Can managed care services be studied with the CMS Medicaid claims data files?
Historically, the states have not been required to report managed care encounters to CMS. There are 2 approaches to identifying Medicaid beneficiaries who were covered under a managed care plan. The Personal Summary File indicates if a beneficiary was in a managed care plan with coverage purchased by the state, and this information is indicated for each month. Primary Care Case Management plans are not included in the indicator since these services are paid fee for service. It may be necessary for other types of plans to determine if the managed care is medical, dental, transportation or some other form. This information can be obtained by examining claims in the Other Therapeutic Claims file. Claims with a Type of Service = ’20’ (premium payment) indicate beneficiaries covered by a managed care plan, and the corresponding managed care plan number can be found in the Provider Number field. Details on the specific type of service could then be obtained from a state listing of provider n
