Managed Long Term Care

  • Part 1 also available in Portable Document Format (PDF, 593KB)

Medicaid Encounter Data Workshop

George Stathidis
Tiffany Tran-Lee
Division of Long Term Care
Office of Health Insurance Programs
November 13, 2013


  • Complete and accurate submission of encounter data for managed long term care enrollees is an essential process for all managed care plans. Medicaid encounter data (MEDS III) is used by the Department of Health for a variety of purposes including:
    • Risk-adjusted premium rate setting
    • Quality Incentive Calculations
    • QARR/HEDIS Reporting
    • Assessing clinical risk, evaluating quality, access and appropriateness of care
    • Service utilization and other research activities
  • Compliance outreach efforts are tracked to assure proper response

MLTC MEDS Workshop

Medicaid Encounter Data in MLTC Rate Setting

James Dematteo
Laura Grassmann
Bureau of Long Term Care Rate Setting
Division of Finance and Rate Setting
November 13, 2013


  • What is encounter data?
  • How is it used in MLTC risk rate development
  • Examples of problematic data

What is Encounter Data?

  • Encounter data provides detailed information on the services that managed care enrollees receive under the capitation benefit
    • Who received the service?
    • Who provided the service?
    • What service was provided?
    • Where the service was provided?
    • When was the service provided?
    • What was the cost of the service?

Goals of Encounter Data

  • Maintain a timely, accurate, complete and high?quality statewide Medicaid Encounter Data System
  • To provide the information necessary to set rates, monitor quality and predict future utilization of various Medicaid activities

General Reporting Requirements

  • Reporting is a contractual requirement
  • Data should be submitted on at least a monthly basis
  • Data must represent all covered services in the model contract
  • Data must represent all services processed since last data submission including new records, adjustments and prior rejected claims
  • Statement of deficiencies are issued for non?compliance

Plan Benefits of Encounter Data

  • Predictive modeling
  • Identifying members for care/disease management programs
  • Profiling the efficiency and quality of network providers
  • Evaluating financial contracts with network providers
  • Documentation for audits

Importance of Accuracy

  • The completeness of encounter data directly impacts the MLTC cost index and Payment Weights
    • Ensure that all data is accepted by eMedNY
    • Accurate completion of procedure codes and units
    • Complete nursing facility data
    • Acute care service reporting (PACE/MAP)

Risk Rate Development Process

  • Validate
  • Shadow Price
  • Acuity
  • Cost Index and Weights
  • Risk Score

Encounter Data Validation

Meds to MMCOR

  • PMPM cost data comparisons between Health plans submitted costs and MMCOR reported costs are conducted
  • Health plan results are then compared to determine which plans have sufficient reporting to be included in the development of the risk adjustment model and payment weight development

Shadow Pricing: Why we Shadow Price

  • In many instances, paid amounts are missing or zero on encounter records
  • Shadow pricing was developed to derive standardized costs to impute costs for service claim lines where paid amounts are missing or zero
  • This more accurately captures costs associated with MLTC services

Shadow Pricing: HHC/PC/Other MLTC

  • For Home Health Care, Personal Care and Other MLTC Services:
    • No lower or upper trim limit was applied
    • Encounters with zero paid amounts are 'shadow' priced with calculated means

Shadow Pricing: Nursing Facility

  • Nursing facility events submitted as inpatient are excluded
  • Nursing facility services are priced using a standardized price per day
  • Lower trim point of $137.50 (April/July 2012)
  • No upper trim applied
  • Fee mean per day of $252.51
  • Total cost is derived by multiplying the per day fee mean by the number of unique nursing facility days reported per enrollee


  • Statistical analyses are preformed using SAAM data combined with encounter records
  • The differences in PMPM cost between various elements are analyzed to determine which elements had a strong, positive statistically significant relationship with LTC costs
  • Final SAAM predictors are then assigned a score used to produce an enrollee's cost index (0?85) (April/July 2012)

Cost Index and Weights

  • The final 33 SAAM predictors (April/July 2012) are assigned a score using regression coefficients
  • Each enrollee is scored to produce the enrollees cost index (0?85) (April/July 2012)
  • Cost weights are then calculated using each enrollee´s cost index group, eligibility information and encounter data costs
  • Average cost PMPM for each cost index group is then calculated and the weight for each group is determined by dividing the average cost in the category by the overall average cost

Risk Scores

  • Recipient Risk Scores
    • Most recent SAAM assessment used for cost index calculation
    • A cost weight is assigned based on the enrollee´s associated cost index group
  • Nursing facility services are priced using a standardized price per day
    • Each enrollee´s member months are weighted using the cost weight and aggregated by health plan and region then weighted by months of enrollment for each health plan and region combination
    • A plan´s relative risk score is computed by dividing their raw risk score by a regional risk score (new plans receive a relative risk score of 1.0)
  • Lower trim point of $137.50 (April/July 2012)
    • Weight the raw plan risk score for each health plan in each region by MMCOR member months

Examples of Problematic Data

  • Individuals with chronic conditions and a low PMPM
    • Example - Dx of paralysis, quadriplegia or dementia shows a $200 PMPM
  • Enrollee´s with high units and low price or low units and a high price
    • Quadriplegia Dx (T1019) having 1 unit and a paid amount of $1,100
  • Plan ID is reported as the Vendor ID
    • Unable to identify and price encounters with HRA fee schedules for continuity of care policies


  • Summary of Methods Documentation
    • Located on the HCS under the Documentation link
    • Also located on the Mercer Connect website

Data Element Dictionary

Version 3.2
May 2012

Prepared by:

Provider Network - MEDS Compliance Unit
Bureau of Managed Care Fiscal Oversight
Division of Health Plan Contracting Oversight
Office of Health Insurance Programs
New York State Department of Health
Phone: (518) 474-5050
Faz: (518) 486-7899
HCS Home Page:



Service Utilization and Cost
Reporting Guide for Medicaid
Managed Care and
Child Health Plus
Health Plans


Version 1.2 (December 2012)

  • Mainstream Medicaid Managed Care Health Maintenance Organizations (HMOs)
  • Medicaid Prepaid Health Services Plans (PHSPs)
  • HIV Special Needs Plans (HIV SNPs)
  • Partial Capitation Managed Long Term Care (Partial MLTC)1 ∗
  • Program for All Inclusive Care for the Elderly (PACE)1 ∗
  • Medicaid Advantage Plus (MAP)1 ∗
  • Dual Eligible Medicaid Advantage (MA)
  • Partial Capitation Managed Care Plans (Partial Cap)
  • Child Health Plus

1 ∗ The MEDS III Submission and Reporting Guide for Managed Long Term Care Plans serves as an additional reference.