hidden
hidden text

Medicaid

The US Medicaid program is a federal and state program that helps with medical costs for the lower-income cohort. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and personal care services.

 

The regulations and restrictions for Medicaid services vary by state. Each state has to regulate its own Medicaid program. Each of these state-based Medicaid programs still has to meet certain standards established by the federal government.

 
 
 

CMS and the federal government have set the following minimum requirements for the program:
  •   Family planning care
  •   Prescription drug costs
  •   Inpatient/outpatient hospital services
  •   Paediatric services
  •   Mental health care
  •   Occupational, speech, and physical therapy
  •   Dental healthcare and related service
A majority of Medicaid subscribers are enrolled in some sort of managed care program through Medicaid. Under this program, subscribers must pay a monthly premium. Poorer elderly individuals are more likely to use the basic fee-for-service (FFS) Medicaid program, while younger Medicaid recipients are more likely to use the managed care option.
 

 

hidden
hidden
This is a hidden content

Available States

So far, HMS has provided access to data from 9 states:

HMS datasets for Nevada and Colorado include claims for all Medicaid claims while the datasets for other states only include FFS claims.
The reported numbers on this page are the total count of Medicaid lives across different ranges of years (Mostly between 2015-2019) based on the HMS internal report. The data available for research might be slightly different.
 
 
 

Data

For each state, there are 4 types of claim data and two information datasets:

 

Institutional: This file contains data items from institutions such as hospitals (including emergency room and one-day surgeries) and other facilities (nursing facility, long term care, federally qualified health centres, dialysis clinics, etc.). The data fields in this file are those that are billed using the “UB04” (CMS-1450) paper claim form or (ANSI X12 837I version 5010) electronic form. UB04 contains “header” information about the provider, patient, and the presenting diagnosis and conditions – as well as (for inpatient claims only) the ICD10 procedures. In addition to the header information, the UB04 also contains detail lines that itemize the service charges (including drugs, prosthetics, operating room, anaesthesia, etc). The detail lines are organized by “Revenue codes” which describe the category of the charge. So, for instance, Revenue Code 250 is for drugs. In most cases, this is all the information that is on the line, but in some cases, there are procedure codes (CPT-4 and HCPCS) that provider further detail on the type of service being billed for on the line.

 

Medical: This file contains information about professional type charges, which are billed on the (CMS 1500) paper form or (837P version 5010) electronic form. This has some header information about the provider and patient, and detail lines for each service rendered. Services are described by means of CPT-4 and HCPCS procedure codes and contain the units billed for each one. The form also contains diagnosis codes.

 

Pharmacy: This file contains information about the drugs that were billed to Medicaid. Most outpatient drugs (from a pharmacy) are billed electronically using an NCPDP standard layout. The key fields for pharmacy are the National Drug Code (NDC) which describes the exact drug, units billed, and days-supply.

 

Dental: Dental Claims are usually billed on (ADA J400) paper form or (837D version 5010) electronic form but contain an extra set of fields that describe the tooth-number.

 

Eligibility: This dataset contains information about the recipients of services including age, gender, race, ethnicity, language, marital status, etc. and the reasons why they are eligible to receive Medicaid services.

 

Provider: This dataset contains information about the providers of medical services including provider’s type, specialty, county, address, etc.
hidden
hidden
hidden text

Accessing Data

DHCRC and HMS have agreed to collaborate to provide an effective means of giving researchers and students access to HMS Medicaid Data. HMS has housed the Data in a secure instance of Amazon Web Services in the United States. Data would be available to researchers and students for the performance of Academic and Non-Commercial Research Purposes. The access is through an interface provided by RONIN which allows for simple management of cost and  AWS resources.

 

HMS and DHCRC do not charge for the data, however, all charges payable by DHCRC or HMS associated with providing the data will be passed on to the users. The links below contain the research agreement form, data agreement form and data request form required for accessing the data.  For further information, please contact [email protected].

Research Usage Agreement

Data Usage Agreement

Data Request Form

Subscribe to our newsletter