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).

Master Beneficiary Summary File (MBSF): Other Chronic or Potentially Disabling Conditions Segment

The Other Chronic or Potentially Disabling Conditions segment of the MBSF flags beneficiary records for the presence of 35 chronic or potentially disabling conditions not included in the original list of 27 conditions, including:

  • Mental health
  • Tobacco use, alcohol and drug use
  • Developmental disorders
  • Disability-related conditions
  • Behavioral health
  • Other chronic physical conditions

What does this file include? (variable highlights)

  • Two flags for each chronic condition:
    • First ever occurrence date
    • End of year indicator

Special considerations

  • This file uses information from Fee-For-Service (FFS) Medicare claims.

Master Beneficiary Summary File (MBSF): Cost and Use Segment

The Cost and Use file segment of the MBSF includes one record for each beneficiary enrolled in Medicare in the calendar year of the file.

What does this file include? (variable highlights)

  • Summary of utilization and total annual payments for services such as:
    • physician visits, dialysis, DME, IP recorded emergency room visits, Ambulatory Surgical Centers, anesthesia, imaging, Part B drugs from Fee-for-service (FFS) Medicare
  • Number of hospital stays, Medicare covered days and total annual inpatient payments for services covered by FFS Medicare
  • Summary of Part D payments, events and prescription fills

This file is a segment that can be requested in addition to the Master Beneficiary Summary File (MBSF) base file.

Master Beneficiary Summary File (MBSF): 27 CCW Chronic Conditions Segment

The Chronic Conditions segment of the Master Beneficiary Summary File (MBSF) flags each Medicare beneficiary for the presence of one of 27 specific chronic conditions.

What does this file include? (variable highlights)

  • Three flags for each chronic condition:
    • First occurrence date
    • Mid year indicator
    • End of year indicator

Special considerations

  • The algorithms used to assign the flags are available from the CCW website.
  • Algorithms requiring a multiple-year look back period are completed without requiring the researcher to order multiple years of data.
  • Algorithms search data from Medicare Fee-For-Service (FFS) claims.
  • The 27 CCW algorithms are being replaced with 30 CCW algorithms starting with CY 2017 data files. See individual variable pages for a description of how the algorithms impact specific variables and the Chronic Conditions File Enhancements white paper for more detailed information.
  • This file is a segment that can be requested in addition to the Master Beneficiary Summary File (MBSF) base file.
  • CCW will no longer produce the 27 CCW Chronic Conditions file after the 2021 calendar year data file.

Master Beneficiary Summary File (MBSF) Base

The MBSF base segment includes beneficiary enrollment information, (A/B/C/D). Medicare Advantage (Part C) and the Prescription Drug Program (Part D) plan enrollment information is included.

What does this file include? (variable highlights)

  • State, county annual SSA codes
  • State, county monthly FIPS codes
  • Zip code, State and County
  • Date of birth, date of death
  • Race
  • Reason for entitlement
  • Monthly enrollment for each part of the Medicare program, A/B/C/D
  • Dual eligible status
  • Part C plan and enrollment information
  • Part D plan and enrollment information
  • Part D low income cost sharing

Special considerations

Value Modifier NPI Practice-Level File

The Value Modifier (VM) NPI Practice-Level Research Identifiable File (RIF) includes one record for each eligible professional associated with a practice subject to the VM based on the given performance year. Using the RIF data, researchers can examine practice specialty composition, size, and practice changes across performance years.

What does this file include? (variable highlights)

  • Practice Identifier
  • Eligible professional NPI
  • Eligible professional subject to the VM
  • Provider specialty
  • No practice-level Quality and Resource Use Report (QRUR) or VM information (must link to VM Practice-Level RIF)

Special considerations

Part D Medication Therapy Management Data File

This file includes beneficiary-level information for participants in the Part D Medication Therapy Management (MTM) program, required of CMS Part D plans. Eligible beneficiaries include those enrolled in Part D plans with multiple chronic disease, those taking multiple Part D drugs and those likely to have expenditures exceeding a specified level as described by federal regulations.

What does this file include? (variable highlights)

  • Whether beneficiary met target criteria
  • Long term care residence
  • Number of drug-therapy recommendations made
  • Number of drug-therapy problems resolved
  • Linking variable

Why do researchers request this file?

  • Assess the effect of medication management on prescribing patterns and clinical outcome
  • Identify cost of illness impact of the Part D MTM program

Special considerations

  • All beneficiaries in the file were enrolled in MTM at some point during the year.  Not everyone in file received MTM services.

Part D Plan Election Type Beneficiary Summary File

This Medicare Part D file identifies beneficiaries covered by the Low Income Subsidy (LIS) program for Part D Plan enrollment. 

What does this file include? (variable highlights)

  • Part D Plan enrollment and disenrollment dates
  • Enrollment type, eg:  auto, facilitated, passive, point of sale
  • Months of LIS subsidy
  • Beneficiary self-selector indicator
  • Contract ID
  • Plan ID
  • Linking variables:
    • CCW Beneficiary ID: linkage to the PDE and all other CMS Medicare or Medicaid data files
    • Contract ID and Plan ID: linkage to the Part D Plan Characteristics file

Why do researchers request this file?

Special considerations

  • There is at least one record for every beneficiary enrolled in Part D during the year; there may be multiple records if more than one plan was elected during the year.
  • This file consists of two sub-files, Part D Plan Election File and Part D Re-Assignment File. When the Part D Plan Election Type Beneficiary Summary File is requested and approved, both sub-files are automatically delivered. The two sub-files link by CCW Beneficiary ID.

Part D Event (PDE) File

When a Medicare beneficiary with Part D coverage fills a prescription, the prescription drug plan submits a record to CMS. The PDE file includes all transactions covered by the Medicare prescription drug plan for both Prescription Drug Plans (PDPs) and Medicare Advantage Prescription Drug Plans (MA-PDs).

What does this file include? (variable highlights)

Why do researchers request this file?

  • Studies that include prescription drugs as a treatment of interest
  • Research comparing outcomes of treatment

Special considerations

  • These files do not have information on drugs given during hospitalizations or which are paid under other auspices (e.g., hospice)
  • If the Drug characteristics variables are selected during the request process, these are appended to the PDE.

Part D Formulary File

The Medicare Part D Formulary file is a suite of five sub-files: Formulary, Excluded Drug, Over-the-Counter Drug, Indication-based Formulary, and Part D Senior Savings (PDSS) Model that contain information on how the plan covers the prescription drugs filled (as described in the Part D Drug Event (PDE) file.

What does this file include? (variable highlights)

  • CCW Formulary Drug Identifier
  • Tier ID
  • Step Therapy Indicator
  • Quantity Limit
  • Prior authorization
  • Linking variables to the PDE file record:
    • Formulary Identification Number (in each sub-file)

Why do researchers request this file?

  • To examine differences in utilization based on formulary inclusion or restrictions
  • To examine plan differences in formularies

Special considerations

  • Linking variables provide information for each Part D Drug Event (PDE) record.
  • The Tier ID available in this file may be linked to the Plan Characteristics File.