Medicare Advantage and Prescription Drug Plans December 28 ...

Plan Communications User Guide Appendices, Version 6.3
F.18 LIS/Part D Premium Data File
Field Size Position Description
1. Claim Number 12 1-12 Beneficiary’s CAN
2. Contract Number 5 13-17 Contract Identification Number
3. PBP Number 3 18-20 Beneficiary’s PBP ID, blank if none
4. Segment Number 3 21-23 Beneficiary’s Segment Identification Number, blank if none
5. Run Date 8 24-31
6. Subsidy Start Date 8 32-39
7. Subsidy End Date 8 40-47
8. Part D Premium
Subsidy Percentage
9. Low-Income Co-
Payment Level ID
10. Beneficiary
Enrollment
Effective Date
11. Beneficiary
Enrollment End
Date
12. Part C Premium
Amount
13. Part D Premium
Amount
14. Part D Late
Enrollment Penalty
Amount
3 48-50
1 51
8 52-59
8 60-67
8 68-75
8 76-83
8 84-91
15. LIS Subsidy Amount 8 92-99
16. LIS Penalty Subsidy
Amount
17. Part D Penalty
Waived Amount
18 Total Premium
Amount
19. De Minimis
Differential Amount
8 100-107
8 108-115
8 116-123
8 124-131
20. Filler 147 132- 278 Filler
Total Length = 278
Data File Generation Date
YYYYMMDD – Format
Beneficiary’s Subsidy Start Date
YYYYMMDD – Format
Beneficiary’s Subsidy End Date
YYYYMMDD – Format
Beneficiary’s LIPS Percent
‘100’ = 100% Premium Subsidy
‘075’ = 75% Premium Subsidy
‘050’ = 50% Premium Subsidy
‘025’ = 25% Premium Subsidy
Co-Payment Category Definitions: ‘1’=High; ‘2’=Low;
‘3’=$0; ‘4’=15%
Beneficiary’s Enrollment effective date,
YYYYMMDD – Format
Beneficiary’s Enrollment End Date
YYYYMMDD – Format Space can remain blank
Beneficiary’s Part C Premium Amount
(----9.99)
Beneficiary’s Part D Premium Amount Net of De Minimis if
Applicable, (----9.99)
Beneficiary’s Part D LEP Amount
(––9.99)
Beneficiary’s LIS Subsidy Amount
(----9.99)
Beneficiary’s LIS Penalty Subsidy Amount,
(----9.99)
Beneficiary’s Part D Penalty Waived Amount,
(----9.99)
Total Calculated Premium for Beneficiary
(----9.99)
Amount by which a Part D De Minimis Plan’s beneficiary
premium exceeds the applicable regional low-income
premium subsidy benchmark.
December 28, 2012 F-97 LIS/Part D Premium Data File