Enrollee-Level External Data Gathering Environment (EDGE) Limited Data Set (LDS)

In the 2020 Payment Notice (see 84 FR 17454 at 17486 through 17490), CMS finalized a policy to create on an annual basis an LDS using masked enrollee-level data submitted to EDGE servers by issuers of risk adjustment covered plans in the individual and small group (including merged) markets, and make this dataset available to requestors who seek the data for research purposes.

The EDGE LDS contains certain masked enrollment and claims data for on- and off-Exchange enrollees in risk adjustment covered plans in the individual and small group (including merged) markets, in states where HHS operated the risk adjustment program required by section 1343 of the Patient Protection and Affordable Care Act, and is derived from the data collected and used for the federally operated risk adjustment program. CMS began collecting enrollee-level data from issuers’ EDGE servers beginning with the 2016 benefit year. For prior years, CMS did not collect enrollee-level EDGE data from issuers (see the 2018 Payment Notice, 81 FR 94058 at 94101).

The EDGE LDS file includes masked randomly generated enrollee numbers to link the enrollment and claims data for each enrollee. The EDGE LDS file does not include data on enrollees’ direct identifiers, plan benefit design, specific cost-sharing elements (deductibles, copayments), provider identifiers, providers' geographic location, enrollees' income level, or enrollees' geographic location, as issuers do not upload these data to their EDGE servers. Issuers do submit enrollees’ state and rating areas as part of the EDGE server submissions, however, as discussed in the 2020 Payment Notice, we do not extract such geographic elements from the EDGE servers under our current policy.

The data files contain system-generated random numbers (SYSIDs) used to link the enrollee records across files. There are 4 components of the EDGE LDS:

• An enrollment file
• Medical claims
• Pharmaceutical claims
• Supplemental claims

2016 EDGE LDS: For the 2016 benefit year, CMS did not collect enrollees’ market indicator (individual or small group, including for enrollees in merged market states), and therefore, this variable is not included in the 2016 EDGE LDS. For the 2016 benefit year, HHS operated the risk adjustment program in all states and the District of Columbia, except for Massachusetts. As such, the 2016 benefit year LDS does not reflect any data from issuers of risk adjustment covered plans in Massachusetts.  The data elements document describes the data elements included in the 2016 benefit year enrollee-level EDGE LDS.  The data creation guide explains the methods, decisions, and key steps taken in creating the 2016 benefit year enrollee-level EDGE claims limited data set (LDS).

2017 and 2018 EDGE LDS:  Beginning with the 2017 benefit year, CMS includes new data elements in the enrollee-level EDGE claims limited data set (LDS): market indicator (individual or small group, including for enrollees in merged market states), and claim identifier field.  The 2017 benefit year enrollee-level EDGE LDS includes data from all states and the District of Columbia. As such, beginning with the 2017 benefit year, the EDGE LDS includes data from the issuers of risk adjustment covered plans in Massachusetts. The data elements document describes the data elements included in the 2017 benefit year enrollee-level EDGE LDS.  The data creation guide explains the methods, decisions, and key steps taken in creating the 2017 benefit year enrollee-level EDGE LDS. 

2019 EDGE LDS: For the 2019 benefit year, the enrollee-level EDGE limited data set (LDS) includes data from all states and the District of Columbia.  The data elements document describes the data elements included in the 2019 benefit year enrollee-level EDGE LDS.  The data creation guide explains the methods, decisions, and key steps taken in creating the 2019 benefit year enrollee-level EDGE LDS.

2020 EDGE LDS:  For the 2020 benefit year, the enrollee-level EDGE limited data set (LDS) includes data from all states and the District of Columbia.  The data elements document describes the data elements included in the 2020 benefit year enrollee-level EDGE LDS.  The data creation guide explains the methods, decisions, and key steps taken in creating the 2020 benefit year enrollee-level EDGE LDS.

2021 EDGE LDS: For the 2021 benefit year, the enrollee-level EDGE limited data set (LDS) includes data from all states and the District of Columbia. The data elements document describes the data elements included in the 2020 benefit year enrollee-level EDGE LDS. The data creation guide explains the methods, decisions, and key steps taken in creating the 2020 benefit year enrollee-level EDGE LDS.

2022 EDGE LDS: For the 2021 benefit year, the enrollee-level EDGE limited data set (LDS) includes data from all states and the District of Columbia. The data elements document describes the data elements included in the 2020 benefit year enrollee-level EDGE LDS. The data creation guide explains the methods, decisions, and key steps taken in creating the 2020 benefit year enrollee-level EDGE LDS.

Redaction of Substance Use Disorder (SUD) Claims: To comply with the Substance Abuse and Mental Health Services Administration (SAMHSA) regulations as 42 CFR Part 2, Substance Use Disorder (SUD) claims will be redacted from the enrollee-level EDGE LDS.  A further description of the redaction, redaction codes, and impact on the data is included in the data use guide and accompanying SUD redaction impact table.