Brief Issue Description
This document outlines the challenges states have faced when reporting the geographic service areas that managed care plans serve and recommends best practices for states' reporting.
Background Discussion
Context
The MANAGED‐CARE‐SERVICE‐AREA data element found in the Managed Care file is an indicator that describes the geographic service area for which the managed care plan is under contract to provide services. These areas are defined as statewide, county, city, region, zip code, and other[1]. It is reported on the Managed Care file as the data element MANAGED‐CARE‐SERVICE‐AREA on the MANAGED‐CARE‐MAIN‐MCR00002 record segment. The specific geographic service area is reported in the Managed Care file as the data element MANAGED‐CARESERVICE‐AREA‐NAME on the MANAGED‐CARE‐SERVICE‐AREA‐MCR00004 record segment. The MANAGED‐CARESERVICE‐AREA‐NAME must be consistent with the MANAGED‐CARE‐SERVICE‐AREA and specifies the relevant American National Standards Institute (ANSI) code associated with the geographic service area. They consist of Federal Information Processing Series (FIPS) codes and Geographic Names Information System (GNIS) Identifiers.
Challenge
MANAGED‐CARE‐SERVICE‐AREA captures the geographic units that a managed care plan contracts with a state to cover. This data element documents whether coverage is statewide or provided on a less than statewide basis, such as counties cities, zip codes, or some other geographic unit. There are two challenges that stem from reporting this information. The first is ensuring that the value reported in the MANAGED‐CARE‐SERVICE‐AREA is consistent with MANAGED‐CARE‐SERVICE‐AREA‐NAME. For example, that if the MANAGED‐CARE‐SERVICE‐AREA value is "2," indicating that the plan provides services to beneficiaries in specified counties, then the MANAGEDCARE‐SERVICE‐AREA‐NAME must be all of the valid ANSI county codes for the relevant state. The second challenge is that reporting requirements are different if the managed care plan's service area is at the state level. When the managed care plan's service area is the entire state, not all data elements in the record are required to be completed.
CMS Guidance
States should review each managed care plan's contract and ensure that the managed care service area is being accurately reported. There can only be one MANAGED‐CARE‐SERVICE‐AREA value reported for each managed care plan. This is reported on the MANAGED‐CARE‐MAIN000002 segment. Because only one type of MANAGEDCARE‐SERVICE‐AREA value can be attributed to each plan, the most granular service area category should be used. If a state has service areas that fall under county and zip code type, then the service area of zip code should be reported. For example, if a managed care plan serves Cecil County, Harford County and the following zip codes in Baltimore County: 21161, 21111, 21013, 21082, 21087, 21156, 21085 and 21162, then zip codes would be the only way to uniformly describe the entire service area. The state should use the MANAGED‐CARESERVICE‐AREA value "5" for zip code and the service area segment, MANAGED‐CARE‐SERVICE‐AREA‐MCR00004 should include each covered zip code in Baltimore County as well as each zip code in Cecil and Harford County. An exception is when the more granular service area category is larger than the service area. In these instances, MANAGED‐CARE‐SERVICE‐AREA = "Other" should be used and states may report a mix of relevant granular MANAGED‐CARE‐SERVICE‐AREA‐NAMES. For example, if the service area is part of a county the state may report a mix of zip codes and cities in the MANAGED‐CARE‐SERVICE‐AREA‐NAMES segment if zip codes cross service area boundaries and reporting only zip codes does not accurately describe the service area.
The information reported for MANAGED‐CARE‐SERVICE‐AREA‐NAME on the MANAGED‐CARE‐SERVICE‐AREAMCR000004 segment must be consistent with the value reported in the MANAGED‐CARE‐SERVICE‐AREA. For example, if the managed care service area is distinguished by zip codes, then zip codes must also be reported in MANAGED‐CARE‐SERVICE‐AREA‐NAME. If the managed care service area reported is either a city or a county, then the ANSI values should be used for the MANAGED‐CARE‐SERVICE‐AREA‐NAME[2]. Although there can only be one MANAGED‐CARE‐SERVICE‐AREA value reported for each managed care plan, there can be multiple managed care service area names reflecting the managed care plan's service area. For example, if the managed care service area is zip code, the managed care entity could service multiple zip codes.
When the state reports a MANAGED‐CARE‐SERVICE‐AREA value of "1" (statewide, meaning the plan provides services to beneficiaries throughout the entire state), a MANAGED‐CARE‐SERVICE‐AREA‐MCR000004 segment is not required.
[1] The defined area types represent the 6 valid values that can be reported in T‐MSIS. The "other" valid value should be selected when the other five valid values are not applicable to the managed care service area.