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Data Source(s): Due to the various data collection and reporting methodologies likely to be used by individual States, immunization coverage levels will not be directly

comparable across States. However, each State will measure its own progress, using a consistent measurement methodology.

The Health Plan Employer Data Information Set (HEDIS®), the Clinical Assessment and Software Application (CASA), and immunization registries provide standardized measurement of childhood immunization. HEDIS provides a plan-based measure of the care delivered to enrollees; it is the national standard in performance measurement for managed care organizations (MCOs). The HEDIS® Childhood Immunization Measure estimates the percentage of children in an MCO who received all of the appropriate immunizations by their second birthday. CASA is a public domain tool that was developed by the CDC for measuring immunization performance at the provider or clinic level.

Verification and Validation: The means for verifying and validating immunization data will vary from State to State, depending on the State-specific data collection methodology. A key part of the technical assistance provided by CMS and the CDC will include helping States address data reliability.

Number of States/ Territories

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Performance Goal MMA3-02

Provide to States Linked Medicare and Medicaid Data Files for Dually Eligible Beneficiaries

Discussion: Individuals who are dually eligible for Medicare and Medicaid are an important and growing population. In 2002, there were approximately seven million individuals dually eligible for Medicare and Medicaid at some point in the year. Although dually eligible beneficiaries represent about 17 percent of the Medicare population, they represent 30 percent of total Medicare expenditures. Similarly, while dual eligibles represent approximately 17 percent of the Medicaid population, they represent about 35 percent of total Medicaid expenditures.

Through continued innovation and reform in the Medicare and Medicaid programs, CMS hopes to foster a service delivery system that is better integrated and more flexible in meeting the needs of dually eligible beneficiaries. In order to do this, State Medicaid program administrators need information on their dually eligible populations.

States, as well as providers of care, are increasingly interested in assessing how well our programs respond to the needs of dually entitled beneficiaries. The CMS's development of a tool for matching State finder files against Medicare enrollment files will be of assistance to States to improve the efficiency and effectiveness of the acute and long-term care services received by persons eligible for both Medicare and Medicaid. States will be able to use data from the Medicare linked files to perform analyses that can improve the understanding of the program interactions between Medicare and Medicaid and how the interactions affect access to care, costs, and quality of services. For example, the dual eligible Medicaid/Medicare data will strengthen the ability of CMS and States to develop efficient and effective risk-adjusted payment methods for dual eligibles.

Coordination: The Department of Health and Human Services and CMS have worked together to develop CMS systems tools that will support matching of State finder files against Medicare enrollment and Group Health data, and provide that matched data back

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to States in a standard format. This effort has included collaboration with States to establish useful access to Medicare operational data.

Data Source(s): The joint Federal and State interest in dual eligibles has resulted in an examination of the data that are available to obtain knowledge about the demographic characteristics, health status, disease episodes, support services, health services utilization, and expenditures of this diverse population. The best and most current source for Medicare enrollment and Group Health data is the Medicare enrollment database (EDB). By matching current EDB data against State-submitted Medicaid finder files, CMS can provide States with accurate data identifying dual eligibles in their Medicaid populations. Based on these data, States can perform valuable analyses of their dual eligible populations. States can also then develop target populations for which they can request Medicare billing data. This combination of enrollment and Medicare billing data provides the States a powerful analytic base against which they can evaluate many aspects of dual eligibility.

Verification and Validation: All of the systems serving as sources are crucial operational systems that have built in quality assurance checks.

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Performance Goal MMA4-04

Assist States in Conducting Medicaid Payment Accuracy

Studies for the Purpose of Measuring and Ultimately Reducing Medicaid Payment Error Rates

Baseline: Prior to FY 2001, Illinois, Texas, and Kansas have independently developed methodologies to conduct State level Medicaid payment accuracy studies; no suitable methodology to produce national level estimates has been developed.

FY 2004 Target: Pilot test the CMS PAM Model in up to twenty-five States and develop the final specifications for the model; this model is expected to produce both State specific and national level estimates. This model was developed as a result of FY 2002 experiences and initially pilot tested with twelve States during FY 2003.

FY 2003 Target: Expand the PAM Program to twelve States. Pilot test the CMS PAM Model in all twelve of these States. Assess the FY 2002 nine State experiences and review final reports; collaborate with the States, The Lewin Group, and others in CMS and OIG to develop draft final specifications for the CMS PAM Model.

FY 2002 Target: Nine pilot States will conduct payment accuracy measurement studies. The CMS and The Lewin Group (contractor) will work with the pilot States, and assess Medicare and other Medicaid payment accuracy measurement experience to define several promising methodologies for testing in FY 2003 and 2004. Contingent upon the availability of special grant funds, we will solicit participation by up to 15 States in Year 2 of the pilot (FY 2003).

Performance: Goal met. Nine States have developed payment accuracy methodologies as part of their participation in the pilot study; final reports will be reviewed as part of the FY 2003 Target.

FY 2001 Target: Establish the feasibility of conducting pilot projects within States. We will work with two states to conduct payment accuracy studies. The preliminary data gathered from these two states would be used to help refine payment accuracy methodologies and assess the feasibility of constructing a single methodology that could be used by all States. Performance: Goal not met. Delays in receipt of funding to support State pilot studies and outside consultant assistance, and in soliciting State participation in the pilot, resulted in our not approving until late September 2001 the outside contractor and the initial group of pilot States.

Discussion: The CMS is committed to assisting interested States in developing methodologies and conducting pilot studies to measure and ultimately reduce Medicaid payment error rates. The purpose of this goal is to explore the utility and feasibility of conducting Medicaid payment accuracy studies in all States using a single methodology. No accepted methodology for Medicaid payment accuracy measurement (PAM) currently exists, and only a handful of States have done any work in this area. Those that have done so have all used different approaches, and none have addressed PAM in a managed care environment.

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During FY 2000, CMS, together with the American Public Human Services Association, established a National Medicaid Payment Accuracy Workgroup to help define, guide and coordinate this Federal-State collaborative project. Information was collected on the significant Medicaid payment accuracy studies conducted to date (by Illinois, Texas and Kansas), and discussions were initiated with several States that might be interested in participating in the pilot studies.

Resource constraints have proved a major obstacle to States conducting Medicaid payment accuracy studies. In order to support States in these activities, in FY 2001 and FY 2002, CMS requested funding from the "wedge" portion of the Health Care Fraud and Abuse Control (HCFAC) account; $2,552,000 was approved.

This program funding was used to retain a consultant to work on the project and to subsidize State participation in the first year of the demonstration project. The consulting contract was awarded in September 2001 to The Lewin Group. A letter requesting proposals was sent to all State Medicaid and Program Integrity Directors on July 3, 2001. The CMS approved funding for all nine States that applied: Louisiana, Minnesota, Mississippi, New York, North Carolina, North Dakota, Texas, Washington and Wyoming. The approved first-year budgets for the States total $3.6 million. The pilots will be 100 percent federally funded, with the participating States being reimbursed roughly $1.8 million of their costs through regular Medicaid funds and roughly $1.8 million from the HCFAC grant funds. The participating States will test various approaches to Medicaid PAM and work with CMS and The Lewin Group to maximize the collective learning.

The CMS anticipates expanding the pilot study to twelve States in the second year. FY 2002 HCFAC funds totaling $2,675,000 have been approved to subsidize this project during FY 2003. As in the first year, the HCFAC funding will be used to retain our consultant contractor and partially subsidize State participation. Our goal is to further develop, refine, and pilot test the CMS PAM Model that can be used to produce Statespecific and national Medicaid payment accuracy rates. During the second year of the project, we intend to pilot test the CMS PAM Model in all twelve States. The CMS and The Lewin Group will also develop draft final specifications for the CMS PAM Model to be pilot tested in up to twenty-five States in FY 2004.

Coordination: Coordination within CMS will occur to ensure that our relevant Medicare, Medicaid and program integrity staff work together and with the Office of Inspector General. The CMS will work closely with the pilot States, as well as with States collectively through the National Association of State Medicaid Directors. During the second year, The Lewin Group will be providing technical assistance to all twelve States pilot testing the CMS PAM Model.