Brief Issue Description
This best practice document outlines the challenges states have faced when reporting the types of managed care plans in the T-MSIS Eligible file record segment MANAGED-CARE-PLAN-TYPE-ELG00014 using the data element MANAGED-CARE-PLAN-TYPE. States should use this record segment to report all managed care plans in which a beneficiary is enrolled.
Background Discussion
Context
When a beneficiary is enrolled in more than one managed care plan, the state should report a record segment for each. The state should populate this data element with the managed care plan type code that corresponds to the managed care plan in which the beneficiary is enrolled. Although MANAGED-CARE-PLAN-TYPE is a legacy Medicaid Statistical Information System (MSIS) data element, states should take care when populating the data element. The number of managed care plan types that states can report has expanded in Transformed MSIS (T-MSIS). CMS performs edits to validate that the managed care plan type reported on the Eligible file matches the managed care plan type value reported on the Managed Care file. In addition, checks will be performed to confirm that the managed care capitation payment type of service values and managed care encounter types of service reporting are consistent with the managed care plan type.
Challenge
Three potential challenges have been identified in reporting managed care plan type values. The first challenge is reporting managed care plan types consistent with the T-MSIS database requirements. In MSIS, each beneficiary record included all information that could be related to a beneficiary’s enrollment. This required populating managed care plan type fields even when the beneficiary was not enrolled in a managed care plan. In T-MSIS, managed care plan information is populated only when a beneficiary is enrolled in a managed care plan. The second challenge is ensuring that the managed care plan type on the Eligible file matches the managed care plan type reported in the Managed Care file. States reporting Managed Care files and Eligible files with conflicting managed care plan types for the same plan ID will not be validated. The third challenge is identifying the appropriate managed care plan type for the plan in which the beneficiary is enrolled. The benefits covered by a managed care plan could potentially encompass multiple managed care plan types, such as a health maintenance organization providing coverage for behavioral health.
CMS Guidance
States should review how they populate the managed care plan type in their T-MSIS files to confirm that they report the data appropriately. A beneficiary should have a record for each managed care plan in which they are enrolled, reported on the MANAGED-CARE-PARTICIPATION segment (ELG00014). If the beneficiary is enrolled in two managed care plans, then that beneficiary will have two MANAGED-CARE-PARTICIPATION (ELG00014) record segments reported in the Eligible file, one for each managed care plan. If a beneficiary is enrolled in the same plan during different periods, then a record with the managed care plan type must be recorded for each of the time spans in which the beneficiary was enrolled in that managed care plan. Finally, states should ensure that the value reported for MANAGED-CARE-PLAN-TYPE matches the managed care plan type for that plan ID reported on the Managed Care file. If these do not match, it will cause an editing error on the state’s file submission.