and services provided under the plan.

Carrier (Encounter)

The Medicare Carrier (Encounter) file includes Medicare Advantage plan records for professional providers, including physicians, physician assistants, clinical social workers, nurse practitioners.

Records for some organizational providers are also found in the Carrier (Encounter) file. Examples include independent clinical laboratories, ambulance providers, freestanding ambulatory surgical centers and freestanding radiology centers.

Researchers rarely use this file alone.

This file includes (variable highlights):

  • Part C Benefit Package and Contract number
  • Diagnosis (ICD diagnosis)
  • HCPCS code
  • Date of service (line date)
  • NPI for line rendering physician
  • No payment information

Special considerations:

  • Many Medicare Advantage Plans offer extra coverage in addition to services covered under traditional fee-for-service Medicare (e.g., vision, hearing, dental, and/or health and wellness programs). Encounter data may include records for some of these additional items and services provided under the plan.

Risk Score Files

The Risk Score Files are created from the final CMS risk adjustment model outputs for a payment year. These risk scores are used to adjust CMS payments to Medicare Advantage (Part C) plans to account for differences in relative costs among plan enrollees. At this time, only Payment Year (PY)14 risk score files are available for research use.  

Please see the Medicare Managed Care Manual, Chapter 7 for a discussion of risk adjustment in the Medicare Advantage program.

The PY14 Risk Score Files includes six segments:  a base file, four files with outputs from Part C models and one for Part D model outputs. All files can be linked to other CCW files via the Bene_ID.

What does this file include? (variable highlights)

PY14 Base file:

  • Part C monthly risk payment scores
  • Part C monthly model segment codes
  • Part D model risk payment scores
  • Part D monthly model segment codes
  • Part C monthly institutional indicators
  • Part C community and institutional non-monthly model payment scores
  • Part D non-monthly model payment scores
  • Model Medicaid flag

PY14 Model Output Segments:

  • Model output raw risk scores from 4 Part C model versions, one for ESRD
  • Model output raw risk score from 1 Part D model version
  • Model-specific Hierarchal Condition Codes (HCCs)
  • Model-specific disability information
  • ESRD model-specific information
  • Part D model output including drug HCCs (RXHCCs)

Value Modifier Practice-Level File

The Value Modifier (VM) Practice-Level Research Identifiable File (RIF) includes one record for each practice that was subject to the VM based on the given performance year. Using the RIF data, researchers can examine trends in cost and quality performance and identify factors supporting higher quality at lower cost.

The VM Practice-Level RIF contains Quality and Resource Use Report (QRUR) and VM information. Program and participation information can be found on the CMS website.

What does this file include? (variable highlights)

  • Practice Identifier
  • Quality and Resource Use Report (QRUR) information
  • VM information
  • Benchmark information

Special considerations

Value Modifier Beneficiary-Level File

The Value Modifier (VM) Beneficiary-Level Research Identifiable File (RIF) includes one record for each beneficiary who was attributed to a practice subject to the VM based on the given performance year. Using the RIF data, researchers can examine differences in beneficiary characteristics, costs across practices, and the stability of beneficiaries attributed to a specific practice across time. Program and participation information can be found on the CMS website.

What does this file include? (variable highlights)

  • Beneficiary identifiers
  • Practice identifier for the practice to which the beneficiary was attributed
  • Number and percent of primary care services provided to the beneficiary that were billed by the practice
  • HCC percentile risk score

Special considerations