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.

Table 1. Policy Transaction Reply Report (TRR)
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 Date

Date when the transaction was received

Transaction Effective Date

Effective date for the transaction

Transaction reply code

Inbound CMS transaction reply code

External Correlation ID

Correlation ID as received from an external system

Member PBP Number

Member’s Plan Benefit Package (PBP) Number

Member Segment Number

Member’s Plan Segment Number

Member Contract ID

Contract identifier of the member

Constraints:

It is not allowed to have multiple Policy Transaction Reply Report records with the same File name, Transaction Code, Transaction Reply Code, Member Contract ID, Member PBP Number, Transaction Effective Date, Transaction Date for the same Policy attached data.

Policy Enrollment

Policy Enrollment Medicare Details

Policy Enrollment Medicare details store the enrolled beneficiary’s preferences about written communication and other Medicare-specific details.

Table 2. Policy Enrollment Medicare 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:

Table 3. Values for Written material accessibility format code are:
Accessibility Format Code Meaning

B

Braille

L

Large print

A

Audio CD

The values for CMS reported disability are:

Table 4. Values for Disability Type
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.

Table 5. Policy Enrollment Medicare CARA Status
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?

Transaction Receipt Date Time

Transaction receipt datetime, automatically set when creating a new record with the current timestamp

Transaction Update Date Time

Transaction update datetime, automatically set with the last update timestamp

The values for drug class are:

Table 6. Values for Drug Class
Drug class Meaning

OPI

Opioids

BNZ

Benzodiazepines

The values for POS edit are:

Table 7. Values for POS Edit Codes
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.

Table 8. Policy Enrollment Medicare Part D Creditable Coverage
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

Transaction Receipt Date Time

Transaction receipt datetime, automatically set when creating a new record with the current timestamp

Transaction Update Date Time

Transaction update datetime, automatically set with the last update timestamp

Canceled not in effect?

Canceled and not in effect i.e. has the record been logically deleted?

The values for creditable coverage are:

Table 9. Values for Creditable Coverage flag
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:

Table 10. Values for Uncovered months change reasons
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.

Table 11. Policy Enrollment Medicare Part D Late Enrollment Penalty
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

Transaction Receipt Date Time

Transaction receipt datetime, automatically set when creating a new record with the current timestamp

Transaction Update Date Time

Transaction update datetime, automatically set with the last update timestamp

Canceled not in effect?

Canceled and not in effect? flag indicates whether this occurrence was logically deleted.

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.

Table 12. Policy Medicare Enrollment Part D Low Income Subsidy
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

Transaction Receipt Date Time

Transaction receipt datetime, automatically set when creating a new record with the current timestamp

Transaction Update Date Time

Transaction update datetime, automatically set with the last update timestamp

The values for the Cost share copay levels are:

Table 13. Values for the Cost share copay levels
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:

Table 14. Values for Premium Subsidy Percentage Level
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:

Table 15. Values for Subsidy Source
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.

Table 16. Policy Enrollment Medicare Ethnicity Details
Field Description

Policy Enrollment Medicare Details

Reference to Policy Enrollment Medicare Details

Ethnicity

Selected ethnicity type

The values for ethnicity are:

Table 17. Values for Ethnicity
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.

Table 18. Policy Enrollment Medicare Race Details
Field Description

Policy Enrollment Medicare Details

Reference to Policy Enrollment Medicare Details

Race

Selected race type

The values for race are:

Table 19. Values for Race
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.

Table 20. Policy Enrollment Medicare Periods
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

Transaction Receipt Date Time

Transaction receipt datetime, automatically set when creating a new record with the current timestamp

Transaction Update Date Time

Transaction update datetime, automatically set with the last update timestamp

The values for period type are:

Table 21. Values for Period Type
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.

Table 22. Policy Enrollment Product Medicare Details
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:

Table 23. Values for Election Type Codes
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:

Table 24. Values for enrollment Source
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:

Table 25. Values for enrollment receipt mechanism
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:

Table 26. Values for Interpreter Needed Type Codes
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

Medicare SEP Reasons

Configurable entity that can be used to store Election Type Special Election Period Reason codes.

Table 27. 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?

Medicare Disenrollment Reasons

Configurable entity that can be used to store the list of Medicare Disenrollment reasons.

Table 28. Medicare Disenrollment Reasons Codes
Field Description

Code

Disenrollment reason code

Short description

Disenrollment reason short description

Long description

Disenrollment reason description

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.

Table 29. Policy Enrollment Product Election Responses
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 true or false

The possible values for the Election Response Type are:

Table 30. Values for Enrollment Response Type
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

Medicare OEC SEP Codes

Configurable entity that can be used to store OEC SEP codes along with the OEC question.

Table 31. Medicare OEC SEP Codes
Field Description

Code

OEC SEP code

Description

OEC SEP description

OEC Question

OEC description

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?

Policy Enrollment Product Medicare Other Insurance Details

Other insurance details are as provided by beneficiary on their enrollment application.

Table 32. Policy Enrollment Product Medicare Other Insurance Information

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.

Table 33. Policy Enrollment Product Medicare IC Model Status

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:

Table 34. Values for Type indicator
Type Indicator Meaning

01

VBID

02

MTM

The possible values for the Benefit status are:

Table 35. Values for Benefit status indicator
Benefit Status Meaning

01

Full status

02

Unearned status

The possible values for the End Date Reason are:

Table 36. Values for End Date Reason
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

Table 37. 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

Table 38. 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:

Table 39. Values for End Date Reason
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:

Table 40. Values for Rejection reason
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

Medicare Advantage Polcies User Interface

The Medicare Advantage floorplans for Policies POLICIESMA, POLICYENROLLMENTSMA, and POLICYENROLLMENTPRODUCTSMA are disabled by default and can be enabled using the Floorplans page.

UI uses the field type on the Policy to identify Medicare Advantage policies and uses the same to load appropriate floorplans to render the policies page, that is, policy.type = MEDICARE ADVANTAGE.

It is recommended to configure and use separate floorplan tags for other Policies and policy-related floorplans after enabling the Medicare Advantage floorplans, including the default system floorplans for Policies, that is, POLICIES, POLICYENROLLMENTS, and POLICYENROLLMENTPRODUCTS, to ensure correct floorplans are rendered for non-Medicare Advantage policies.

See Floor Plan Loading and Storage for user interface for additional details on floorplan tags.