Medicare Advantage, Part D, Medicaid

PBP renal dialysis (cleaned view)

medicare_semantic.vw_pbp_renal_dialysis·live·semantic_view·annual

Rows

N/A

Columns

History

2001 to 2026

Card

yesgrain, traps, filters

Typed tools

What it is

1A semantic gold view of the Medicare Advantage PBP (Plan Benefit Package) Section B12 "Renal Dialysis" benefit: one normalized cost-sharing record per MA/MA-PD plan-segment per annual (and in some years quarterly) CMS PBP file release, 2001-2026.
2It captures what enrollees pay out-of-pocket for kidney dialysis under each Medicare Advantage plan, plus auth/referral rules and rich provenance/confidence metadata.
3Used to benchmark MA dialysis cost-sharing across plans and over time.

Grain

Key Grain

Key	Grain
`contract_idplan_idsegment_idreport_yearquarter`	1One row per Medicare Advantage plan-segment per PBP file snapshot. 2The minimal verified-unique key is (contract_id, plan_id, segment_id, report_year, quarter) = 201,488 distinct combinations = 201,488 total rows (exact). 3All five columns are load-bearing: dropping quarter collapses to 114,175; dropping segment_id to 191,793; dropping report_year to 59,740. network_type, renal_dialysis_sub_benefit, and benefit_category are all single-valued ('in_network' / 'renal_dialysis' / 'renal_dialysis') so they are NOT part of the grain. 4The view is already deduplicated to one PBP submission version per plan-snapshot (version is functionally dependent on the grain, not a dedup axis).

contract_idplan_idsegment_idreport_yearquarter

1One row per Medicare Advantage plan-segment per PBP file snapshot.
2The minimal verified-unique key is (contract_id, plan_id, segment_id, report_year, quarter) = 201,488 distinct combinations = 201,488 total rows (exact).
3All five columns are load-bearing: dropping quarter collapses to 114,175; dropping segment_id to 191,793; dropping report_year to 59,740. network_type, renal_dialysis_sub_benefit, and benefit_category are all single-valued ('in_network' / 'renal_dialysis' / 'renal_dialysis') so they are NOT part of the grain.
4The view is already deduplicated to one PBP submission version per plan-snapshot (version is functionally dependent on the grain, not a dedup axis).

How to read it

1Benchmark MA dialysis coinsurance for a given year, deduping the quarter fan-out: SELECT coinsurance_pct, COUNT(*) FROM medicare_semantic.vw_pbp_renal_dialysis WHERE report_year=2026 AND quarter=1 AND coinsurance_pct IS NOT NULL GROUP BY coinsurance_pct ORDER BY 2 DESC; -- answers 'what coinsurance % do MA plans charge for renal dialysis in 2026' (you'll see 20% dominate).
2For trend, group by report_year with quarter=1 (or max quarter per year) to avoid 4x-counting plans in multi-quarter years.
3Join to plan-level enrollment via (contract_id, plan_id, segment_id, report_year).

Traps

1QUARTER FAN-OUT is the #1 trap: report_year is the real time axis, but for 2018-2020 and 2022-2024 CMS ships multiple quarterly snapshots, so the SAME plan-year appears up to 4x (one row per quarter, each with a distinct sha256_content_hash). Most years are Q1-only. To get one row per plan per year you MUST filter to a single quarter (e.g. quarter=1) or pick max(quarter) - otherwise you 4x-count plans in those years.
2DOLLAR AMOUNTS DO NOT EXIST HERE: copay_amount, benefit_amount (and its whole _kind/_annualized/_pmpm/_period family), limit_quantity/limit_text/limit_unit/limit_period_code, max_oop_applies, and normalization_status/basis/aggregation_policy are ALL 100% NULL. The only populated cost lever is coinsurance_pct (and its min/max/string). This is by design (numeric_amount_observability='offered_without_numeric_amounts') - PBP B12 records dialysis cost-share as a coinsurance %, the standard being 20% (73% of rows).
3MANY COLUMNS ARE SINGLE-VALUED (degenerate), so they look meaningful but never filter anything: benefit_category, renal_dialysis_sub_benefit, network_type ('in_network'), offered_status ('offered'), source_pbp_section ('B12'), source_silver_table, lmi_authorities, confidence_tier ('source_faithful'), numeric_amount_observability, null_amount_reason, annualization_policy, combined_limit_policy, consumer_document_reconciliation_status. network_type='in_network' for ALL rows means out-of-network dialysis cost-share is NOT in this view.
4NULLS ENCODE DATA VINTAGE, not 'no/zero': auth_required is NULL for every year before 2018 (legacy PBP layouts didn't capture it - it is not 'no auth required'). Numeric coinsurance_pct only begins ~2009. segment_id is empty-string '' (not '0') in 2001-2005, the pre-segmentation era - normalize ''->'0'/null before joining.
5has_* booleans are INDEPENDENT of the numeric columns and can contradict them: has_copay=TRUE in ~14,458 rows while copay_amount is always null; has_coinsurance=TRUE while coinsurance_pct is null in 5,212+ rows. Trust the flag for presence, but never infer a dollar amount from it. Use coinsurance_pct_min<>coinsurance_pct_max (7,034 rows) to detect coinsurance RANGES rather than point values.
6version is NOT a dedup key you need to apply: the grain (contract_id, plan_id, segment_id, report_year, quarter) is already unique, so the view has pre-selected one PBP submission version per plan-snapshot. Likewise sha256_content_hash and source_url are per-file-snapshot (40 distinct), not per-row identifiers - do not GROUP BY them expecting row uniqueness.

Columns (50)

Column	Type	Meaning
`contract_id`	string	CMS Medicare Advantage contract ID (e.g. 'H0028'). Prefix encodes type: H = local MA/MA-PD (1,933 contracts, 197,609 rows), R = regional PPO (37 contracts), E = employer/EGWP (2 contracts). Grain key part 1. 1,972 distinct.
`plan_id`	string	Plan ID within the contract (3-char, e.g. '001','014'). Identifies a specific benefit package under the contract. Grain key part 2. NOT unique on its own (656 distinct, reused across contracts).
`segment_id`	string	Plan segment ID (geographic/benefit segment). '0' for non-segmented plans (181,424 rows). Empty string '' (5,074 rows) is the LEGACY non-segmented representation used only in 2001-2005 - treat as null/0 for joins. Values '1'-'27' for segmented plans. Grain key part 3.
`version`	double	PBP file resubmission version within the year (plans refile multiple times). 0 for 2001-2006 (single-version era); 1-27 for 2007+. FUNCTIONALLY DEPENDENT on the grain - the view already keeps one version per plan-snapshot, so it is NOT needed to make rows unique and should not be treated as a key.
`report_year`	double	Benefit/contract year the PBP applies to (2001-2026). THIS IS THE REAL TIME AXIS for trend analysis, not 'quarter'. Stored as double.
`quarter`	double	Within-year CMS file-release snapshot (1-4). Most years have only Q1; but 2018-2020 and 2022-2024 ship multiple quarterly releases, so the SAME plan-year can appear up to 4x (one row per quarterly snapshot, each with its own sha256). This is the #1 fan-out trap. Stored as double.
`benefit_category`	string	Constant 'renal_dialysis' for every row (degenerate). Identifies the PBP service category.
`cost_share_string`	string	Human-readable cost-share render, e.g. '20.0%'. EMPIRICALLY ALWAYS a coinsurance percent string - never contains a dollar copay or 'copay' text (0 dollar-like values observed). Pure restatement of coinsurance_pct. Null in 46,445 rows. 155,043 filled.
`copay_amount`	double	ALWAYS NULL (0 of 201,488 filled). Renal dialysis in PBP B12 is recorded as coinsurance, never a flat-dollar copay. Scaffolding column shared with sibling PBP views.
`coinsurance_pct`	double	Enrollee coinsurance percent for dialysis - the ONLY populated numeric cost lever. 20% dominates (146,858 rows = 73%, the standard Medicare Part B dialysis coinsurance); 0% (6,612); other values 2-100% (1,573). Null in 46,445 rows (older vintages + not-extracted). Numeric coverage starts ~2009. 155,043 filled.
`limit_text`	string	ALWAYS NULL (0 filled). Benefit-limit free text - never populated for renal dialysis.
`auth_required`	boolean	Boolean: prior authorization required for the benefit. NULL FOR ALL YEARS BEFORE 2018 (field not parsed in legacy PBP layouts) - null means 'not recorded in that vintage', not 'no auth'. 139,729 non-null (all 2018+).
`referral_required`	boolean	Boolean: referral required. Populated from 2002 onward (null only in 2001 and a few stragglers). 188,899 non-null. Null in early-2001 vintage means not-recorded.
`network_type`	varchar(10)	Constant 'in_network' for every row (degenerate). This view only carries the in-network cost-share leg; out-of-network is not represented here.
`max_oop_applies`	boolean	ALWAYS NULL (0 filled). Whether the benefit counts toward the plan MOOP - not populated for this benefit.
`limit_quantity`	double	ALWAYS NULL (0 filled). Numeric benefit limit - not populated.
`limit_unit`	string	ALWAYS NULL (0 filled). Unit for limit_quantity - not populated.
`limit_period_code`	string	ALWAYS NULL (0 filled). Period code for the limit - not populated.
`limit_period_label`	string	Always null (paired with limit_period_code). Human label for limit period - not populated.
`limit_quantity_per_year`	double	ALWAYS NULL (0 filled). Annualized limit quantity - not populated.
`benefit_amount`	double	ALWAYS NULL (0 filled). Plan-paid/benefit dollar amount - the entire benefit_amount_* family is empty for renal dialysis (this benefit is cost-share-only, not a dollar allowance like OTC/dental).
`benefit_amount_kind`	string	ALWAYS NULL (0 filled). Kind/type of benefit amount - not populated.
`benefit_amount_period_code`	string	Always null. Period code for benefit amount - not populated.
`benefit_amount_period_label`	string	Always null. Human label for benefit-amount period - not populated.
`benefit_amount_annualized`	double	ALWAYS NULL (0 filled). Annualized benefit dollars - not populated.
`benefit_amount_pmpm`	double	ALWAYS NULL (0 filled). Per-member-per-month benefit dollars - not populated.
`normalization_status`	string	ALWAYS NULL (0 filled). Status of the dollar-amount normalization pipeline - this benefit has no dollar amounts to normalize.
`normalization_basis`	string	ALWAYS NULL (0 filled). Basis used for normalization - not populated.
`aggregation_policy`	string	ALWAYS NULL (0 filled). Aggregation policy for combined limits - not populated.
`offered_status`	varchar(15)	Constant 'offered' for every row (degenerate). Every row represents a plan that offers the renal-dialysis benefit (Medicare requires MA plans to cover dialysis).
`numeric_amount_observability`	varchar(31)	Constant 'offered_without_numeric_amounts' for every row. Declares the central caveat of this view: the benefit is offered but PBP B12 carries no dollar amounts (only coinsurance %).
`null_amount_reason`	varchar(30)	Constant 'unknown_requires_crosswalk' for every row. Explains why dollar amounts are null - resolving them would require an external crosswalk.
`annualization_policy`	varchar(17)	Constant 'not_numeric' for every row. No numeric amount exists to annualize.
`combined_limit_policy`	varchar(29)	Constant 'none_detected' for every row. No combined/shared benefit limit detected.
`consumer_document_reconciliation_status`	varchar(11)	Constant 'not_checked' for every row. These records have not been reconciled against consumer-facing documents (EOC/SB).
`confidence_tier`	varchar(23)	Constant 'source_faithful' for every row. Indicates values are a faithful transcription of the CMS PBP source (no inference applied).
`coinsurance_pct_max`	double	Upper bound of the coinsurance band. 152,283 filled. Equals coinsurance_pct_min for point values (145,249 rows); differs in 7,034 rows where the plan files a coinsurance RANGE.
`coinsurance_pct_min`	double	Lower bound of the coinsurance band. 155,043 filled. Use (min,max) together to detect ranges; equals the point value when min=max.
`copay_amount_max`	double
`copay_amount_min`	double
`has_coinsurance`	boolean	Boolean parsed from the PBP yes/no flag, INDEPENDENT of the numeric column. Can be TRUE while coinsurance_pct is NULL (5,212+ rows: flag set but % not extracted). 191,289 non-null. Null only in 2001 vintage.
`has_copay`	boolean	Boolean copay flag from PBP. NOTE: has_copay=TRUE in ~14,458 rows even though copay_amount is ALWAYS null - the flag is preserved from source but the dollar value was never captured. Do not infer a copay dollar from this flag.
`has_deductible`	boolean	Boolean: a deductible applies to the benefit (from PBP flags). Almost always false; a handful of true rows. No deductible dollar column is populated.
`has_max_enrollee_oop`	boolean	Boolean: a max enrollee OOP applies (from PBP flags). Almost always false. Independent of the (always-null) max_oop_applies column.
`renal_dialysis_sub_benefit`	string	Constant 'renal_dialysis' for every row (degenerate). Placeholder for sub-benefit breakout that PBP B12 does not split for this view.
`source_pbp_section`	varchar(3)	Constant 'B12' for every row. The CMS PBP section this benefit is parsed from (Section B12 = Renal Dialysis).
`source_silver_table`	varchar(46)	Constant 'medicare_silver.pbp_section_b12_renal_dialysis'. The upstream silver-tier table this gold view is built from.
`lmi_authorities`	string	Constant single LMI URL (CY2026 PBP Service Category Descriptions PDF). The authoritative benefit-definition reference; same for all rows.
`source_url`	string	CMS PBP source zip for that snapshot - varies by (report_year, quarter). 40 distinct URLs. Legacy years use the mcradvpartdenroldata path; 2018+ use cms.gov/files/zip/pbp-benefits-YYYY[-quarter-N].zip. One file per snapshot.
`sha256_content_hash`	string	Content hash of the source PBP file snapshot (40 distinct = one per file release). It is PER-SNAPSHOT-FILE, not per-row: the same plan in different quarters of one year has DIFFERENT hashes (each quarterly release is a distinct file). Provenance/dedup anchor, not a row key.

Query it

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

Item	Value
Typed tools that read it	get_pbp_benefit
Identity key	`contract_id,plan_id,segment_id`
Join	`how_to_join(source_fqn="medicare_semantic.vw_pbp_renal_dialysis")`
Raw door	Athena (read-only via query_substrate): medicare_semantic.vw_pbp_renal_dialysis
Note	Cleaned PBP reasoning surface (categories/renal_dialysis/contract.yaml); raw is pbp_section_*.

This page as markdown: /docs-md/data/medicare_semantic_vw_pbp_renal_dialysis.md · every page in one file: /llms-full.txt