Medicare Advantage Data Model
The following entities and attributes store US Medicare Advantage policy-related details:
Attached Policy Data
Transaction Reply Report (TRR)
The policy transaction reply report keeps track of the incoming transaction replies from the Centers for Medicare and Medicaid Services (CMS) for US Medicare Advantage (MA) and Prescription Drug (Part D) plan (PDP) members.
Field | Description |
---|---|
Attached Policy Data |
Reference to the Attached Policy Data for which the TRR is generated or received |
Update source contract ID |
CMS Contract number of the source entity triggering this reply |
Cleanup ID |
Unique cleanup identifier assigned by CMS |
CMS processing timestamp |
Centers for Medicare and Medicaid services processing timestamp |
File name |
File name of TRR, which led to the update |
CMS tracking ID |
CMS tracking identifier for the reply |
Transaction code |
Inbound CMS transaction code |
Transaction reply code |
Inbound CMS transaction reply code |
External Correlation ID |
Correlation ID as received from an external system |
Policy Enrollment
Policy Enrollment Medicare Details
Policy Enrollment Medicare details store the enrolled beneficiary’s preferences about written communication and other Medicare-specific details.
Field | Description |
---|---|
Policy Enrollment |
Reference to the policy enrollment |
Written material accessibility format |
Written material accessibility format preferred by beneficiary |
Receive email materials? |
Has the member opted to receive written materials by email? |
Opted Email materials |
Comma-separated list of materials that the beneficiary opted to receive via email |
Disability |
CMS-reported disability code |
The values for the written material accessibility code are:
Accessibility Format Code | Meaning |
---|---|
B |
Braille |
L |
Large print |
A |
Audio CD |
The values for CMS reported disability are:
Disability Code | Meaning |
---|---|
0 |
No disability |
1 |
Disabled without ESRD |
2 |
ESRD only |
3 |
Disabled with ESRD |
Policy Enrollment Medicare Comprehensive Addiction and Recovery Act (CARA) Statuses
This stores the status of notifications and/or implementation of CARA prescription drug management policies mandated by CMS.
Field | Description |
---|---|
Policy Enrollment Medicare Details |
Reference to Policy Enrollment Medicare Details |
Drug class |
Drug class identifier |
Start date |
Start date for the CARA notification |
End date |
End date for the CARA notification |
Implementation start date |
CARA implementation start date |
Implementation end date |
CARA implementation end date |
POS Edit |
POS edit code |
POS Edit Status? |
Has the POS edit status been implemented, or a notification of a POS edit status sent? |
Prescriber limitation? |
Has the prescriber limitation been implemented, or a notification of a prescriber limitation sent? |
Pharmacy limitation? |
Has the pharmacy limitation been implemented, or a notification of a pharmacy limitation sent? |
The values for drug class are:
Drug class | Meaning |
---|---|
OPI |
Opioids |
BNZ |
Benzodiazepines |
The values for POS edit are:
POS Edit Code |
---|
PS1 |
PS2 |
Constraints:
-
An overlap in time validity for Comprehensive addiction and recovery status with the same Drug Class and Policy Enrollment Medicare Details is not allowed.
Policy Enrollment Medicare Part D Creditable Coverage
This stores the beneficiary’s Part D creditable coverage information.
Field | Description |
---|---|
Policy Enrollment Medicare Details |
Reference to Policy Enrollment Medicare Details |
Creditable coverage Flag |
Creditable coverage indicates whether the beneficiary had creditable coverage prior to enrollment in the current Medicare part D product plan |
First enrollment start date |
Start date of beneficiary’s first enrollment in a part D product plan under this Policy |
Uncovered months incremental |
Number of calendar months in which beneficiary did not have creditable part D coverage prior to joining current part D product plan |
Uncovered months cumulative |
Total number of uncovered months the beneficiary has accumulated. This is the basis for calculation of Late Enrollment Penalty (LEP) amount the beneficiary is assessed. |
Uncovered months change reason |
Reason describing why the number of uncovered months was changed |
Coverage gap start date |
Coverage gap start date |
Coverage gap end date |
Coverage gap end date |
Canceled not in effect? |
Canceled and not in effect i.e. has the record been logically deleted? |
The values for creditable coverage are:
Creditable Coverage | Meaning |
---|---|
Y |
Covered |
N |
Not Covered |
A |
New IEP |
L |
Low Income |
R |
Other reasons |
T |
Territory Part D |
U |
Reset removed |
The values for Uncovered months change reasons are:
Uncovered months change reasons code | Meaning |
---|---|
LATEATTEST |
Creditable Coverage Attestation received within 60 days after deadline |
PLANERROR |
Changes to calculated Uncovered months due to plan error |
LEPRECON |
Changes according to CMSs LEP Reconsideration decision |
PRIORPLAN |
Adjustments reported by members prior plan |
Constraints:
-
It is not allowed to have multiple Part D Creditable Coverage with the same First Enrollment Start date and Policy Enrollment Medicare Details where Canceled and not in effect = false.
Policy Enrollment Medicare Part D Late Enrollment Penalty
This stores Late Enrollment Penalty (LEP) amounts assessed on the beneficiary effective for the current policy duration.
Field | Description |
---|---|
Policy Enrollment Medicare Details |
Reference to Policy Enrollment Medicare Details |
LEP amount |
The late enrollment penalty amount |
LEP currency |
The currency of late enrollment penalty amount |
Start date |
Penalty period start date |
End date |
Penalty period end date |
Canceled not in effect? |
|
Constraints:
-
An overlap in time validity for Part D late enrollment penalty details for the same Policy Enrollment Medicare Detail is not allowed.
Policy Medicare Enrollment Part D Low Income Subsidy (LIS)
This stores the beneficiary’s Part D Low Income Subsidy details effective for the current policy duration.
Field | Description |
---|---|
Policy Enrollment Medicare Details |
Reference to Policy Enrollment Medicare Details |
Cost share copay level |
Low Income Cost Share (LICS) copay level also called as copay category |
Premium subsidy level |
Low Income Premium Subsidy (LIPS) percentage level |
Premium subsidy amount |
Low-income premium subsidy amount |
Premium subsidy currency |
Low-income premium subsidy currency |
Subsidy source |
Low-income subsidy source |
Start date |
Start date for low-income subsidy profile |
End date |
End date for low-income subsidy profile |
The values for the Cost share copay levels are:
Cost share copay level | Meaning |
---|---|
0 |
None, not low-income |
1 |
1 - High |
2 |
2 - Low |
3 |
3 - 0% |
4 |
4 - 15% |
5 |
Unknown |
The values for the premium subsidy percentage level are:
Premium Subsidy Percentage Level | Meaning |
---|---|
000 |
No subsidy |
025 |
25% subsidy level |
050 |
50% subsidy level |
075 |
75% subsidy level |
100 |
100% subsidy level |
The values for Subsidy source are:
Subsidy Source | Meaning |
---|---|
A |
Approved social security administration (SSA) applicant |
D |
Deemed eligible by CMS |
Constraints:
-
An overlap in time validity for Part D low income subsidy periods for the same Policy Enrollment Medicare Detail is not allowed.
Policy Enrollment Medicare Ethnicity Details
Ethnicity details are as provided by the beneficiary either during enrollment or post-enrollment on the Medicare enrollment form. These are optional details that the beneficiary can choose not to supply.
Field | Description |
---|---|
Policy Enrollment Medicare Details |
Reference to Policy Enrollment Medicare Details |
Ethnicity |
Selected ethnicity type |
The values for ethnicity are:
Ethnicity | Meaning |
---|---|
MX |
Mexican chicano |
CUB |
Cuban |
PR |
Puerto rican |
OTH |
Another hispanic spanish latin origin |
NA |
Non-hispanic spanish latin origin |
NR |
Choose not to respond or declined a response |
Constraints:
-
It is not allowed to have the same ethnicity twice for a Policy Enrollment Medicare Detail.
Policy Enrollment Medicare Race Details
Race details are as provided by the beneficiary either during enrollment or post-enrollment on the Medicare enrollment form. These are optional details that the beneficiary can choose not to supply.
Field | Description |
---|---|
Policy Enrollment Medicare Details |
Reference to Policy Enrollment Medicare Details |
Race |
Selected race type |
The values for race are:
Race | Meaning |
---|---|
101 |
White |
201 |
Black or African American |
300 |
American Indian or Alaska native |
401 |
Asian Indian |
411 |
Chinese |
421 |
Filipino |
431 |
Japanese |
441 |
Korean |
451 |
Vietnamese |
499 |
Other Asian |
501 |
Native Hawaiian |
511 |
Samoan |
521 |
Guamanian or Chamorro |
599 |
Other Pacific Islander |
999 |
Choose not to respond or declined a response |
Constraints:
-
It is not allowed to have the same race twice for a Policy Enrollment Medicare Detail.
Policy Enrollment Medicare Periods
Beneficiary’s Medicare-specific statuses and their effective time-periods as received from CMS.
Field | Description |
---|---|
Policy Enrollment Medicare Details |
Reference to Policy Enrollment Medicare Details |
Period type |
The type of the period received on the update |
Period value |
Value for the period, if applicable. Example Hospice provider number |
Canceled not in effect? |
Medicare period record was canceled and is not in effect; that is a logical record deletion |
Start date |
Period start date |
End date |
Period end date |
The values for period type are:
Period Type | Meaning |
---|---|
DYLS |
Dialysis period |
ESRD |
End-stage renal disease period |
KIDN |
Kidney transplant period |
MES |
Medicaid status period |
RAFME |
The risk adjustment factor for Medicaid status |
MASP |
Medicare secondary payer period |
PARTA |
Part A period |
PARTB |
Part B period |
PARTD |
Part D eligibility period |
INST |
Institutionalized period |
HOSP |
Hospice period |
WORK |
Working aged period |
SCC |
State and county |
OOA |
Out of area |
OPTOD |
Opt out of the part D period |
OPTOM |
Opt out of the Medicare-Medicaid plan period |
NHC |
Nursing home certifiable period |
Constraints:
-
An overlap in time validity for the Additional Medicare periods for the same Period Type and the Policy Enrollment Medicare Detail is not allowed where Canceled and not in effect = false.
Policy Enrollment Product
Policy Enrollment Product Medicare Details
Medicare specific enrollment and disenrollment details for Policy Enrollment Product.
Field | Description |
---|---|
Policy Enrollment Product |
Reference to the policy enrollment product |
Enrollment Election type |
Election type code associated with the election period being used by the beneficiary for an enrollment in this Medicare plan product |
Enrollment SEP reason |
Reference to the reason code for using special election period for an enrollment in this Medicare plan product |
Enrollment Source |
The source of beneficiary enrollment in this Medicare plan product |
OEC SEP reason code |
CMS online enrollment center (OEC) special election period reason code |
OEC SEP CMS reason code |
CMS online enrollment center special election period reason, as approved by CMS |
Drug subsidy override |
Flag indicating whether beneficiary understood that enrolling in Part D plan will end the Retiree Drug Subsidy their employer gets |
ESRD override code |
Override code for ESRD beneficiary to enroll in this Medicare plan-product |
Enrollment application signature date |
Date the beneficiary signed the enrollment application to request coverage for Medicare plan product |
Enrollment signature date defaulted? |
Was the enrollment application signature date defaulted? |
Requested Enrollment Effective date |
Broker requested enrollment effective date |
Enrollment plan receipt datetime |
Health plan enrollment request received date time |
OEC submission datetime |
OEC portal enrollment request submission datetime |
Enrollment plan year |
The plan year for the enrollment |
Employer group health plan? |
Is this a employer group health plan? |
Enrollment channel code |
Channel through which this particular enrollment was received |
Enrollment Receipt mechanism |
This is the channel through which this enrollment was received |
Enrollment Confirmation number |
Confirmation number provided to member at the time of signing off on their enrollment application |
Scope of appointment? |
For a broker or agent-assisted enrollments, was this enrollment received as part of a scheduled appointment with beneficiary? |
Scope of appointment number |
Scheduled appointment number for a broker or agent-assisted enrollments |
Auto enrolled? |
Was this enrollment result of auto-enrollment by CMS? |
Renewal enrollment? |
Was this enrollment result of an annual renewal? |
Rollover enrollment? |
Was this enrollment result of a rollover? |
Enrollment denial reason |
Denial reason if Enrollment was denied |
Enrollment rejection reason |
Rejection reason for a CMS rejected enrollment |
Canceled not in effect? |
Canceled not in effect indicator |
Disenrollment election type |
Election type code associated with the election period being used by beneficiary for disenrollment from this Medicare plan-product |
Disenrollment SEP reason |
Reason code for using special election period for disenrollment from this Medicare plan-product |
Disenrollment reason |
Reason Code for disenrollment |
Disenrollment receipt datetime |
Data timestamp of when the disenrollment request was received by the health plan |
Disenrollment source contract number |
CMS Contract number of the source entity triggering this disenrollment |
Prior CMS contract number |
Previous CMS contract number |
Prior PBP number |
Previous PBP Number |
Prior CMS contract troop |
Previous CMS contract for TrOOP transfer |
Prior PBP number troop |
Previous PBP for TrOOP transfer |
Prior active CARA contract number |
Prior CMS contract number that assigned active CARA status to member |
Applicant work status? |
Work status as provided on the enrollment application |
Applicant spouse work status? |
Spouse’s work status as provided on the enrollment application |
Applicant Medicaid enrollment status? |
Applicant’s Medicaid enrollment status |
Applicant Medicare hospice status? |
Applicant’s Medicare hospice status |
Applicant US residence 183 days? |
Will the beneficiary stay in the USA for 183 days each year for MSA enrollment? |
Applicant beneficiary chronic conditions |
Chronic conditions the beneficiary suffers from |
Applicant Institutionalized? |
Is the applicant institutionalized? |
Applicant Institution name |
Name of institution or nursing home for enrollment in I-SNP plan |
Applicant Institution address |
Address of the institution or nursing home |
Applicant Institution phone |
Phone number of the institution or nursing home |
Applicant Institution admit date |
Institution or nursing home admission date |
Applicant Interpreter needed |
Type of interpreter’s service required by the applicant |
The values for election-type codes are:
Election Type | Meaning |
---|---|
A |
AEP |
C |
Plan-submitted rollover |
D |
MADP |
E |
IEP |
F |
IEP2 |
I |
ICEP |
J |
DEM |
L |
Dual or LIS quarterly SEP |
M |
MA OEP |
N |
OEP NEW |
O |
OEP |
R |
5 star SEP |
S |
Other SEP |
T |
OEPI |
U |
Dual or LIS SEP |
V |
Permanent change in residence SEP |
W |
EGHP SEP |
X |
Administrative action SEP |
Y |
CMS or casework SEP |
Z |
Auto-enrollment |
The possible values for the enrollment source are:
Enrollment Source | Meaning |
---|---|
A |
Auto enrolled by CMS |
B |
Beneficiary election |
C |
Facilitated enrollment by CMS |
D |
CMS annual rollover |
E |
Plan initiated auto-enrollment |
F |
Plan initiated facilitated-enrollment |
G |
Point-of-sale enrollment |
H |
CMS or plan reassignment |
I |
Invalid submitted value, transaction is not rejected |
J |
State-submitted passive enrollment |
K |
CMS-submitted passive enrollment |
L |
MMP beneficiary election |
N |
Rollover by Plan Transaction |
The possible values for the enrollment receipt mechanism are:
Enrollment receipt mechanism | Meaning |
---|---|
PAPER |
Received on paper |
TELEPHONIC |
Received over phone |
ELECTRONIC |
Received from plans own or partners website or electronic devices |
CMSOEC |
Received from CMS online enrollment center |
TRR |
Auto enrollments or MARx UI enrollments received on TRR |
OTHER |
Other mechanism |
The possible values for the interpreter type codes are:
Interpreter Needed Type | Meaning |
---|---|
SPOKEN |
Spoken |
SIGN |
Sign |
NO |
Not required |
Constraints:
-
For the field
Enrollment SEP reason
, only SEP reasons where indicator enrollment SEP = Y can be selected. -
For the field
Disenrollment SEP Reason
, only SEP reasons where indicator disenrollment SEP = Y can be selected.
SEP Reasons
Read only entity with the list of Medicare Election Type special election period Reason Codes.
Field | Description |
---|---|
code |
SEP reason code |
Short description |
SEP reason short description |
Long description |
SEP reason description |
Enrollment? |
Is the SEP reason applicable for enrollment? |
Disenrollment? |
Is the SEP reason applicable for disenrollment? |
Seeded values special election period reason Codes.
CODE | Short Description | Long Description | Enrollment SEP? | Disenrollment SEP? |
---|---|---|---|---|
01 |
GOVT EMERGENCY OR DISASTER |
Government entity declared disaster or other emergency. |
Y |
Y |
02 |
CODE DEACTIVATED |
Code deactivated |
Y |
Y |
11 |
CMS TERM OF CONTRACT |
CMS initiated termination of contract. Includes contract term by CMS, and immediate term by CMS where CMS provides notice of term to a Plan’s members and the term may be midmonth. |
Y |
Y |
12 |
TERM/CNTRCT MOD MUTUAL CONSENT |
Plan initiated terminations/contract modifications by mutual consent. Includes contract non-renewals, Plan service area reductions, term/mod of contract by mutual consent. |
Y |
Y |
21 |
ACCESSIBLE FRMT RECEIPT DELAY |
For providing individuals who requested materials in accessible formats equal time to make enrollment decisions. |
Y |
Y |
22 |
INVOL LOSS OF CRED CVG |
For involuntary loss of creditable prescription drug coverage. |
Y |
N |
23 |
DISENROLL DUE TO CMS SANCTION |
Individuals who disenroll in connection with a CMS sanction. |
Y |
Y |
24 |
PART D DISENR FOR OTH CRED CVG |
Individuals may disenroll from a Part D Plan (PDP, MAPD) to enroll in or maintain other creditable drug coverage. May disenroll from MAPD by enrolling in MA-only Plan. |
Y |
Y |
25 |
INVOL DISENROLL LOSS OF PART B |
Individuals involuntarily disenrolled from an MA-PD Plan due to loss of Part B. |
Y |
N |
26 |
MA OEPI DISENROLL FROM MA |
MA-PD enrollees using the MA Open Enrollment Period for Institutionalized Individuals (OEPI) to disenroll from an MA-PD Plan are eligible for a coordinating Part D SEP that permits enrollment in a PDP. |
Y |
N |
27 |
PACE |
Disenroll from an MA/MA-PD/PDP to enroll in PACE or PACE disenroll to enroll in MA/MAPD. |
Y |
Y |
28 |
COST PLANS NON-RENEWALS |
Individuals enrolled in Cost Plans that are non-renewing their contracts. |
Y |
N |
29 |
DROP MEDIGAP IN TRIAL PERIOD |
Individuals who terminated a Medigap policy when they enrolled for the first time in an MA Plan, and who are still in a trial period. If used to disenroll from MA-PD Plan, may enroll in PDP. |
Y |
Y |
30 |
CHRONIC CARE C-SNP |
Enrollment into a CSNP and for individuals found ineligible for a CSNP. |
Y |
N |
31 |
INSTITUTIONAL INDIVIDUAL |
SEP Reason Code 31 corresponds to the SEP for Institutionalized Individuals 42 CFR 423.38(c)(15). This SEP permits enrollment in, or disenrollment from, a Part D Plan. |
Y |
Y |
32 |
RETRO ENTITLEMENT DETERM |
Individuals whose Medicare entitlement determination was made retroactively. |
Y |
N |
33 |
BENES AGE 65 (SEP65) |
Beneficiaries age 65 (SEP65). If the individual using the SEP65 is disenrolling from an MA-PD Plan, he or she may use this Part D SEP to enroll in a PDP Plan. |
Y |
Y |
34 |
PART B GEP ENROLLMENT |
Individuals who enroll in Part B during the Part B General Enrollment Period (GEP). (MAPD and PDP) Individuals who have Parts A and B for the first time are eligible for ICEP. |
Y |
N |
35 |
LOSS OF SNP |
Individuals enrolled in a SNP who are no longer eligible for the SNP because they no longer meet the specific special needs status. |
Y |
N |
36 |
COST DISENRL OR OPT SUP PART D |
Individuals disenrolling from a Cost Plan who also had the Cost Plan Optional Supplemental Part D Benefit. |
Y |
N |
37 |
LAWFULLY PRESENT |
Non-U.S. citizens who become lawfully present. |
Y |
N |
38 |
QUALIFIED/LOSE SPAP ELIG |
Individuals who belong to a qualified SPAP or who lose SPAP eligibility. |
Y |
N |
39 |
PLAN IN RECEIVERSHIP |
Individuals enrolled in a Plan offered by an MA or PDP organization that is placed into receivership by a State or territorial regulatory authority. |
Y |
Y |
40 |
CMS ID CONSISTENT POOR PERF |
This SEP exists while the individual is enrolled in the low performing MA or PDP Plan. (Plan with star rating of less than 3 stars for the last 3 years.) |
Y |
Y |
41 |
MA ADD PART D IEP |
Individuals eligible for an additional Part D IEP, such as an individual currently entitled to Medicare due to a disability and who is attaining age 65, has an MA SEP to coordinate with the additional Part D IEP for MA only enrollment or MA/ MA-PD disenrollment. |
Y |
Y |
90 |
MISINFORM CREDITABLE STATUS |
CMS determined that the beneficiary was not adequately informed of the creditable status of drug coverage provided by a Plan required to give such notice, or a loss of creditable coverage. Permits enrollment in MA-PD or PDP only. |
Y |
N |
91 |
PROVIDER NETWORK |
CMS determines that changes to a Plan’s provider network are significant based on the affect, or potential to affect, current Plan enrollees. |
Y |
Y |
92 |
CONTRACT VIOLATION |
CMS determined the individual is able to demonstrate to CMS that the MA/MAPD/PDP organization of which he/she is a member substantially violated a material provision of its contract. |
Y |
Y |
93 |
OTHER EXCEPTIONAL CIRCUMSTANCE |
Circumstances beyond the beneficiaries control that prevented him or her from submitting a timely request to enroll or disenroll from a Plan during a valid election period. |
Y |
Y |
94 |
INSULIN SEP |
All Medicare beneficiaries who use a Part B or Part D covered insulin product and assert that they wish to add, drop, or change to a PDP or MAPD Plan due to the insulin price cap change. |
Y |
Y |
95 |
PLAN LIST CORRECTION SEP |
This SEP is available for all LIS beneficiaries who receive the corrected LIS Plan premium notice from CMS. |
Y |
Y |
96 |
OTH EXC CIRC MARKET MISREP |
Other exceptional circumstance SEP specific to marketing misrepresentation established by CMS on a case by case basis where the enrollment or disenrollment in an MA Plan or PDP was based on misleading or incorrect information provided by a Plan representative or SHIP, or enrollment in a Plan without knowledge or consent of the beneficiary. |
Y |
Y |
Y1 |
EXCEPTIONAL CIRCUMSTANCE CASEWORK SEP |
Circumstances beyond the beneficiaries control that prevented him or her submitting a timely request to enroll or disenroll from a Plan during a valid election period. (CMS/Casework SEP) |
Y |
Y |
Y2 |
INVALID ENROLLMENT CASEWORK SEP |
SEP for individuals affected by a federal employee error. Beneficiary states his or her enrollment was based on misleading or incorrect information provided by a Plan representative, SHIP, or CMS. Beneficiary states Plan enroll without knowledge or consent. (CMS/Casework SEP) |
Y |
Y |
Y3 |
PROVIDER NETWORK CASEWORK SEP |
CMS determines that changes to a Plan’s provider network are significant based on the affect, or potential to affect, current Plan enrollees. (CMS/Casework SEP) |
Y |
Y |
Y4 |
CONTRACT VIOLATION CASEWORK SEP |
CMS determined the individual is able to demonstrate to CMS that the MA/MAPD/PDP organization of which he/she is a member substantially violated a material provision of its contract. (CMS/Casework SEP) |
Y |
Y |
Y5 |
EXCEP CIRC MARKET MISREP CASEWORK SEP |
Enrollment or disenrollment in an MA Plan or PDP was based on misleading or incorrect information provided by a Plan representative or SHIP, or enrollment in a Plan without knowledge or consent of the beneficiary. (CMS/Casework SEP) |
Y |
Y |
YA |
GOVT EMERGENCY OR DISASTER CASEWORK SEP |
Government Entity-Declared Disaster or Other Emergency. (CMS/Casework SEP) |
Y |
Y |
YB |
GOVT EMERGENCY OR DISASTER COVID19 CASEWORK SEP |
Government Entity-Declared Disaster or Other Emergency related to COVID-19. (CMS/Casework SEP) |
Y |
Y |
Disenrollment Reasons
Read only entity with the list of Medicare Disenrollment Reason Codes.
Field | Description |
---|---|
Code |
Disenrollment reason code |
Short description |
Disenrollment reason short description |
Long description |
Disenrollment reason description |
Code | Short Description | Long Description |
---|---|---|
01 |
PREMIUMS NOT PAID |
Failure to pay premiums |
02 |
RELO OUT OF AREA |
Relocation out of plan service area (No special provisions) |
03 |
NOT CONVERT TO RISK |
Failure to convert to risk provisions |
04 |
FRAUD |
Fraud |
05 |
LOSS OF PART B |
Loss of part B entitlement |
06 |
LOSS OF PART A |
Loss of part A entitlement (Plan-specific) |
07 |
FOR CAUSE |
For cause |
08 |
REPORT OF DEATH |
Report of death |
09 |
CONTR TERMD CMS |
Termination of contract (CMS-initiated) |
10 |
CONTR TERMD PLAN |
Termination of contract/Plan Benefit Package (PBP)/Segment (Plan withdrawal) |
11 |
VLNTRY DSNR THRU PLN |
Voluntary disenrollment through plan |
12 |
VLNTRY DSNR THRU DOF |
Voluntary disenrollment through district office |
13 |
ENR IN OTHER PLAN |
Disenrollment because of enrollment in another plan |
14 |
RETROACTIVE |
Retroactive |
15 |
TERM IN ERR CMS |
Terminated in error by CMS system |
16 |
END OF SCC COND ENRL |
End of state and county code (SCC) conditional enrollment period |
17 |
AGE CRIT NOT MET |
Beneficiary does not meet age criterion (Plan-specific) |
18 |
ROLLOVER |
Rollover |
19 |
TERM BY SSA DO |
Terminated by social security administration (SSA) district office |
20 |
ESRD AUTO DISENROL |
Invalid enrollment with end stage renal disease (ESRD) |
21 |
BAD HEALTH/CANT TRVL |
Cannot travel/Poor Health/To Health Maintenance Organization (HMO)/Plan Doctors |
22 |
SPOUSE PLN TERMINATD |
Spouse is no longer member of HMO/Plan |
23 |
CANT USE MEDICARE |
Could not use Medicare card to see other plan |
24 |
NO KNOWLEDGE OF ENRL |
Did not know I joined this HMO |
25 |
CANT REACH DR BY PHN |
Difficulty reaching HMO/plan doctor by phone problem |
26 |
GOT NO HLP W/PROBLEM |
Called HMO/Plan could not get help with problem |
27 |
DISSATISFIED W/CARE |
Dissatisfied with medical care/doctors or hospital |
28 |
TLD BY PRVDR TO DSNR |
Told by plan doctors or staff I should disenroll |
29 |
PREFER REG MEDICARE |
Prefer traditional Medicare |
30 |
NOT USING MEDICARE |
Have other health insurance benefits available |
31 |
PLAN TOO CONFUSING |
Found HMO/Plan to be too confusing |
32 |
CLAIMS/BILS NOT PAID |
My claims/bills were not paid |
33 |
COUDNT PIK SPECIALST |
Had little or no choice of specialist |
34 |
BAD TRTMNT BY PRVDR |
Treated discourteously by doctor/nurse/staff |
35 |
NO CHG IN CONDITION |
Doctor could not improve my condition |
36 |
PLN LOC TOO FAR AWAY |
HMO/Plan medical group was located too far away |
37 |
COULDNT PIK PRM PHYS |
Had limited or no choice of my primary doctor |
41 |
LIVE OUTSDE SVC AREA |
You moved permanently out of area where plan provides service |
42 |
TOLD BY DR TO DSNR |
Your doctor or the plan told you to disenroll |
43 |
POOR QUALITY OF CARE |
Your doctor did not give you good quality care |
44 |
RX ALLOWANCE USED UP |
You used up the prescription allowance |
45 |
PLAN COST TOO MUCH |
The plan cost you too much |
46 |
LACK OF TIMELY CARE |
You could not get care when you needed it |
47 |
DOCTOR NOT IN PLAN |
Your doctor is not in the plan |
48 |
DIDNT SIGN UP 4 PLAN |
You did not know you signed up for this plan |
49 |
DIDNT LIKE PLAN |
You did not like how the plan worked |
50 |
RLVR ENRT RMVD/AUDT |
Rolled over enrollment removed/audited |
54 |
PART A OR B START DATE CHANGE |
Part A or B start date change |
56 |
BEN MEDICAID PERIOD RCD |
Beneficiary Medicaid period received |
57 |
BEN HOSPICE PERIOD RCD |
Beneficiary hospice period received |
59 |
INVALID ENR W HOSPICE |
Invalid enrollment with hospice |
60 |
IN US LT 183 DAYS |
Beneficiary lives in USA less than 183 days a year |
61 |
LOSS OF PART D |
Loss of Part D eligibility |
62 |
FAILURE TO PAY IRMAA |
Part D disenrollment due to failure to pay IRMAA |
63 |
ENRL OPT OUT MMP |
MMP (Medicare and Medicaid plan) opt-out after enrolled |
64 |
LOSS OF FA DEMO ELIG |
Loss of demonstration eligibility |
65 |
LOSS OF EGP ELGBLTY |
Loss of employer group plan eligibility |
70 |
CONFIRMED INCARC |
Confirmed incarceration |
71 |
NOTLAW PRESENT |
Not lawfully present |
72 |
PLAN ROLL |
Disenrollment due to plan submitted rollover |
88 |
CONVERSION |
Conversion |
90 |
ENRL CNCL BENE MRG |
Enrollment canceled due to beneficiary merge |
91 |
INV DIS PREMIUMS NOT PAID |
Involuntary Disenrollment for failure to pay plan premiums |
92 |
INV DIS RELO OUT OF AREA |
Involuntary Disenrollment for a move out of plan service area |
93 |
INV DIS LOST SNP |
Involuntary Disenrollment for loss of special needs plan (SNP) Eligibility |
99 |
OTHER |
Other (Not supplied by beneficiary) |
Y8 |
REPORT OF DEATH DATE CHANGE |
Report of death date change |
Policy Enrollment Product Election Responses
Medicare election period eligibility responses provided by the beneficiary on their Enrollment or Disenrollment application. This entity uses the CMS online enrollment center SEP reason codes to capture these responses for all election periods, inclusive of special election periods.
Field | Description |
---|---|
Policy Enrollment Product Medicare Details |
Reference to policy enrollment product medicare details |
Medicare OEC SEP Code |
Reference to the OEC SEP code |
Type |
Election response type |
Reported Date |
Date as provided by the member |
Response? |
Response to the OEC question, as reported by the member: That is |
The possible values for the Election Response Type are:
Type | Meaning |
---|---|
E |
Enrollment |
D |
Disenrollment |
Constraints:
-
For the field Medicare OEC SEP Code, availability of OEC SEP Code depends on the type of election response i.e.,
-
If type = Enrollment then OEC SEP codes with indicator Enrollment = Y can be selected.
-
If type = Disenrollment then OEC SEP codes with indicator Disenrollment = Y can be selected.
-
-
For the field Reported Date, it can only be set if indicator Reported Date Allowed = Y for the selected OEC SEP code.
OEC SEP Codes
Read only entity with the list of Medicare OEC SEP Codes along with the OEC question.
Field | Description |
---|---|
Code |
OEC SEP code |
Description |
OEC SEP description |
OEC Question |
OEC Question |
Enrollment? |
Is the OEC SEP code applicable for enrollment? |
Disenrollment? |
Is the OEC SEP code applicable for disenrollment? |
Reported date allowed? |
Reported as of date allowed? |
OEC SEP CODE | OEC Question | Enrollment OEC SEP? | Disenrollment OEC SEP? | As of Date Required? |
---|---|---|---|---|
NEW |
I’m new to Medicare. |
Y |
N |
N |
ICE |
I already have Hospital (Part A) and recently signed up for Medical (Part B). I want to join a Medicare Advantage Plan. |
Y |
N |
N |
RET |
I’m new to Medicare, and I was notified about getting Medicare after my Part A and/or Part B coverage started. |
Y |
Y |
N |
MRD |
I had Medicare prior to now, but I’m now turning 65. |
Y |
N |
N |
OEP |
I’m in a Medicare Advantage Plan (or have had Medicare for less than 3 months) and want to make a change. |
Y |
Y |
N |
MOV |
I moved to a new address that’s outside my current plan’s service area, or I recently moved and this plan is a new option for me. |
Y |
N |
Y |
RUS |
I moved back to the U.S. after living outside the country. |
Y |
N |
Y |
INC |
I was released from incarceration. |
Y |
N |
Y |
LAW |
I recently got lawful presence status in the U.S. |
Y |
N |
Y |
LT2 |
I live in a long-term care facility, like a nursing home or a rehabilitation hospital. |
Y |
Y |
N |
LTC |
I recently moved out of a long-term care facility, like a nursing home or a rehabilitation hospital. |
Y |
Y |
Y |
LEC |
I left (or am joining) coverage from my employer or union (including COBRA coverage) |
Y |
Y |
Y |
LCC |
I lost other, non-Medicare drug coverage that’s as good as Medicare drug coverage (creditable coverage), or my other, non-Medicare coverage changed and is no longer considered creditable. |
Y |
N |
Y |
EOC |
I lost my coverage because my plan no longer covers the area that I live or it ended its contract with Medicare. |
Y |
Y |
N |
MYT |
I lost my coverage because Medicare ended its contract with my plan. I got a letter from Medicare saying I could join another plan. |
Y |
Y |
N |
PAC |
I dropped my coverage in a PACE (Programs of All-Inclusive Care for the Elderly) plan. |
Y |
Y |
Y |
SNP |
I lost my Special Needs Plan because I no longer have a condition required for that plan. |
Y |
N |
Y |
CSN |
I want to join a Special Needs Plan that tailors its benefits to my chronic condition. |
Y |
N |
N |
MDE |
I have both Medicare and Medicaid, my state helps pay for my Medicare premiums, or I get Extra Help paying my Medicare drug coverage. |
Y |
Y |
N |
MCD |
I recently had a change in my Medicaid (newly got Medicaid, had a change in my level of Medicaid, or lost Medicaid). |
Y |
Y |
Y |
NLS |
I recently had a change in my Extra Help paying for my drug costs (newly got Extra Help, had a change in my level of Extra Help, or lost Extra Help). |
Y |
Y |
Y |
DIF |
I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. |
Y |
Y |
Y |
PAP |
I’m in a State Pharmaceutical Assistance Program, or I’m losing help from a State Pharmaceutical Assistance Program. |
Y |
N |
N |
12G |
I dropped a Medicare Supplement Insurance (Medigap) policy when I first joined a Medicare Advantage Plan. It’s been less than 12 months since I left my Medigap policy. I want to switch to Original Medicare so I can go back to my Medigap policy, and I’m joining a Drug Plan (Part D). |
Y |
N |
N |
DST |
I was affected by an emergency or a major disaster (as declared by the Federal Emergency Management Agency, or by Federal, my state, or my local government). One of the other statements on this page applied to me, but I was unable to make my request because of the disaster. |
Y |
Y |
N |
12J |
I joined a Medicare Advantage Plan with drug coverage when I turned 65. It’s been less than 12 months since I joined this plan. I want to switch to Original Medicare, and I’m joining a Drug Plan. |
Y |
Y |
N |
5ST |
I am enrolling in a 5-star Medicare plan. |
Y |
N |
N |
LPI |
I’m in a plan that’s had a star rating of less than 3 stars for the last 3 years. I want to join a plan with a star rating of 3 stars or higher. |
Y |
Y |
N |
REC |
I’m in a plan that was recently taken over by the state because of financial issues. I want to switch to another plan. |
Y |
Y |
N |
ACC |
I requested Medicare information in an accessible format. I got less time to make my decision, or I didn’t get it in time to make a choice before my enrollment period ended. |
Y |
Y |
N |
INV |
I lost my Medicare Advantage Plan with drug coverage because I lost Medical (Part B) coverage. I want to join a Medicare drug plan. |
Y |
N |
N |
IIP |
I live in a long-term care facility, like a nursing home or a rehabilitation hospital. I dropped my Medicare Advantage Plan with drug coverage and I want to join a Medicare drug plan. |
Y |
N |
N |
OSD |
I dropped my Cost Plan with drug coverage and switched to Original Medicare. I want to join a Medicare drug plan. |
Y |
N |
N |
IND |
I live in or (within the past 2 months) moved out of a long-term care facility, like a nursing home or a rehabilitation hospital. I want to join a Medicare drug plan. |
Y |
Y |
N |
IEP |
I had Medicare before, but I’m now turning 65. |
Y |
Y |
N |
CRE |
I wasn’t properly notified that my private drug coverage wasn’t creditable, or was no longer creditable. |
Y |
N |
N |
PRO |
I was notified by my plan that it had or will have a significant provider network change. |
Y |
Y |
N |
VIO |
I’m in a plan that violated its contract with me. |
Y |
Y |
N |
EXC |
Marketing Misrepresentation SEP: I was enrolled in a plan based on misleading or incorrect information, or I was enrolled into a plan without my knowledge or consent. |
Y |
Y |
N |
SAN |
I was affected by an item directly related to my plan’s sanction. |
Y |
Y |
N |
OTH |
Other. |
Y |
Y |
N |
PRE |
I pay a premium for Part A and I signed up for Part B during the General Enrollment Period (January 1 - March 31 each year). I want to join a Medicare drug plan (Part D) or Medicare Advantage Plan with drug coverage. |
Y |
N |
N |
CSP |
I signed up for Part A (Hospital Insurance) or Part B (Medical Insurance) during a Special Enrollment Period I qualified for because of an exceptional circumstance. I want to join a Medicare Advantage Plan (with or without drug coverage). |
Y |
N |
N |
DSP |
I signed up for Part A (Hospital Insurance) or Part B (Medical Insurance) during a Special Enrollment Period I qualified for because of an exceptional circumstance. I want to join a Medicare drug plan (Part D). |
Y |
N |
N |
Policy Enrollment Product Medicare Other Insurance Details
Other insurance details are as provided by beneficiary on their enrollment application.
Field |
Description |
Policy Enrollment Product Medicare Details |
Reference to policy enrollment product Medicare details |
Other Ins drug benefits? |
Does the other insurance provide drug benefits? |
Member ID |
Other insurance member identifier |
Group ID |
Other insurance group’s identifier |
Rx BIN |
Other insurance benefit identification number (RxBIN) |
Rx PCN |
Other insurance processor control number (RxPCN) |
Start date |
Other insurance start date |
End date |
Other insurance end date |
Constraints:
-
An overlap in time validity for the Other Insurance Details for the same Member ID, Group ID and the Policy Enrollment Product Medicare Detail is not allowed.
Policy Enrollment Product Medicare IC Model Status
Medicare Innovative Care (IC) model status for beneficiary.
Field |
Description |
Type indicator |
IC model type indicator |
Benefit status |
IC model benefit status code |
End date reason |
IC model end date reason Code |
Start date |
IC Model start date |
End date |
IC Model end date |
The possible values for the Type indicator are:
Type Indicator | Meaning |
---|---|
01 |
VBID |
02 |
MTM |
The possible values for the benefit status are:
Benefit Status | Meaning |
---|---|
01 |
Full status |
02 |
Unearned status |
The possible values for the End Date Reason are:
End Date Reason | Meaning |
---|---|
01 |
No longer eligible |
02 |
Opted out of program |
03 |
Benefit Status Change |
Constraints:
-
An overlap in time validity for the IC Model Statuses with the same Type Indicator, and the Policy Enrollment Product Medicare Detail is not allowed.
Policy Enrollment Product Part D 4RX Details
Field |
Description |
Policy Enrollment Product Medicare Details |
Reference to policy enrollment product Medicare details |
Rx member ID |
Part D Rx member identifier |
Rx group ID |
Part D Rx group identifier |
Rx BIN |
Part D Rx benefit identification number (RxBIN) |
Rx PCN |
Part D Rx processor control number (RxPCN) |
Start date |
Part D Rx start date |
End date |
Part D Rx end date |
Constraints:
-
An overlap in time validity for the Part D 4RX Details for the same the Policy Enrollment Product Medicare Detail is not allowed.
Policy Enrollment Product Medicare Premium Payment Options
Field |
Description |
Policy Enrollment Product Medicare Details |
Reference to policy enrollment product Medicare details |
Premium payment option |
Premium withhold/Premium payment option code |
Rejection reason |
Rejection code received from the withholding agency on TRR |
Start date |
Premium withhold start date |
End date |
Premium withhold end date |
The possible values for the Premium Payment Options are:
End Date Reason | Meaning |
---|---|
D |
Direct bill |
R |
Withheld from railroad retiree board benefit check |
S |
Withheld from social security benefit check |
N |
No premium due from member |
The possible values for the Rejection reasons are:
Rejection reason | Meaning |
---|---|
V001 |
SSN mismatch |
V002 |
HIC or RRB mismatch |
V003 |
Date of Birth mismatch |
D0002 |
Deferral |
E0002 |
Reason not specifically related to the CMS enrollment change |
I0002 |
Insufficient Funds |
S0002 |
Suspension of Benefits |
T0002 |
Termination of Benefits |
E0003 |
Invalid Payment Status |
E0004 |
Dual Entitlement |
E0005 |
RRB Jurisdiction |
S100 |
Beneficiary is in suspense (RRB) |
T100 |
Beneficiary benefits are terminated (RRB) |
C100 |
Beneficiary changed in jurisdiction to SSA (RRB) |
I100 |
Insufficient funds (RRB) |
D100 |
Beneficiary is deceased (RRB) |
M100 |
Reject in the RRB check writing process |
W100 |
RRB Systems are out of sync |
E999 |
Unforeseen error condition (RRB) |
E300 |
SSN and date of birth mismatch for RRB number |
E310 |
HICN on RRB mismatch |