As of June 2020, the Colorado All Payer Claims Database (CO APCD) contained nearly 920 million claims for approximately 65 percent of insured individuals in Colorado with medical coverage, reflecting over 3.4 million lives. When those with dental and pharmacy coverage are added, the CO APCD spans over 5 million unique lives with information from over 40 commercial health insurance plans, including Medicare Advantage and voluntarily submitted Employee Retirement Income Security Act (ERISA) and mandated non-ERISA self-insured employer plans, Medicaid, and Medicare Fee-for-Service (FFS) claims. The CO APCD does not contain claims for people covered by Federal health insurance programs such as the Veterans Administration, TRICARE federal employees, or Indian Health Services, and does not include information for uninsured Coloradans.

This is the final installment of a series focusing on CO APCD data submitted by payer line of business – commercial health plans, Medicaid, and Medicare. The data in each line of business has different nuances that are helpful to be aware of when using the CO APCD.

Medicare Advantage vs. Medicare Fee-For-Service

When we talk about Medicare claims, it’s important to specify which type we are talking about. There are two types of Medicare coverage: Medicare Fee-For-Service (FFS), or traditional Medicare, and Medicare Advantage which can be purchased and is administered through commercial health plans. CIVHC is one of the few organizations that collects and is able to release data on both types.

The difference comes in which services each plan covers. There are four central parts to Medicare plans:

Part A Provides inpatient/hospital coverage
Part B Provides outpatient/medical coverage
Part C Also known as Medicare Advantage, the alternative way to receive coverage for Part A and Part B
Part D Prescription drug coverage

Under Medicare FFS, which is administered by the Centers for Medicare and Medicaid Services (CMS), parts A and B will be covered and you have the option to join a separate program to receive part D coverage. There are also options to purchase supplemental Medicare FFS to cover portions care outside of regular FFS coverage. Medicare Advantage is considered a “bundled” plan, which includes parts A, B, and D and sometimes includes additional benefits such as vision, hearing, and dental coverage. Some of the common types of Medicare Advantage plans are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Private Fee-For-Service (PFFS).

The payment process between the plans is also different. While Medicare FFS is paid directly through the federal government, under Medicare Advantage, private plans contract with the government and receive funding for enrollments through CMS.

 

Medicare FFS Claims Collection in the CO APCD 

CIVHC operates through two different programs to request Medicare FFS data. CIVHC first began collecting Medicare FFS claims data in 2014 through the State Agency Request Program, which allows access to de-identified Medicare FFS data only for non-public analyses to serve the state in identifying trends and patterns in health care delivery.

In 2019, CIVHC became one of only a handful of nationally approved organizations to use Medicare FFS data through the Qualified Entity Certification Program. Under the program, CIVHC is required to combine Medicare FFS data with Medicaid and Commercial data to produce public reporting on provider performance, and is able to provide stakeholders actionable data to improve quality of care. For more information on release rules around Medicare FFS data, visit our FAQ.

Medicare FFS Release Schedule Variation 

Medicare FFS claims for medical and pharmacy are submitted on an annual as opposed to a monthly basis for all other payers. As a result, Medicare FFS claims are not available for the complete time period displayed in the CO APCD Insights dashboard and are currently only available in the dashboard through December 2019 for medical claims and December 2018 for pharmacy claims. Similarly, Medicare FFS eligibility records are available through December 2019 only. Medicare FFS does not offer dental coverage and therefore it is not available as a coverage type for Medicare. For more information about what’s currently available in the CO APCD (paid through dates), click here and download the “CO APCD Paid Through Dates” document under the Resources tab.