Can I identify Medicaid beneficiaries who are eligible due to a waiver program using Medicaid Analytic eXtract (MAX) service (claims) records?
Identifying waiver enrollees through service records has many potential pitfalls. In general, it should be noted that not all states correctly report claims for services provided under waivers. There are at least four major issues:
(1) Some states may not submit claims for all waiver services,
Also, not all persons enrolled in waiver programs use waiver services.
For 1999 and later
For MAX 1999 (and later) data, the claims data element “Program Type” has two code values to identify waiver services:
6 = Home and Community Based Care for Disabled Elderly and Individuals Age 65 and Older - Section 1915(d)
7 = Home and Community Based Care Waiver Services – Section 1915(c)
Attachment 5, Program Type Reference, to the MSIS instructions to states provides definitions for each of these code values: States are to code 1915(d) waivers as type 6 and 1915(c) as type 7 waivers. However, as a practical matter, most states did not differentiate between 1915(c) and 1915(d) waivers. To the extent that states actually reported waiver services in this way, most used only one of the two values (either 6 or 7, regardless of the types of home and community based waivers they had). So, when using the program type variable to identify waiver services, it is best to use both values 6 and 7. It should be noted that this categorization does not identify the specific waiver under which a service is delivered.
As noted above, the reporting of waiver services has been incomplete. There has been improvement, but not all states are reporting waiver services and many states may be including only some of their waiver services in MSIS or only identifying a subset of all waiver services as waiver services via the “Program Type” codes (as of August, 2004). For reasons that are unclear, some enrollees who are identified as waiver enrollees appear to never receive services through the waiver. There are several possible reasons: services are not reported, services are not identified as waiver services, some enrollees die before they receive any waiver services, or they did not actually use services.
It is possible that waiver services could be identified from state-specific procedure (service) codes that were in use prior to HIPAA implementation (in April, 2004) and sometimes in use after HIPAA implementation. However, this approach would be tedious, resource-intensive and would vary from state to state because codes may vary from state to state and perhaps across years within a state.
In particular, since some services provided through a waiver could also be provided to non-waiver enrollees under state plan provisions (e.g. personal care), using procedure or service codes may not precisely identify waiver recipients.
In summary, it may be very difficult to develop a consistent approach to identify either waiver enrollees or waiver services prior to 1999. Beginning in 1999, the expansion of eligibility codes to include Section 1115 waiver enrollees should improve reporting for these waiver enrollees. Also, addition of the “Program Type” data element should remove some of the ambiguity in MSIS reporting requirements. However, there may still be inconsistencies in the reporting of waiver services. The addition of Waiver Type and Waiver ID data elements in Fiscal 2005 should greatly improve identification of enrollees in Section 1115, 1915(b) and 1915(c) waivers.