SC HealthViz Definition of Key Terms

June, 2017 Data Tables:

Source Data: Data were pulled using IBM Corporation, Truven Health Analytics Inc., Advantage Suite® Version 3.0.3-850, Adhoc Report Writer. Enrollment and demographic information were derived from the SC Medicaid Management Information System (MMIS). The MMIS is an integration of computer systems that work together to process Medicaid claims and other pertinent information related to the management of the SC Medicaid Program. Note: After the implementation of the Affordable Care Act, changes in the way race information is collected and reported in the system has resulted in a greater proportion of missing race and county demographic information during recent years. 

Enrollment Notes: These data are current as of June 15, 2017 and have been separated into two categories, full and limited benefits. To minimize duplication, the year represents data for one incurred month during each state fiscal year. Duplication may still exist; as such, do not sum subtotals to obtain total membership. Caution should be taken when comparing preliminary 2016 enrollment to prior years. Due to recent changes in the SC Medicaid managed care program, the presentation of data is as of 2013. Eligibility definitions may shift from year to year, accounting for differences in current data to archived. 

Benefits & Services Notes: These data are current as of June 15, 2017 and represent claims paid through May 31, 2017. The year represents data for the state fiscal year (July 1 – June 30). These data do not account for 90 days of retroactive eligibility. Although generally administrative claims or enrollment data is of high quality, some issues with these data may exist due to miscoding or misclassification. Aggregate totals by demographic or plan type may not match overall totals due to confidentiality rules being applied, missing values, or the fact that some members may be represented in more than one category in a single fiscal year, such as having lived in two counties. 

Confidentiality Rules: Benefits and services data with a value of less than 10 do not provide sufficient information to ensure the health information privacy of SC DHHS Medicaid clients; therefore, these data were rolled up to 10.


DEFINITIONS FOR MEDICAID ENROLLMENT, MEDICAID BENEFITS AND SERVICES, AND QUICK FACTS


Age is the age of the person in years calculated as of January 1st for the year of eligibility. Age has been grouped into three categories for SC HealthViz: Children (ages 0-18), Adults (ages 19-64), and Older Adults (ages 65 and older). 

Behavioral Health patients are grouped under Major Diagnostic Codes 19 (mental diseases or disorders) and 20 (alcohol/drug use or induced mental disorders) OR have had a claim with a primary behavioral health diagnosis based on ICD-9 or ICD-10 codes.

Clinical Condition is the Truven Health Advantage Suite description for a clinical condition, based on valid ICD-9 principal diagnosis codes (for example, asthma, diabetes, coronary artery disease, or cerebrovascular disease).

County is the county description for the member’s place of residence as detailed on his or her eligibility form.

Dental Patients is the unique count of members who received professional services provided under dental coverage.

Dental Visits is the number of outpatient professional visits provided under dental coverage. The number of visits is based on the count of unique patient, service date, and provider combinations.

Diagnosis Related Group or DRG is the description assigned to inpatient admissions excluding the Present on Admission (POA) logic by the DRG Grouper software (CMS).

Emergency Department is defined as revenue codes: 0450-0459, 0981, OR place of service=23 (emergency room hospital), OR Healthcare Common Procedure Coding System (HCPS) codes associated with ED use: G0380-G0384, OR Current Procedural Terminology (CPT) codes for ED visit: 99281-99285.

Emergency Department Admissions is the number of emergency department facility visits resulting in an admission provided under medical coverage. The number of visits is based on the count of unique patient and service date combinations.

Emergency Department Patients is the unique count of patients being served in the emergency department. 

Emergency Department Visits is the number of emergency department facility visits provided under medical coverage. The number of visits is based on the count of unique patient and service date combinations. This includes both ED visits that resulted in an admission and those that did not.

Fee-For-Service represents the Medicaid population where the method in which health care providers are paid for each service performed and not through a capitated rate.

Full Benefits refers to individuals who are eligible for all services that are covered by SC Medicaid Program. 

Gender is the gender of the person (male or female) as reported on the member’s eligibility form. Recipients categorized as “Unknown Gender of the Unborn were excluded.

Incurred Fiscal Year is the fiscal year (July 1 – June 30) for the time period record. Medicaid enrollment is reported on an incurred basis, which means a member is counted even if he or she has not had a paid claim during the fiscal year reported. Enrollment is captured for only one incurred month of each year to represent a more accurate depiction of total membership at any given point in time.

Inpatients is defined as a patient receiving care in a hospital inpatient setting, place of service = 21, Inpatient Hospital. This does not include place of service code = 51, Inpatient Psychiatric Facility.

Limited Benefits describes certain categories of eligibility (COE) that have limited Medicaid Benefits, which means that individuals with those COEs are not eligible for all services covered by SC Medicaid. Some examples include women with family planning-only coverage and Qualified Medicare Beneficiary. 

Managed Care represents those clients enrolled in a managed care plan approved to enroll persons eligible for Medicaid. As of 2014, the majority of full benefits population in the SC Medicaid Program was enrolled in a managed care organization plan. 

Major Diagnostic Category or MDC is the Centers for Medicare & Medicaid Services standard description for the Major Diagnostic Category (MDC). MDCs are formed by dividing all possible principal diagnoses (from ICD-9) into 25 mutually exclusive diagnosis areas that correspond with a single organ system or medical specialty. DRG codes are grouped into MDC categories. 

Medicaid eligibility consists of full benefits assigned by aid category for Children, Elderly Adults, Disabled Adults, and Other Adults, or limited benefits assigned using by a variety of considerations. The limited benefits include family planning services, partial benefits, and emergency services, which includes services extended to special populations such as members of group homes and inmates. To read more about SC Medicaid eligibility, click here.

Members is the unique count of members with any coverage type. Each member is counted once regardless of their number of eligible months. A member becomes a patient when he or she has a claim for facility, professional, or pharmacy services.

Member Months is the sum of members by month with any coverage type. Each member is counted once for each month of eligibility.

Paid Fiscal Yearis the fiscal year (July 1 – June 30) for the time period record. The Medicaid Benefits and Services are reported in paid fiscal years, which mean that a claim for the specific benefit or service was submitted and paid during the fiscal year reported.

Patients is the unique count of members who received facility, professional, or pharmacy services. Benefits covered by SC Medicaid are detailed here.

Race is the client-specific description for the race of the person as reported on the member’s eligibility form. For SC HealthViz, race has been grouped into four categories: “White” (White/Caucasian), “Black” (Black or African American), “Hispanic/Latino” (Hispanic), or “Other” (all other race categories, missing, and other/unknown).