Frequently Asked Questions

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How good is the quality of encounter records for persons enrolled in prepaid plans (HMOs, HIOs, PHPs, etc.) in the Medicaid Statistical Information System (MSIS) and Medicaid Analytic eXtract (MAX)?

First, enrollment data for persons in prepaid plans should be complete and should identify the months of enrollment in prepaid plans. In addition, “claim” records for premium payments should be complete and consistent.  Many Medicaid eligible individuals receive care from both fee-for-service systems and prepaid plans.  This is because many Medicaid eligible individuals who are enrolled in comprehensive plans (e.g. Health Maintenance Organizations - HMOs and Health Insuring Organizations - HIOs) often have plan carve-outs for selected services, such as prescription drugs.  Also many other Medicaid eligible individuals are enrolled in Prepaid Health Plans - PHPs which cover a limited array of services, such as behavioral health, dental or other services.  The record of services provided through fee-for-service providers should be reasonably complete for prepaid plan enrollees. However, the same is not necessarily true for service utilization data provided under prepaid managed care plans and represented by encounter records in each of the four MAX claims files.  Although the completeness and quality of reporting of encounter records for these eligible individuals has varied substantially across states and years, it has been improving.  Under a previous MAX contract, we provided technical assistance to a number of states to help them improve encounter data reporting in MSIS.  Information about that work and related reports can be found here.  In addition, several useful reports and issue briefs that analyze the completeness and accuracy of encounter reporting in MSIS are available here.   

Users should note that these same limitations do not apply for eligible individuals receiving care from Primary Care Case Management (PCCM) plans because care delivered to persons in these plans is usually reimbursed through fee-for-service systems.


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