The Centers for Medicare and Medicaid Services (CMS) transmits many types of files to Medicare Advantage organizations (MAOs). These files are used for managing plan performance, developing Medicare Advantage bids, and for financial reporting purposes. All MAOs should know what these files are and how to use information in them to gain insights into their plan performance.

This paper serves as a primer for actuaries and other data professionals at MAOs in understanding the various files plans receive from CMS, their naming conventions, and how they are typically used by MAOs when developing Medicare Advantage bids. There may be other uses for these files from financial reporting and plan performance management perspectives that are not addressed in this paper. This paper only addresses a subset of commonly used files that MAOs receive from CMS and should not be considered a comprehensive reference. CMS shares most of these files with MAOs through the Medicare Advantage Prescription Drug (MARx) system and through the Health Plan Management System (HPMS). Some of these files are distributed monthly or weekly while some are distributed annually or less frequently. MAOs can refer to the Medicare Advantage Prescription Drug Contracting (MAPD) Plan Communications User Guide (PCUG)¹ for additional details on the files exchanged through the MARx system. PCUG contains information for using the MARx system, an overview of how MAOs will send data to CMS, and the layouts for files exchanged between MAOs and CMS. Figure 1 identifies the various types of files MAOs receive from CMS and the frequency and timing for the availability of these reports, as well as the naming conventions to identify these files.

Figure 1: Selected CMS File Types

CMS files

Monthly Membership Records (MMRs). The MMRs contain member eligibility, risk scores, and prospective payments the MAO receives for each member in the upcoming month. They also contain retroactive adjustments to prior months’ records, for instance if a member passed away or was determined to have a different eligibility status. After updating risk scores in a “sweep” to include additional diagnosis data, CMS issues retroactive adjustments in an upcoming month to account for the change in revenue that results. CMS may also issue corresponding MMR summary files, which have “MONMEMSD” in the file name.

After compiling the MMRs to incorporate all retrospective records, MAOs may use the data to summarize their membership, risk scores, and revenue by:

• Plan benefit package (PBP) and segment
• County
• Month
• Status (ESRD, hospice, dual eligible, etc.)

Note that MMRs do not include the premium revenue that the MAO collects from each member. That information is contained in the Bid Pricing Tool (BPT) for each plan.

There are two ways of aggregating risk scores: one in which risk scores are weighted by the number of months the member was active during the period in question, and one in which they are weighted by the risk-based revenue earned over those active months. Both ways are appropriate in different contexts, and it is important to remember which is being used, as results will differ slightly.

Prescription drug events (PDEs). The PDEs are records of all drugs dispensed under the Part D program. The periodicity varies, and several contracts may be included in a single PDE file. There are two types of PDE files: those that MAOs must submit to CMS, and the files that CMS later returns with indications of the acceptance status of each claim. It is the latter that typically have “DDPS.RTN.RPT” or “PDERESP” in the file name.

The PDEs include the RxNorm concept unique identifier (RxCUI)² number associated with each drug. To obtain cost-sharing information, the MAO would need to reference the formulary file the plan had in effect at the time, which would indicate the tier number associated with that drug. The MAO would then reference the Plan Benefit Package (PBP) data for that plan to obtain the cost sharing associated with that tier.

After compiling the PDE data, MAOs may join it to the MMRs for the corresponding period by matching on the Medicare Beneficiary Identifier (MBI),³ with the eligibility month of the MMR matching the month containing the date of service of the PDE. The MAO can use this combined data for:

• Analysis by Part D payment phase
• Distribution of cost per prescription
• Distribution of annual cost per member
• Analysis of accumulations, with particular attention to members who joined midyear

Model Output Reports (MORs). Similar to MMRs, the MORs contain a record for each member. That record indicate CMS’s hierarchical condition codes (HCCs)⁴ for each member from CMS’s risk adjustment models. There are two varieties of MORs, for Parts C and D respectively, as each uses different models. In addition to these monthly files, CMS issues “final” MORs once or twice per year with updated information after the year has ended and planned runout data has been collected. These files have “HCCMOFD” or “PTDMOFD” in the name. Finally, CMS may issue data reports accompanying the monthly MORs, with “HCCMODR” or “PTDMODR” in the name. These are human-readable files that list the HCCs applicable to each member, with accompanying names and HCC descriptions.

Plan Payment Reports (PPRs). The Plan Payment Report (PPR) includes contract-level payment information. This report itemizes the final prospective monthly payments to the MAO. It is produced by the Automated Plan Payment System (APPS) after the final monthly payment is calculated based on payment data inputs from MARx and other systems. The PPR includes Part C and Part D capitated payments, premiums, fees and adjustments, the National Medicare Education Campaign (NMEC), coordination of benefits (COB) user fees, and premium settlement information. The PPR displays the net payment amount that corresponds to the amount deposited by the U.S. Treasury to the MAOs’ bank accounts each month. MAOs use information from the PPRs for medical loss ratio (MLR) reporting as well as comparing their revenue accrual estimates to final payments.

Risk Adjustment Processing System (RAPS) response files. The RAPS files contain member and diagnosis data reported by the MAO, to be used as inputs into CMS’s risk adjustment models. CMS is phasing out RAPS to use EDS files (defined below), and risk scores in recent years have been based on a blend of the scores produced by the risk adjustment models using the two sets of inputs. RAPS is scheduled to cease affecting revenue after payment year 2021.

Encounter Data System (EDS)⁵ response files. The most commonly used EDS files are called “MAO-004” and contain line-level claim data in a format CMS can use to determine which diagnoses to apply to the HCC risk score models. There have been several updates to the layout since EDS files first started being used. The current version is known as Phase 4, Version 0. These files are released monthly. In addition, CMS transmits EDS report cards⁶ on a quarterly basis.

Plan-to-plan (P2P) payment files. These P2P files include several different types of files. Among them are “COV42” files, which record, at a line level, Part D claims that were adjudicated under one PBP but should be ascribed to another. MAOs “shift” this amount when analyzing experience by PBP. “COV43” files contain summaries of the COV42 data. Both files typically come once per contract, per year.

Full Enrollment File Data (FEFD) files. The FEFD files are released by CMS to MAOs on a monthly basis and contain information on active plan membership as of the date the file is run. These files include a field for a low-income copay category applicable to Part D, and are often used to project the distribution of low-income members under different Part D low-income copay categories.

Beneficiary-level files. The beneficiary-level files report each member’s Medicaid status for each month of the preceding year, as well as the member’s risk score under the CMS risk adjustment model after it has been rerun to include RAPS and EDS submissions through January. They represent an update to the statuses and risk scores in the prior year’s monthly MMR files that is not reflected in current MMRs’ retrospective records for several more months. They should thus be used once they become available. When CMS is transitioning from one iteration of its models to another (e.g., the 2017 HCC Model to the 2019 HCC Model), the outputs from both models are included. There are three types of beneficiary-level files corresponding to three parts of Medicare Advantage: Part C, Part D, and the end-stage renal disease (ESRD) program. The layout varies between models and from year to year, and CMS publishes a specification document when the files are released, typically in April.

Quality bonus payment (QBP) file. CMS publishes the QBP file in the spring of each year to inform MAOs of the star rating that each contract has been awarded for the upcoming payment year. For example, the QBP file in April 2021 contained star ratings applicable to 2022, based on plan performance in 2019. Contracts that were new in 2020 or 2021 or had low enrollment in 2019 received default star ratings. The file can be downloaded from HPMS and will contain all contracts to which that HPMS user has access.

Total beneficiary cost (TBC) data files. CMS provides two files during bid development to enable MAOs to verify compliance with limits on the permissible year-over-year increase in total beneficiary cost (TBC). The first file shows the steps used to calculate this increase for each applicable plan, with inputs variously coming from within the file, from the CMS out-of-pocket cost (OOPC) tool (based on formularies and benefits for the upcoming year), from the plan’s intended premium for the upcoming year, and from certain published information from CMS, such as the Part B premium and TBC increase limit.

The second file shows the composition by service category for the OOPC underlying the starting TBC amount (i.e., before increase) for each plan.

The TBC calculations from CMS assume no service area changes from one year to the next, so certain special rules apply when MAPD plans merge, split, transfer a county from one segment to another, or make changes that alter a plan's star rating, such as novating one contract to another. In particular, changing the star rating will cause the data element “Payment Adjustment Based on Plan Situation” to differ from its reported value in the TBC data file. MAOs can apply these rules and rederive the payment adjustment based on a plan situation during bid development to verify compliance.

Formulary Reference Files (FRFs). The FRFs supply, in tabular form, the drug-specific information underlying CMS’s rules regarding formulary compliance, such as minimum coverage and protected classes. It is typically released twice per year, at which time MAOs can use it to update their formularies and verify compliance. In between FRF updates, MAOs are constrained regarding permissible formulary changes. They can add drugs to the formulary and alter their pharmacy management protocols (prior authorization, step therapy) but can neither remove drugs nor change the tier. This file does not contain a comprehensive list of drugs but rather only those related to the minimum regulatory requirements.

Processing files: Putting it all together

The flowchart in Figure 2 is an example of how the various files are used by MAOs to process information and how they fit into generating the final Part C and Part D Bid Pricing Tools (BPTs). It is intended to be illustrative and does not include all the steps in bid preparation.

We assume that MAOs have their own internal processes and tools to summarize the different files and information they receive. The flowchart in Figure 2 is just one example of how the different files fit into the bid pricing and financial monitoring processes. The files above include those that are most relevant to bid development. CMS releases many other files and more information during the year and MAOs should watch for notifications from CMS to understand how to use and process this information in order to gain insights into their MA membership and develop product strategies.

Caveats and limitations

The information in this paper is intended to assist actuaries and management at MA and Part D plans with understanding various commonly used files plans receive from CMS. These files typically have multiple uses, including Medicare Advantage bid development, financial reporting, and managing plan performance. This paper reflects our best understanding of the current files and naming conventions. To the extent that the file names and conventions change in the future, some of the information in this paper may no longer be valid. Additionally, this paper is only a brief summary and does not capture every single file and all information plans receive from CMS. This paper may not be appropriate for other purposes and our interpretations should not be interpreted as legal interpretations.

The material in this report represents the opinion of the authors and is not representative of the views of Milliman. As such, Milliman is not advocating for or endorsing any specific views in this report related to Medicare Advantage and Part D.

¹ CMS. MAPD Plan Communications User Guide (PCUG). Retrieved February 2, 2022, from https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Plan_Communications_User_Guide.

² National Library of Medicine. RxNorm Overview. Retrieved February 2, 2022, from https://www.nlm.nih.gov/research/umls/rxnorm/overview.html.

³ CMS (March 19, 2020). New Medicare Beneficiary Identifier (MBI) Get It, Use It. MLN Matters. Retrieved February 2, 2022, from https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se18006.pdf.

⁴ Berger, C.N. & Goetsch, E.P. (January 2011). Medicare Advantage Hierarchical Condition Categories: Targeting Chart Reviews. Retrieved February 2, 2022, from https://advice.milliman.com/en/insight/medicare-advantage-hierarchical-condition-categories-targeting-chart-reviews.

⁵ Bell, D., Koenig, D., & Mills, C. (September 2016). Medicare Advantage and the Encounter Data Processing System: Be Prepared. Milliman White Paper. Retrieved February 2, 2022, from https://www.milliman.com/en/insight/medicare-advantage-and-the-encounter-data-processing-system-be-prepared.

⁶ U.S. Department of Health and Human Services (October 4, 2019). Encounter Data Report Card Re-design. Guidance Portal. Retrieved February 2, 2022, from https://www.hhs.gov/guidance/document/encounter-data-report-card-re-design.