Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 Item Field Size Position Description 23 24 25 26 27 28 29 30 31 32 33 Default Risk Factor Code Risk Adjuster Factor A Risk Adjuster Factor B Number of Paymt/Adjustmt Months Part A Number of Paymt/Adjustmt Months Part B Adjustment Reason Code Paymt/Adjustment/M SA Start Date Paymt/Adjustment/M SA End Date Demographic Paymt/Adjustmt Amount A Demographic Paymt/Adjustmt Amount B Monthly Paymt/Adjustmt Amount A 1 71-71 7 72-78 NN.DDDD 7 79-85 NN.DDDD 2 86-87 99 2 88-89 99 2 90-91 Prior to 2004, ‘Y’ indicates a new enrollee risk adjustment (RA) factor was in use. In the period 2004 through 2008, ‘Y’ indicates that a default factor was generated by the system due to lack of a RA factor. For 2009 and after, for payments and payment adjustments and regardless of the effective date of the adjustment, the following applies: ‘1’ = Default Enrollee- Aged/Disabled ‘2’ = Default Enrollee- ESRD dialysis ‘3’ = Default Enrollee- ESRD Transplant Kidney, Month 1 ‘4’ = Default Enrollee- ESRD Transplant Kidney, Months 2- 3 ‘5’ = Default Enrollee- ESRD Post Graft, Months 4-9 ‘6’ = Default Enrollee- ESRD Post Graft, 10+Months ‘7’ = Default Enrollee Chronic Care SNP Blank = The beneficiary is not a default enrollee. FORMAT: 99 Always Spaces on Payment and MSA Deposit or Recovery Records 8 92-99 FORMAT: YYYYMMDD 8 100-107 FORMAT: YYYYMMDD 9 108-116 9 117-125 9 126-134 FORMAT: -99999.99 Prior to 2008, Demographic Paymt/Adjustmt Amount A is displayed. In 2008 and beyond, Demographic Paymt/Adjustmt Amount A is displayed as 0.00. FORMAT: -99999.99 Prior to 2008, Demographic Paymt/Adjustmt Amount B is displayed. In 2008 and beyond, Demographic Paymt/Adjustmt Amount B is displayed as 0.00. Part A portion for the beneficiary’s payment or payment adjustment dollars. For Medicare Savings Account (MSA) Plans, the amount does not include any lump sum deposit or recovery amounts. It is the Plan capitated payment only, which includes the MSA monthly deposit amount as a negative term. FORMAT: -99999.99 December 28, 2012 F-38 Monthly Membership Detail Data File
Plan Communications User Guide Appendices, Version 6.3 Item Field Size Position Description 34 35 Monthly Paymt/Adjustmt Amount B LIS Premium Subsidy 9 135-143 36 ESRD MSP Flag 1 152-152 37 38 39 MSA Part A Deposit/Recovery Amount MSA Part B Deposit/Recovery Amount MSA Deposit/Recovery Months 40 Current Medicaid Status 41 42 Risk Adjuster Age Group (RAAG) Previous Disable Ratio (PRDIB) Part B portion for the beneficiary’s payment or payment adjustment dollars. For MSA Plans, the amount does not include any lump sum deposit or recovery amounts. It is the Plan capitated payment only, which includes the MSA monthly deposit amount as a negative term. FORMAT: -99999.99 8 144-151 FORMAT: -9999.99 8 153-160 8 161-168 2 169-170 1 171-171 4 172-175 7 176-182 43 De Minimis 1 183-183 As of January 2011: T = Transplant/Dialysis P = Post Graft Blank = ESRD MSP not applicable Prior to 2011: Format X. Values = ‘Y’ or ‘N’(default) Indicates if Medicare is the Secondary Payer MSA lump sum Part A dollars for deposit/recovery. Deposits are positive values and recoveries are negative. FORMAT: -9999.99 MSA lump sum Part B dollars for deposit/recovery. Deposits are positive values and recoveries are negative. FORMAT: -9999.99 Number of months associated with MSA deposit or recovery dollars Beginning mid-2008, this field reports the beneficiary current Medicaid status. (Prior to 11/07, Medicaid status was reported in field #19.) ‘1’ = Beneficiary is determined as Medicaid as of CPM minus two (CPM –2) or minus one (CPM – 1), ‘0’ = Beneficiary was not determined as Medicaid as of CPM minus two (CPM – 2) or minus one (CPM – 1), Blank = This is a retroactive transaction and Medicaid status is not reported. The four sources to determine Current Medicaid Status are: 1. MMA State files or Dual Medicare Table 2. Low Income Territory Table 3. Medicaid Eligibility Table (Only valid records with a Medicaid source code of "003U" and "003C" are used.) 4. Point of Sale Table BBEE BB = Beginning Age EE = Ending Age Beginning in 2011, if the risk adjuster factor is from RAS, the RAAG reported is the one used by RAS in calculating the risk factor NN.DDDD Percentage of Year (in months) for Previous Disable Add-On. Only on pre-2004 adjustments Prior to 2008, flag is spaces. Beginning 2008: ‘N’ = “de minimis” does not apply, ‘Y’ = “de minimis” applies. December 28, 2012 F-39 Monthly Membership Detail Data File
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Medicare Advantage and Prescription Drug Plans December 28 ...

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