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.