PBP home health (cleaned view)

What it is

1. 1A normalized, source-faithful view of the Medicare Advantage home-health benefit (PBP Section B6) for every MA/Part-C plan-benefit-package, derived from CMS's annual/quarterly PBP Public Use Files.
2. 2One row states, for a given plan in a given filing snapshot, the member cost-share for in-network home health (copay and/or coinsurance flags), plus authorization/referral requirements and full provenance.
3. 3It is a plan-benefit-design (consumer-facing cost-share) table, NOT a paid-claims or fee-schedule table.

Grain

How to read it

1. 1To get the current-year in-network home-health cost-share for every MA plan, deduping the redundant quarterly snapshots: SELECT contract_id, plan_id, segment_id, copay_amount, has_copay, has_coinsurance, auth_required, referral_required FROM medicare_semantic.vw_pbp_home_health WHERE report_year = 2026 (2026 has a single annual snapshot = 7,420 plan rows; of these 3,455 specify a copay - 3,447 of them $0 - and 1,295 use coinsurance).
2. 2For multi-snapshot years (e.g.
3. 32023) add a quarter filter such as AND quarter = 1, or wrap in ROW_NUMBER() OVER (PARTITION BY contract_id,plan_id,segment_id ORDER BY quarter DESC, version DESC) = 1, to avoid double-counting plans.
4. 4Answers: 'what does each MA plan charge a member for home health, and does it require prior auth/referral, for a given year?'

Traps

1. 1GRAIN TRAP - quarter is a re-release index, not a calendar quarter, and snapshots are REDUNDANT: for 2018-2020/2022-2024 a plan appears under 2-4 quarterly snapshots whose copay never drifts (0 of 38,598 multi-quarter plan-years differ). Querying without deduping inflates plan counts ~2x for those years. To get one row per plan-year, filter to one quarter (e.g. WHERE quarter = 1) or qualify by ROW_NUMBER over quarter DESC. There is NO is_current / latest flag — you must pick the snapshot yourself.
2. 2COINSURANCE IS A DEAD END FOR NUMBERS: coinsurance_pct is 100% NULL even though has_coinsurance=TRUE on 39,227 rows. You can tell a plan USES coinsurance but you cannot get the percent from this table. Likewise benefit_amount and its entire annualized/pmpm/period family are 100% NULL (home health carries no $-allowance), as are all limit_* columns.
3. 3COPAY COVERAGE IS PARTIAL AND $0-DOMINATED: copay_amount is populated on only 79,807/201,488 rows (40%); 96% of those are $0 (home health is $0 under Original Medicare). A NULL copay does NOT mean $0 - it means either a coinsurance plan or cost-share-not-captured. Do not impute 0 for nulls.
4. 4MANY 'POLICY' COLUMNS ARE DEGENERATE/MISLEADING IN THIS VIEW: numeric_amount_observability ('offered_without_numeric_amounts'), null_amount_reason, annualization_policy, combined_limit_policy, consumer_document_reconciliation_status ('not_checked'), confidence_tier ('source_faithful'), offered_status, benefit_category, network_type, home_health_sub_benefit, source_pbp_section, source_silver_table, lmi_authorities each have exactly ONE value across all rows. In particular numeric_amount_observability='offered_without_numeric_amounts' is self-contradictory here (40% have copay numbers) - it describes the benefit_amount family, not copay. Never filter on these expecting variety.
5. 5NULLS ENCODE VINTAGE, NOT ABSENCE: auth_required is ~100% NULL for report_year 2001-2017 then populated 2018+; has_copay/has_coinsurance are NULL on 10,175 older rows. A NULL flag means 'CMS PBP of that year did not capture this field', not 'no auth / no cost-share'. Cohort your analysis by report_year. Also consumer_document_reconciliation_status='not_checked' everywhere: these are raw PBP design values, NOT validated against published Summary-of-Benefits/EOC docs.
6. 6NOT A PAID-CLAIMS / FEE-SCHEDULE TABLE: this is MA plan BENEFIT-DESIGN member cost-share (copays/coinsurance flags) from CMS PBP filings - it is not what Medicare or the plan PAYS providers and is not a fee schedule. For provider-paid home-health amounts use the Medicare fee-schedule / claims sources, not this view.

Columns (49)

Query it

describe_data_source(source_fqn="medicare_semantic.vw_pbp_home_health")     # the card, live
query_substrate(sql="SELECT * FROM medicare_semantic.vw_pbp_home_health WHERE contract_id = '<value>' AND plan_id = '<value>' AND segment_id = '<value>' AND report_year = '<value>' AND quarter = '<value>' LIMIT 100")