Task 1: Medicare: Sources and Structure of Linked Datasets

Medicare enrollment and fee-for-service (FFS) claims data are available for NCHS respondents who are considered linkage eligible and matched to the CMS Denominator file. To link the NCHS survey respondents with their Medicare data, the following identifiers were used: Social Security Number (SSN), date of birth (month, day, year), and sex. To be considered a successful match, the NCHS survey respondent’s record needed to match exactly to the CMS Denominator file on all three items listed above. CMS provided NCHS with Medicare FFS claims data for all successfully matched NHANES participants. CMS also provided Medicare Part D prescription drug event data to NCHS, beginning with the onset of the Part D benefit in 2006. Refer to Course 1, Module 4, Task 2 “Years of NHANES-CMS linked data” for the range of NHANES and CMS years of data that are linked.

The CMS claims files linked to NHANES data are all finalized claims files. These files are generated from raw claims through final action algorithms that match the original claim with adjusted claims to resolve any adjustments. Finalized claim files are available from CMS approximately nine months into the following calendar year (for example: 2007 data will become available in September of 2008). The files are annual and are available for Part A (inpatient, outpatient, Skilled Nursing Facility, hospice, or Home Health Agency) and for Part B (Carrier, Durable Medical Equipment).

The files contain information collected by Medicare to pay for health care services provided to a Medicare beneficiary.  There is one record in the file for each claim (note some episodes of care include more than one claim). 

Available Linked Data Sets

The following is a list and description of Medicare files that have been linked with NHANES. 

Diagram: NHANES-Medicare Linked Data Structure

View text version of Diagram

Denominator Files

Denominator File: The Denominator File contains basic demographic and enrollment information about each beneficiary entitled to Medicare during each calendar year and is needed to construct an analytic data file, particularly to identify Medicare beneficiaries enrolled in a Medicare Part C plan. Medicare Part C plans are also referred to as Medicare Advantage (MA) and include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. 

Part D Denominator File: The Medicare Part D Denominator File contains demographic and enrollment data, with additional Part D enrollment data, for each beneficiary enrolled in Medicare during the calendar year.

Summary Files

Chronic Condition Summary File: The Chronic Condition Summary File is used to indicate the presence of the 21 Chronic Condition Warehouse condition indicators for all beneficiaries.

Summary Medicare Enrollment and Claims (SMEC) File: The SMEC files, created by NCHS, were designed to be used for analyzing Medicare cost and claims data from multiple Medicare service files. 

Claims Files

Home Health Agency (HHA) Claim File: The HHA Claim File contains claims data submitted by HHA providers.

Hospice Claim File: The Hospice Claim File contains claims data submitted by hospice providers.

Outpatient Claim File: The Outpatient Claim File contains claims data submitted by institutional outpatient providers.

Medicare Provider Analysis and Review (MedPAR) and Skilled Nursing Facility (SNF) Files: The MedPAR Hospital and SNF Files contain inpatient hospital and skilled nursing facility (SNF) stay data. An inpatient "stay" record summarizes all services rendered to a beneficiary from the time of facility admission through discharge.

Carrier Claim File: The Carrier Claim File (previously referred to as the Physician/Supplier Part B file) contains claims data submitted by non-institutional providers.

Durable Medical Equipment (DME) Claim File: The DME File contains claims data submitted by DME regional carriers to CMS.

Part D Drug Event (PDE) File: The PDE File contains prescription drug costs and payment data that enable CMS to make payments to the plans and otherwise administer the Part D benefit.