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 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.
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? |
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:
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 |
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:
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 |
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? |
|
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 |
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:
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 |
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:
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
Medicare SEP Reasons
Configurable entity that can be used to store 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? |
Medicare Disenrollment Reasons
Configurable entity that can be used to store the list of Medicare Disenrollment reasons.
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.
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
Medicare OEC SEP Codes
Configurable entity that can be used to store OEC SEP codes along with the OEC question.
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.
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 |
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.