MA pbp section c oon

What it is

1. 1CMS Medicare Advantage Plan Benefit Package (PBP) Section C — out-of-network (OON) outpatient cost-sharing.
2. 2One row per OON benefit cost-share group within an MA plan, giving the member's out-of-network coinsurance %, copay $, deductible, and per-benefit maximum for outpatient services.
3. 3Sourced from CMS quarterly PBP-benefits ZIP releases (e.g. pbp-benefits-2020-quarter-2.zip).
4. 4Applies to plan types that permit out-of-network use (Local PPO, Regional PPO, PFFS);
5. 5HMOs barely appear.

Grain

How to read it

1. 1Get the 2024 out-of-network member cost-share for each PPO plan, de-duplicated across the quarterly republications: SELECT contract_id, plan_id, segment_id, pbp_c_oon_outpt_group_num_id, pbp_c_oon_outpt_grp_lbl, pbp_c_oon_outpt_coins_max_pct, pbp_c_oon_outpt_copay_max_amt FROM pbp_section_c_oon WHERE report_year=2024 AND quarter=(SELECT max(quarter) FROM pbp_section_c_oon WHERE report_year=2024) AND pbp_a_plan_type IN ('04','31') -- Local/Regional PPO.
2. 2This answers 'what does a member pay out of network for outpatient services in each PPO plan', one row per OON cost-share group, without quarter-driven double counting.

Traps

1. 1QUARTER IS A REPUBLICATION SNAPSHOT, NOT A KEY YOU CAN SUM OVER. For 2018-2020 the same annual bid was republished in Q1-Q4 with ~identical values (of 13,082 multi-quarter plan+group keys in 2020, only 13 had any coinsurance change). A query like WHERE report_year=2020 without pinning one quarter double/triple-counts every plan. Pick a single quarter (e.g. the max quarter per plan-year), or dedup on the 6-col grain minus quarter, before aggregating. Note row counts per year reflect this: 2026 is huge (192K) because it has many bid VERSIONS in Q1, while 2018-2020 are inflated by 4x quarterly republication.
2. 2version IS in the grain via year+quarter but is a RED HERRING as a standalone dedup axis. Within one (report_year, quarter) each plan has exactly ONE version, and different versions hold different plans — version is the CMS bid-submission counter, not competing snapshots of one plan. Do NOT filter to 'version=latest' to dedup a plan; that would drop most plans entirely.
3. 3Many money/flag columns are NULL-because-not-applicable, not missing data. ded_amt is null unless ded_yn='1' (only 1,637 rows). maxplan_amt/maxplan_per are null unless maxplan_yn='1' (34K rows, mostly supplemental benefits). The entire cs_* family and cost_share/coins_cov are ~99% null — they exist only for a tiny set of plans with secondary/tiered structures. coins_*pct is null where coins_yn!='1', copay_*amt null where copay_yn!='1'. Always gate on the matching _yn flag before reading the amount.
4. 4bid_id is 100% derivable (contract_id||'_'||plan_id||'_'||segment_id) and observed_period/effective_period_start/effective_period_end are 100% derivable from report_year — none add information; do not treat them as independent dimensions or join keys.
5. 5This is the OUT-OF-NETWORK table (PPO/PFFS only). Sibling tables in medicare_silver are pbp_section_c (main Section C / in-network outpatient benefits) and pbp_section_c_pos (point-of-service). To compare in- vs out-of-network member cost you must join this to pbp_section_c on contract_id+plan_id+segment_id+report_year(+quarter). HMOs (plan_type 01) are nearly absent here because they generally cover no out-of-network outpatient benefit.
6. 6Benefit applicability lives in semicolon-delimited code LISTS (pbp_c_oon_out_mc_bendesc_cats for Medicare-covered, _nmc_ for supplemental), using the CMS PBP benefit-category code system (e.g. 10a1=ambulance, 15=Part B drugs, 17a=eye exam). You cannot filter to 'ambulance OON cost' by a single column — you must string-match the category code within these list fields. grp_lbl is free text (plan-chosen, e.g. '30%', 'Dental') and is not a reliable controlled vocabulary.

Columns (50)

Query it

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