PBP outpatient hospital (cleaned view)

What it is

1. 1A normalized, analytics-ready semantic view of the Medicare Advantage (Part C) Plan Benefit Package (PBP) Section B9a — outpatient hospital benefits — flattening CMS's quarterly PBP submissions into one tidy enrollee cost-share record per plan, per snapshot, per outpatient-hospital sub-benefit.
2. 2It tells you what an MA enrollee pays out-of-pocket (copay/coinsurance) for outpatient hospital services and outpatient observation, plus authorization/referral rules, for ~7,400 plans/year going back to 2010.

Grain

How to read it

1. 1Get the latest enrollee out-of-pocket cost for outpatient hospital services per MA plan for plan-year 2026, de-duplicated to one snapshot: SELECT contract_id, plan_id, segment_id, cost_share_string, copay_amount, coinsurance_pct, auth_required FROM medicare_semantic.vw_pbp_outpatient_hospital WHERE report_year=2026 AND quarter=1 AND outpatient_hospital_sub_benefit='outpatient_services'.
2. 2Answers: 'for each 2026 MA plan, what does a member pay (flat copay or % coinsurance) for an outpatient hospital visit, and is prior auth required?' To compare across plan years, hold quarter fixed (e.g. the max quarter per year) so you don't count the same plan multiple times.

Traps

1. 1SNAPSHOTS, NOT HISTORY — querying without filtering quarter double/triple/quadruple-counts plans. The same plan-year is republished across Q1-Q4 with identical benefits (verified: H0028/013 shows the same $40 copay across all four 2019 quarters). There is NO is_current column. To get one row per plan-year, filter to a single snapshot, e.g. the MAX(quarter) per report_year. report_year is the real history axis (2010-2026), NOT the 'quarter' column the auto-profiler labeled as time.
2. 2MINIMAL GRAIN needs outpatient_hospital_sub_benefit — (contract_id, plan_id, segment_id, report_year, quarter) gives 179,479 rows but the table has 358,958 because every plan-snapshot has 2 rows: 'outpatient_services' and 'outpatient_observation'. Forgetting this column doubles your counts. Adding network_type/source_pbp_section/benefit_category does NOT help — they are constants (in_network / B9A / outpatient_hospital).
3. 3has_copay / has_coinsurance are STRUCTURAL design flags, not value-present flags — has_copay=True with copay_amount NULL in 60,377 rows; has_coinsurance=True with coinsurance_pct NULL in 49,529. They mean 'the cost-share design includes this component', not 'the number was extracted'. All four has_* booleans are also nullable (NULL in 17,804 rows). To find rows with an actual dollar/percent, test copay_amount IS NOT NULL / coinsurance_pct IS NOT NULL, not the has_* flags.
4. 4An ENTIRE family of columns is 100% NULL here because this is a shared wide schema across all PBP categories: every limit_* field, every benefit_amount* field, normalization_status/basis, aggregation_policy, and max_oop_applies. Do not expect benefit limits or dollar-allowance fields from this view — they apply to other categories (dental allowances, transportation trip caps), not outpatient hospital.
5. 5Several 'quality/provenance' columns are constant single-values and carry NO discriminating signal in this view: numeric_amount_observability='offered_without_numeric_amounts' (MISLEADING — many numeric amounts ARE present), null_amount_reason='unknown_requires_crosswalk', offered_status='offered', confidence_tier='source_faithful', annualization_policy='not_numeric', combined_limit_policy='none_detected', consumer_document_reconciliation_status='not_checked'. Treat confidence_tier='source_faithful' + reconciliation='not_checked' as the real caveat: these are raw PBP values, NOT independently corroborated against consumer Summary-of-Benefits docs.
6. 6copay_amount_min/max and coinsurance_pct_min/max are a PLAN-LEVEL RANGE across the plan's B9a cost-share tiers, not per-row bounds and not cross-plan statistics. copay_amount is the headline value; copay_amount_max can be much higher (differs in 55,312 rows, e.g. headline $110, max $325). Use min/max to see the full copay spread within a plan; use copay_amount/cost_share_string for the headline.
7. 7version and quarter both look like keys but are snapshot/file attributes, not benefit dimensions. version is uniquely determined by (plan, report_year, quarter) — exactly 1 per snapshot — and changes year-over-year as plans resubmit; it is CMS's PBP file version, not part of the grain.

Columns (67)

Query it

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