OTHER ENROLLMENT FILES

The Other Enrollment Files group contains five files:

• TPEARTH Master File
• GHP Master File
• HISKEW File
• Denominator File
• Name and Address File

The TPEARTH Master File contains a history of third parties liable for a beneficiary's SMI or HI premiums. The GHP Master File contains information on beneficiaries who are or have been enrolled in a Managed Care Organization. The HISKEW File, like the EDB, contains data for all beneficiaries ever enrolled in Medicare. However, the HISKEW File contains a subset of the data elements contained in the EDB. The Denominator File combines EDB beneficiary information from the EDB and third party liability information from the TPEARTH Master File. The Name and Address File is a subset of the data elements of the EDB.

Third Party (TPEARTH) Master File

The Third Party Master File, or TPEARTH Master File, contains records for Medicare beneficiaries for whom HI or SMI premiums are paid by a third party such as a state welfare agency or private group. This file supplements the beneficiary data maintained on the EDB. The TPEARTH Master File is used to update the EDB with information on the dual entitlement status of beneficiaries (those who are eligible for both Medicare and Medicaid) and to flag premium payer status.

File Creation

The TPEARTH Master File contains data from 1966 to present for active beneficiaries and data for inactive accounts from 1990. Inactive data are retrieved and added to the active file if there is subsequent activity for that account number. The file contains records for all Medicare beneficiaries who have ever had a third party identified as the payer of their HI or SMI premiums. The information in the TPEARTH Master File is collected by SSA field offices, state welfare agencies, private groups, and the Office of Personnel Management (OPM). The collected data are sent to CMS for monthly updates. As updates are posted to the TPEARTH Master File, a series of validation edits are performed. Most of the 5.7 million active individuals tracked by the TPEARTH Master File are Medicare beneficiaries with dual entitlement. Approximately 100,000 other beneficiaries are civil servants for whom Medicare Part B premiums are withheld by OPM from retirement annuities. Another 11,000 beneficiaries have their Medicare Part A or Part B premium paid by a private group.

File Maintenance

The TPEARTH Master File is updated monthly with data received from SSA, state welfare agencies, private groups, and OPM. A small number of updates are completed at the CMS central office; however, most updates are received via electronic data transmission from states. Once monthly updates are applied to the file, a billing file is sent to each state. Edits are performed on each transaction as updates are made to the TPEARTH Master File. For example, state buy-in transactions are checked against the EDB to verify that the transaction is valid. If a state submits a record with data that cannot be verified by the EDB, the record is corrected using EDB data. If the record cannot be corrected, it is rejected and returned to the state for correction.

File Structure and Usage

The TPEARTH Master File contains records for beneficiaries for whom HI or SMI premiums are or have been paid by a third party. Third parties include state welfare agencies, OPM, religious orders, and private group payers such as unions. Beneficiaries are identified by HIC number and dates of enrollment and disenrollment. The unit of analysis is the beneficiary. Each beneficiary can have up to two records on the file: one each for Part A and Part B premiums. In 1994, all inactive beneficiaries were purged from the file. Since then, no beneficiaries have been purged from the file. CMS uses the TPEARTH Master File to track third party enrollment and to bill states and private groups accordingly. Dual entitlement status information contained in the file of beneficiaries is used to update the EDB. The file is also used to update the membership file for those GHPs that interact directly with CMS to obtain reimbursement for each dually entitled plan member entitled to Part B coverage.  

Data Structure and Usage

The TPEARTH Master File is a flat file comprised of over 10.5 million variable length records. Each record contains beneficiary identification information, third party history, and accounts receivable information. Beneficiary identification information includes name, sex, and date of birth. Third party history information includes agency codes, and third party accretion and deletion codes and dates for up to 40 occurrences. Third party administrative information includes premium amount and transaction codes, dates, and agency identification number. The TPEARTH Master File identifies individuals by HIC number and dates of third party accretion and deletion so that longitudinal files can be created. The data are used internally by CMS to bill agencies for Part A and Part B premiums. The TPEARTH Master File is used to determine Medicaid status in the GHP Master File.

Methods of Access

The TPEARTH Master File is available on cartridge. Specialized versions of the TPEARTH Master File are available on request.

Migration of Data

In the future, third party beneficiary data will be incorporated into the EDB. When the data are added to the EDB, the amount of duplicate data maintained by CMS (such as name and HIC number) will be reduced. However, only beneficiary-specific data will be added to the EDB. Other data, such as agency data, will continue to be maintained in separate files. Once the third party information from the TPEARTH Master File is stored in the EDB, it will be accessible in the same way as other EDB data. As part of the transition to this future processing environment, CMS operates the SMI Premium Accounting, Collection, and Enrollment (SPACE) System Database. This M204 database replicates the data maintained in the TPEARTH Master File. The SPACE Database resides at HDC. It is updated monthly to reflect any changes made to the file. Online access to the SPACE Database is available to organizations within SSA and CMS.

List of Data Elements

A list of the data elements contained in the TPEARTH Master File, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov.

Group Health Plan (GHP) Master File

The GHP Master File contains information for all beneficiaries who have ever been enrolled in an MCO under contract with CMS. For beneficiaries enrolled in MCOs, Medicare benefits are not paid per claim. Instead, Medicare pays a per capita amount to MCOs for each enrolled beneficiary regardless of beneficiary service utilization. The GHP Master File supplements beneficiary information maintained in the EDB.

File Creation

The GHP Master File contains data on beneficiaries who are currently enrolled or have ever been enrolled in a MCO under contract with CMS. The file is created by writing off a version of the GHP Database each month, after it has been updated by MCO data transmissions related to enrollment, disenrollment, and corrections to some beneficiary characteristics.

File Maintenance

Since the GHP Master File is a monthly write-off of the GHP Database, the data contained in the file are updated when the GHP Database is updated. The GHP Database is updated with new beneficiary information through the following process:

• ;An MCO transmits batch enrollment/disenrollment/correction data to the GHP Database.
• An online system allows selected users to enter managed care enrollment/disenrollment/ correction data into the GHP Database.
• The EDB is queried when a beneficiary is new to Managed Care.
• The EDB Medicare enrollment, entitlement, and demographic data are sent to the GHP Database for that beneficiary.
• The GHP updates the EDB with MCO enrollment data.
• The CWF Health Insurance Master Record (HIMR) is updated with the new GHP data from the EDB.

File Structure and Usage

The GHP Master File includes basic beneficiary identification data, Part A and Part B entitlement information, and current MCO membership information. Each record represents one beneficiary and each beneficiary has one record. The GHP Master File can be used to study beneficiaries who are currently enrolled in CMS contracted MCOs.

Data Structure and Usage

The GHP Master File consists of approximately 10.5 million variable length records. The records contain information for up to six of the most recent managed care enrollment periods for all beneficiaries ever enrolled in a MCO. However, it does not include dates for ESRD, hospice, institutional, or state buy-in entitlement (factors used in determining the capitation payment). Each record contains beneficiary identification data such as the HIC number, date of birth, date of death, name, and state and county codes; current Part A and Part B enrollment options and entitlement information; and managed care enrollment information such as dates of membership and MCO contract number.

Methods of Access

Monthly versions of the GHP Master File are available on compressed cartridges. Additional information about the GHP Master File can be obtained by contacting the CHPP, PDIG, HPPOS Plan Communications Action Desk at (410) 786-7613.

Migration of Data

The beneficiary-specific enrollment data maintained in the GHP Database has been migrated to the EDB. It is possible to retrieve the information currently provided by the GHP Master File as a view of EDB data using the EDBW.

List of Data Elements

A list of the data elements contained in the GHP Master File, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov.

Health Insurance Skeleton Eligibility Write-off (HISKEW) File

The HISKEW File is a subset ("skeleton") of the data elements of the EDB, but, like the EDB, it contains data for every beneficiary ever entitled to Medicare. The HISKEW supports tabulation of enrollment data for program statistical reports and matches of enrollment to utilization data for the extraction of beneficiary cohorts. The HISKEW that is created from the end- of- March data for each year from 1989 can be accessed through the DSAF. The current quarter is available to registered users on robot access. Other quarters from 1989 to the present are available on magnetic tape.

File Creation

The HISKEW is created quarterly from the UEDB, which is a sequential file version of the EDB that is created at the end of each month from the EDB. The HISKEW is created from the last monthly UEDB of each quarter and, with rare exceptions, contains data through the last Friday of each quarter. The HISKEW data for the quarter are usually available within a few days after the end of the quarter.

File Maintenance

File Structure and Usage

The current HISKEW is created from the UEDB and follows its file structure. Both the HISKEW and the UEDB are arranged into 10 segments, from 0 through 9, depending on the eighth digit of the Social Security Number. Within each segment the records are arranged in ascending HIC number sequence. Prior to the third quarter (September) of 1992, the HISKEW was derived from a different source. Arranged into 10 segments, the segments were organized sequentially in ascending HIC number sequence from the beginning of the first segment through the end of the last segment. Division into segments was by an arbitrary account number. The segments were not all the same size. Before the third quarter of 1992, there was also a quarterly "Inactive" HISKEW, which contains the data of beneficiaries who have been dead for at least six months and have had no activity on the account for at least six months. (See Data Structure and Usage for data details.) All HISKEW files are fixed block and have fixed-length records. The record length as of the third quarter of 1992 is different from the previous HISKEW version. CMS uses the HISKEW to prepare enrollment tabulations that detail the number and characteristics of Medicare beneficiaries by state and county of beneficiary residence.

Data Structure and Usage

The HISKEW contains one fixed-length record for each of the 80 million Medicare beneficiaries and approximately 160 million records that cross-reference HIC numbers and the Beneficiary's Own Account Number (BOAN). The cross-reference records contain only the cross-referenced HIC number and/or BOAN, the HIC number of the full record where the beneficiary's data is located, and the control character 4 in both the Part A and Part B termination code locations. The rest of the cross-reference record is blank. Fields in the record are in display format. There are no binary or Comp-3 fields. The data contain personal identifiers and other material covered by the Privacy Act and, therefore, require authorization for use. The HISKEW is arranged into 10 segments, from 0 through 9, depending on the eighth digit of the HIC number. In each segment, the records are arranged in ascending HIC number sequence. The current HISKEW is created from the UEDB and follows its file structure. Prior to the third quarter (September) of 1992, the HISKEW was derived from a different source. Although HISKEW files created before and after the third quarter of 1992 contain substantially the same data, there are some differences in the new HISKEW as noted in the following list:

• Record length is 170 characters not 120.
• All dates are eight characters in CCYYMMDD format.
• First cross-referenced Social Security Number is on the full record not on a cross-referenced record.
• ZIP Code is nine characters not five.
• Names and content of certain codes have changed or been deleted.
• Certain fields have been moved into more logical groupings. Prior to the third quarter of 1992, there were "Active" and "Inactive" versions of the HISKEW. (See File Structure and Usage for file details.)

The Inactive HISKEW has the same format as the Active version but contains the data of beneficiaries who have been dead for at least six months and have had no activity on the account for at least six months. From 1988 until 1992, no new accounts were put on the Inactive HISKEW, but those accounts that showed some activity were migrated to the Active HISKEW. The Inactive file thus declined in numbers from a high of 15.5 million in 1988. During June, July, and August of 1994, all remaining Inactive accounts were migrated to the EDB. During the period of time between the third quarter of 1992 and the third quarter of 1994, an unsuccessful search on the HISKEW could be continued on the Inactive HISKEW of the second quarter of 1992, the final Inactive HISKEW. From the third quarter of 1994 and, thereafter, an unsuccessful search of the HISKEW means that the account is not on the files.

Methods of Access

The current HISKEW File is available to registered users on robot-accessed magnetic tapes. Each quarter is replaced by the current quarter's data within a few days after the end of that quarter. Prior quarterly versions are available on magnetic tape from 1985 to the present. The HISKEW can also be accessed through the DSAF, a menu-driven system for retrieving data from a variety of claims, utilization, and enrollment files and databases. Data can be selected by HIC number, specific data field combinations, or specific percentage of records. The HISKEW File is also available as an Beneficiary Encrypted File (BEF) and is described in the Beneficiary Encrypted Files Data chapter.

Migration of Data

When the CMS enrollment data systems environment changed from the HIMA processing environment to the EDB environment in 1992, the HISKEW file and data formats also changed.

As of the third quarter of 1992, the HISKEW is organized into 10 segments by the eighth digit of the HIC number, and each segment is in ascending HIC number sequence. The prior HISKEWs are organized into 10 segments that were fixed at an arbitrarily-chosen point (a HIC number) in the past; all the HIC numbers are in ascending HIC number from the first HIC number in the first segment through the last HIC number in the last segment. The segments of HISKEW created before the third quarter of 1992 are not uniform in size. (See File Structure and Usage for details.)

In the data format, a century indicator was added to all dates. In addition, some codes for entitlement have changed or are no longer available; two fields, a nine-character SSN and an eight-character beneficiary residence change date, have been added. (See Data Structure and Usage for details.)

Before 1988, an Inactive HISKEW was created from the Health Insurance Inactive Master (HIIM), which contained accounts of persons who had been dead at least six months and had no activity on the accounts for at least six months.

From 1988 until the creation of the last Inactive (HIIM and HISKEW) files in the second quarter of 1992, no new accounts were added to the Inactive files, but accounts that did show activity (possibly because of late entry/lag items) did migrate to the Active files.

During June, July, and August of 1994, all remaining Inactive accounts were incorporated into the EDB and, as a result, appear in HISKEW.

Between the third quarter of 1992 and the third quarter of 1994, an unsuccessful search on the HISKEW could be continued on the Inactive HISKEW of the second quarter of 1992, the final Inactive HISKEW. From the third quarter of 1994 and, thereafter, an unsuccessful search of the HISKEW means that the account is not on the files.

List of Data Elements

A list of data elements contained in the HISKEW File, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov.

Denominator File

The Denominator File combines Medicare beneficiary entitlement status information from administrative enrollment records with third party payer information and MCO enrollment information. The Denominator File contains data on all Medicare beneficiaries with entitlement in a given year. Like the HISKEW File, it is an abbreviated version of the EDB. It does not, however, contain data on all beneficiaries ever entitled to Medicare; it contains data only for beneficiaries who were entitled during a particular year.

File Creation

The Denominator File is a skeleton enrollment file derived from the UEDB and the TPEARTH Master File. The UEDB provides beneficiary entitlement data and periods of MCO enrollment. The TPEARTH Master File is used to annotate Part B state buy-in beneficiaries in the Denominator File.

The Denominator File is created in April for the previous calendar year, allowing a three-month lag for update transactions to occur. The cut-off date for data is generally the last Friday in March. The file is available for calendar years 1984 to the present. The following processing occurs to create the Denominator File.

Beneficiaries with any entitlement during the year are selected from the UEDB and are sorted by HIC number. The entitlement dates are converted to monthly indicators and the total months of HI, SMI, and MCO coverage are calculated for each beneficiary.

The information from the UEDB and TPEARTH Master File is combined. If a beneficiary's buy-in agency is identified as the state, the periods covered are converted to monthly indicators. Buy-in indicators are omitted if the beneficiary was not entitled during the month, and buy-in periods are deleted if the beneficiary was not selected from the UEDB as an individual entitled to Medicare during the year. The total number of months of buy-in or MCO coverage are computed.

When the Denominator File is created, OIS generates a table containing the distribution of beneficiaries by demographic characteristics such as age, sex, race, and Medicare status code. These counts are used to compare file data from one year to another, to show trends in the data, and to identify data anomalies. For example, the 1993 Denominator File contained data for beneficiaries with a Medicare status code of 10 who were not age 65. The problem has been remedied.

File Maintenance

Maintenance of the Denominator File is discussed under File Creation. The data from the UEDB and TPEARTH Master File are validated prior to their use in creating and updating the Denominator File.

File Structure and Usage

The Denominator File captures enrollment and entitlement information, including third party and GHP information, for all beneficiaries who are entitled to Medicare benefits during a given year. The Denominator File is often used by researchers who want to compare Medicare entitlement with Medicare utilization.

Data Structure and Usage

The Denominator File is comprised of fixed length records containing data elements such as HIC number, state and county codes, ZIP Code, date of birth, date of death, valid date of death indicator, sex, race, age, reasons for entitlement, state buy-in indicators, and GHP indicators. The records are sorted by HIC number. Another version of the Denominator File is also created that is organized in five segments based on state code and is sorted by state, county, and HIC number. The 5% Denominator File, a version of the Denominator File that contains the same data elements for five percent of beneficiaries, is also created and organized by HIC number.

The Denominator File is used to determine the composition of the Medicare population by demographic characteristics, basis of entitlement, and beneficiary participation in MCOs. Also, the file may be linked to claims data to determine rates of service utilization. One limitation of the Denominator File is that any changes to beneficiary records that occur in January, February, or March of the file creation year appear in the file, although the change may not be applicable for the file year. For example, if a beneficiary is included in the 1992 file because of a disability and his or her 65th birthday is in January, February, or March of 1993, he or she will appear on the 1992 Denominator File as a beneficiary who is aged as opposed to a beneficiary with a disability.

Methods of Access

The Denominator File and its variations are available on tape. These data files can also be accessed through DSAF, a menu-driven system for retrieving data from a variety of claims, utilization, and enrollment databases and files including the Denominator File. DSAF provides access to current and historic Medicare claims, as well as enrollment and entitlement data. Data can be selected based on HIC number, specific data field combinations, or a specified percentage of records. The Denominator File is also available as a BEF and is described in the Beneficiary Encrypted Files Data chapter.

Migration of Data

Beginning in April 1993, the Denominator File was created using the UEDB instead of the HISKEW. With the exception of a few data element valid values, the file has remained unchanged.

List of Data Elements

A list of the data elements contained in the Denominator File, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov.

Name and Address File

The Name and Address File is a subset of the data elements of the Enrollment Database (EDB). The particular information in each file is tailored to the request and is used to support health care researchers. It is created through the DSAF.

File Creation

The Name and Address File is created as needed by specific request from the EDB using DSAF. The request-specific file is created through a numeric search using a list of HIC numbers or SSNs.

File Maintenance

There is no file maintenance. As soon as the file is created, it is shipped to the requestor.

File Structure and Usage

Each file contains fixed-length records, usually arranged sequentially. The length of the record in a particular file is the same, but the length of the record depends on the information requested and the search argument that is incorporated into each record. The search argument, i.e., numeric, alpha, or demographic, is provided by the requestor.

Data Structure and Usage

Fields in the record are in display format. There are no binary or Comp-3 fields. The data contain personal identifiers and other material covered by the Privacy Act and, therefore, require authorization for use. The ZIP Code is five characters not nine. Beneficiary data are demographic: name and address, state, sex, race, date of birth, date of death, etc. There is no last date of service or other non-demographic data in the file.

Methods of Access

The Name and Address File can be accessed through DSAF. Data can be selected by HIC number or SSN, specific data field combinations, or specific percentage of records.

Migration of Data

Not applicable.

List of Data Elements

A list of the data elements contained in the Name and Address File, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov.

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