CY 2014 PBP Changes
When installing the PBP, the default installation location has been updated so the software will save directly into the root directory (C: drive), instead of the location C:\Program Files.
PBP SCREEN/CATEGORY: PBP File Pass screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_a_2012_12_03.doc
REASON WHY CHANGE IS NEEDED: To allow PBP users who use the Microsoft 7 operating system the ability to seamlessly read and write to the PBP database.
IMPACT ON BURDEN: Lowers Impact
The phrases “EST” or “Eastern Standard Time” have been updated throughout the PBP and SB to “Eastern Time.”
PBP SCREEN/CATEGORY: Section B-15 Home Infusion Bundled Services screen, B-20 Home Infusion Bundled Services screen, Medicare Rx General 2 screen, Alternative – Enhanced Alternative Characteristics screen,
DOCUMENT: PBP_2014_screenshots_section_b_2012_12_03.doc, PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc: 167, 212; Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc: 2, 29
CITATION: (Release 1, 6414, and Release 2, 6634)
REASON WHY CHANGE IS NEEDED: To improve accuracy.
The phrase "Highly Integrated D-SNPs" has been updated to "Dual Eligible SNPs with Highly Integrated Services" throughout the PBP software.
PBP SCREEN/CATEGORY: Section B – 13G – Dual Eligible SNPs with Highly Integrated Services – Base 1 Screen, 13G – Dual Eligible SNPs with Highly Integrated Services – Base 2 Screen, 13G – Dual Eligible SNPs with Highly Integrated Services – Base 3 Screen, Section C – OON – General - Base 2 Screen, OON – Groups – Base 1 Screen, POS – General – Base 1 Screen, POS – General – Base 2 Screen, POS – General – Base 4 Screen, POS – General – Base 5 Screen, POS – Groups – Base 1 Screen, Plan Deductible LPPO/RPPO Base 1 Screen, Plan Deductible LPPO/RPPO Base 2 Screen, Plan Deductible LPPO/RPPO Base 3 Screen, Plan Deductible LPPO/RPPO Base 5 Screen, Plan Deductible (Combined) - Base 1 Screen, Plan Deductible (Combined) - Base 2 Screen, Plan Deductible (In-Network) - Screen, Plan Deductible (Out-of-Network) - Screen, Plan Deductible (Non-Network) - Screen, Max Enrollee Cost Limit (Combined) – Base 1 Screen, Max Enrollee Cost Limit (Combined) – Base 2 Screen, Max Enrollee Cost Limit (In-Network)Screen, Max Enrollee Cost Limit (Out-of-Network)Screen, Max Enrollee Cost Limit (Non-Network)Screen, Max Plan Benefit Coverage Screen, Max Plan Benefit Coverage (Non-Network) Screen, PFFS Balance Billing, MMP – Medicaid/plan covered cost sharing,
Optional Supplemental – Service Categories Screen, MMP – Medicaid/plan covered cost sharing Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc, Appendix_C_PBP_2014_screenshots_section_c_2012_12_03.doc, Appendix_C_PBP_2014_screenshots_section_d_2012_12_03.doc,
PAGE(s): Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc: 145-147; Appendix_C_PBP_2014_screenshots_section_c_2012_12_03.doc: 2, 11, 13-14, 16-17, 27; Appendix_C_PBP_2014_screenshots_section_d_2012_12_03.doc: 1-3, 5, 7-18, 20, 22, 26,
CITATION: Section 1115A of the Social Security Act, codified at 42 U.S.C. 1315a
REASON WHY CHANGE IS NEEDED: To accurately depict the true naming convention
IMPACT ON BURDEN: No Impact, as MMPs are exempt from PRA approval.
The following new MMP Non-Medicare-covered benefits have been added to the Non-Medicare-covered picklists in Section C and D:
6: Home Health Services
7c: Occupational Therapy Services
7i: Physical Therapy and Speech-Language Pathology Services
11a: Durable Medical Equipment (DME)
11b: Non-Medicare-covered Prosthetics/Medical Supplies
13h: Additional Services
SOURCE: Industry
PBP SCREEN/CATEGORY: Section C – OON – General – Base 2 Screen, OON – General – Base 1 Screen, POS – General – Base 1 Screen, POS – General – Base 2 Screen, POS – General – Base 4 Screen, POS – General – Base 5 Screen, POS – Groups – Base 1 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_c_2012_12_03.doc, PBP_2014_screenshots_section_d_2012_12_03.doc
PAGE(s): 2, 11, 13-14, 16-17, 27
CITATION: Section 1115A of the Social Security Act, codified at 42 U.S.C. 1315a
REASON WHY CHANGE IS NEEDED: To include new MMP non-Medicare-covered benefits to the picklist, and make the list accurate.
IMPACT ON BURDEN: No Impact, as MMPs are exempt from PRA approval.
1. The following question has been added for all Non-$0 D-SNP plans on the Section A-2 screen: “Under this plan, has the state agreed to cover all Medicare premiums and coinsurance for enrollees in your full-benefit dual eligible SNP, including any that either don't have eligibility for, or have not enrolled in the QMB program?”
SOURCE: Industry
PBP SCREEN/CATEGORY: Section A-2 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_a_2012_12_03.doc
PAGE(s): 3
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: If users select yes to this question, then the SB accurately displays the $0 cost sharing as applicable. This is to reduce beneficiary confusion.
IMPACT ON BURDEN: Low Impact
2. The referral questions have been deleted for 10a: Ambulance Services within Section A, B, and C.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section A-5 Screen, Section B – 10a – Ambulance Services – Base 2 Screen, Section C – POS – General – Base 5
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_a_2012_12_03.doc, Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc, Appendix_C_PBP_2014_screenshots_section_c_2012_12_03.doc
PAGE(s): Appendix_C_PBP_2014_screenshots_section_a_2012_12_03.doc: 6; Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc: 111; Appendix_C_PBP_2014_screenshots_section_c_2012_12_03.doc: 17
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Referral is not permitted for ambulance.
IMPACT ON BURDEN: Lessens Impact
Plans must enter at least 10 characters in any notes field in Section B.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B - 1A - Inpatient Hospital-Acute – Base 12 Screen, Section B - 1A - Inpatient Hospital-Acute (B-Only) – Base 4 Screen, Section B – 1B - Inpatient Hospital Psychiatric – Base 12 Screen, Section B – 1B - Inpatient Hospital Psychiatric (B-Only) – Base 5 Screen, Section B – 2 – Skilled Nursing Facility – Base 7 Screen, Section B – 2 – Skilled Nursing Facility (B-Only) – Base 4 Screen, Section B – 3 – Cardiac and Pulmonary Rehabilitation Services – Base 4 Screen, Section B – 4A – Emergency Care – Base 4 Screen, Section B – 4B – Urgently Needed Care – Base 3 Screen, Section B – 4C – Worldwide Coverage – Base 3 Screen, Section B – 5 – Partial Hospitalization – Base 2 Screen, Section B – 6 – Home Health Services – Base 3 Screen, Section B – 7A – Primary Care Physician Services – Base 2 Screen, Section B – 7B – Chiropractic Services – Base 4 Screen, Section B – 7C – Occupational Therapy Services – Base 2 Screen, Section B – 7D – Physician Specialist Services – Base 2 Screen, Section B – 7E – Mental Health Specialty Services – Base 3 Screen, Section B – 7F – Podiatry Services – Base 3 Screen, Section B – 7G – Other Health Care Professional – Base 2 Screen, Section B – 7H – Psychiatric Services – Base 3 Screen, Section B – 7I – Physical Therapy and Speech Language Pathology Services – Base 2 Screen, Section B – 8A – Outpatient Diagnostic Procedures/Tests/Lab Services – Base 4 Screen, Section B – 8B – Outpatient Diagnostic/Therapeutic Radiological Services – Base 3 Screen, Section B – 9A – Outpatient Hospital Services – Base 3 Screen, Section B – 9B – Ambulatory Surgical Center Services – Base 3 Screen, Section B – 9C – Outpatient Substance Abuse – Base 3 Screen, Section B – 9D – Outpatient Blood Services – Base 2 Screen, Section B – 10A – Ambulatory Services – Base 2 Screen, Section B – 10B – Transportation Services – Base 3 Screen, Section B – 11A – Durable Medical Equipment – Base 2 Screen, Section B – 11B – Prosthetics/Medical Supplies – Base 3 Screen, Section B – 11C – Diabetic Supplies and Services – Base 2 Screen, Section B – 12 – End-Stage Renal Disease – Base 2 Screen, Section B – 13A –Acupuncture and Other Alternative Therapies – Base 3 Screen, Section B – 13B – OTC Items and Services– Base 3 Screen, Section B – 13C –Meal Benefit – Base 3 Screen, Section B – 13D – Other 1 – Base 3 Screen, Section B – 13E – Other 2 – Base 3 Screen, Section B – 13F – Other 3 – Base 3 Screen, Section B – 13G – Dual Eligible SNPs with Highly Integrated Services – Base 3 Screen, Section B – 13H – Additional Services – Base 4 Screen, Section B – 14A – Medicare-covered Preventive Services Screen, Section B – 14B – Annual Physical Exam – Base 3 Screen, Section B – 14C – Supplemental Education/Health Management Programs – Base 5 Screen, Section B – 14D – Kidney Disease Education Services – Base 3 Screen, Section B – 14E – Diabetes Self-Management Training – Base 3 Screen, Section B – 15 – Medicare Part B Rx Drugs – Notes (Optional) Screen, Section B – 16A – Preventive Dental – Base 5 Screen, Section B – 16B – Comprehensive Dental – Base 6 Screen, Section B – 17A – Eye Exams – Base 3 Screen, Section B – 17B – Eye Wear – Base 6 Screen, Section B – 18A – Hearing Exams – Base 4 Screen, Section B – 18B – Hearing Aids – Base 5 Screen, Section B – 20 – Outpatient Drugs – Notes (Optional) Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_08_23.doc
PAGE(s): 12, 16, 28, 33, 40, 44, 48, 52, 55, 58, 60, 63, 67, 71, 73, 76, 79, 82, 84, 87, 89, 95, 98, 101, 104, 107, 109, 111, 114, 116, 121, 124, 126, 129, 132, 135, 138, 141, 144, 147, 151-152, 155, 160, 163, 166, 169, 175, 181, 184, 190, 194, 199, 204
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To ensure that users do not provide a note that does not provide full explanation of a benefit.
IMPACT ON BURDEN: Low Impact
New screens have been added for MMPs so they can enter new Non-Medicare-covered services in 6: Home Health Services, 7c: Occupational Therapy Services, 7i: Physical Therapy and Speech-Language Pathology Services, 11a: Durable Medical Equipment (DME), 11b: Non-Medicare-covered Prosthetics/Medical Supplies,
SOURCE: Industry
PBP SCREEN/CATEGORY: Section B – 6 – Home Health Services – MMP Services – Base 1 Screen, 6 – Home Health Services – MMP Services – Base 2 Screen, 7c – Occupational Therapy Services – MMP Services – Base 1 Screen, 7i – Physical Therapy and Speech Language Pathology Services – Base 1 Screen, 7i – Physical Therapy and Speech Language Pathology Services – Base 2 Screen, 11a – Durable Medical Equipment – MMP Services – Base 1 Screen, 11a – Durable Medical Equipment – MMP Services – Base 2 Screen, 11b – Prosthetics/Medical Supplies – MMP Services – Base 1 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 64-65, 74, 90-91, 117-118, 122
CITATION: Section 1115A of the Social Security Act, codified at 42 U.S.C. 1315a
REASON WHY CHANGE IS NEEDED: To allow MMPs to enter Non-Medicare-covered services where the PBP currently does not allow for them.
IMPACT ON BURDEN: No Impact, as MMPs are exempt from PRA approval.
B-1: Inpatient Hospital Services
The term “global deductible” has been deleted from the following label on the 1a – Base 7, and 1b – Base 7 screens: “If you do not have a service-specific deductible for this benefit but offer a plan-specific, then enter the plan deductible in Section D.”
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 1a Inpatient Hospital-Acute – Base 7 screen, Section B – 1b Inpatient Hospital Psychiatric – Base 7 screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 7, 23
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: For increased accuracy.
IMPACT ON BURDEN: No Impact
B-2: Skilled Nursing Facility (SNF)
A validation has been added ensuring Cost Plans do not have cost sharing for the first 20 days for SNF.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 2 – Skilled Nursing Facility – Base 2 Screen, Section B – 2 – Skilled Nursing Facility – Base 5 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 35, 38
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Aligns PBP data entry with the policy of not allowing Cost plans to charge cost sharing for the first 20 days.
IMPACT ON BURDEN: Lessens Impact
B-4: Emergency Care/Urgently Needed Services
The enhanced benefit, Worldwide Coverage, has been moved from 4a: Emergency Care into a new section in 4c: Worldwide Coverage that only contains Worldwide Coverage. (Release 4, 5555)
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 4a – Emergency Care – Base 1 Screen, 4a – Emergency Care – Base 2 Screen, 4a – Emergency Care – Base 3 Screen, 4c – Worldwide Coverage – Base 1 Screen, 4c – Worldwide Coverage – Base 2 Screen, 4c – Worldwide Coverage – Base 3 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 49-51, 56-58
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Reduce confusion in data entry in the PBP software.
IMPACT ON BURDEN: Low Impact
B-7: Health Care Professional Services
The following question has been deleted on the 7i - Base 1 screen: “Do you apply the Medicare coverage limit?”
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 7i – Physical Therapy and Speech Language Pathology Services – Base 1 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 88
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: This is a confusing question in that the coverage limit does not apply if medically necessary.
IMPACT ON BURDEN: Lessens Impact
The new supplemental benefit "Medical Transport" has been added to 10b: Transportation Services.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section B – 10b – Transportation Services – Base 1 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 112
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Previously not an option in the picklist, that many plans indicated they are offering. .
IMPACT ON BURDEN: Low Impact
B-11: DME, Prosthetics, and Medical & Diabetic Supplies
The questions for Medical Supplies have been changed from blue to red, since SB sentences will now generate with the values entered.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section B – 11b – Prosthetics/Medical Supplies – Base 1 Screen, 11b – Prosthetics/Medical Supplies – Base 2 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 119, 120
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: These questions will now generate cost sharing sentences in the SB.
IMPACT ON BURDEN: No Impact
B-13: Other Supplemental Services
The name of 13a: Acupuncture has been changed to 13a: Acupuncture and Other Alternative Therapies.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 13a – Acupuncture and Other Alternative Therapies – Base 1 Screen, 13a – Acupuncture and Other Alternative Therapies – Base 2 Screen, 13a – Acupuncture and Other Alternative Therapies – Base 3 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 127-129
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Clarification on the type of data entry permitted in this section. Organizations are permitted to cover both acupuncture and other alternative therapies.
IMPACT ON BURDEN: No Impact
The name of B13b: OTC has been changed to 13b: OTC Items and Services.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 13b – OTC Items and Services – Base 1 Screen, 13b – OTC Items and Services – Base 2 Screen, 13b – OTC Items and Services – Base 3 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 130-132
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Clarification of the type of Part C other the counter items covered includes OTC items, such as diaplers.
IMPACT ON BURDEN: No Impact
The following label has been added to the 13b – Base 1 screen: “Medicare-Medicaid plans may not use this section to provide benefit information about any OTC drugs or items that are submitted under the integrated formulary. Information about those benefits will be entered in the Rx section of the PBP. This section should only be used to provide benefit information about OTC drugs and items that are covered as a supplemental benefit.”
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 13b – OTC Items and Services – Base 1 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 130
CITATION: Section 1115A of the Social Security Act, codified at 42 U.S.C. 1315a
REASON WHY CHANGE IS NEEDED: Alerting MMPs that they are not permitted to complete this section.
IMPACT ON BURDEN: No Impact, as MMPs are exempt from PRA approval.
The name of 13g: Highly Integrated D-SNP has been changed to 13g: Dual Eligible SNPs with Highly Integrated Services.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 13g – Dual Eligible SNPs with Highly Integrated Services – Base 1 Screen, 13g – Dual Eligible SNPs with Highly Integrated Services – Base 2 Screen, 13g – Dual Eligible SNPs with Highly Integrated Services – Base 3 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 144-146
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Clarification of the section and which type of D-SNPs are permitted to do data entry.
IMPACT ON BURDEN: No Impact
Ten new “Other” additional service choices have been added to 13h: Additional Services and the following questions have been added to 13h: Additional Services for each service option:
“Is there a service-specific maximum plan benefit coverage amount?”
“Indicate Maximum Plan Benefit Coverage Amount:”
“Indicate Maximum Plan Benefit Coverage Periodicity”
“Is there an enrollee coinsurance?”
“Indicate coinsurance percentage:”
“Is there an enrollee copayment?”
“Enrollee must receive authorization from one or more of the following:”
“Is a referral required for service?”
SOURCE: Industry
PBP SCREEN/CATEGORY: Section B – 13h – Additional Services
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc.
CITATION: Section 1115A of the Social Security Act, codified at 42 U.S.C. 1315a
REASON WHY CHANGE IS NEEDED: To allow for more data entry options for MMP to offer state-specific benefits.
IMPACT ON BURDEN: Medium Impact
B-14: Preventive and Other Defined Supplemental Services
A validation has been added requiring plans to enter text into the notes field if the Annual Physical Exam is chosen in Section 14b.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section B – 14B – Annual Physical Exam – Base 1 Screen, Section B – 14B – Annual Physical Exam – Base 3 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 153, 155
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Users are required to explain if their plans offer an Annual Physical Exam.
IMPACT ON BURDEN: Low Impact
The name of 14c: Supplemental Education/Wellness Programs has been changed to 14c: Supplemental Education/Health Management Programs.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 14c – Supplemental Education/Health Management Programs – Base 1 Screen, 14c – Supplemental Education/Health Management Programs – Base 2 Screen, 14c – Supplemental Education/Health Management Programs – Base 3 Screen, 14c – Supplemental Education/Health Management Programs – Base 4 Screen, 14c – Supplemental Education/Health Management Programs – Base 5 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 156-160
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Clarification of the section.
IMPACT ON BURDEN: No Impact
The supplemental benefit “Nutrition Education” has been renamed “Nutritional Benefit” in 14c: Supplemental Education/Health Management Programs.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 14c – Supplemental Education/Health Management Programs – Base 1 Screen, 14c – Supplemental Education/Health Management Programs – Base 3 Screen, 14c – Supplemental Education/Health Management Programs – Base 4 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 156, 158-159
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Clarification
IMPACT ON BURDEN: No Impact
The following supplemental benefit options have been added to 14c: Supplemental Education/Health Management Programs: “Enhanced Disease Management,” “Tele-Monitoring,” and “Web/Phone-Based Technology.”
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 14c – Supplemental Education/Health Management Programs
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To allow for more accurate data entry of the benefit design.
IMPACT ON BURDEN: Low Impact
Additional notes fields have been added for each supplemental benefit within 14c: Supplemental Education/Health Management Programs with a character limit of 1000.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section B – 14c – Supplemental Education/Health Management Programs
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Organizations are currently entering all of notes in one text box related to all Supplemental Education/Health Management programs. By dividing this out separately for o
IMPACT ON BURDEN: Low Impact
A validation has been added requiring plans to enter a note if any enhanced benefits are chosen in Section 14c.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section B – 14C – Supplemental Education/Wellness Programs – Base 1 Screen, Section B – 14C – Supplemental Education/Wellness Programs – Base 5 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 156, 160
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: For additional clarification for what the benefit offered will specifically entail.
IMPACT ON BURDEN: Low Impact
B-15: Medicare Part B Rx Drugs
The following question has been added for MMPs to the 15: Home Infusion Bundled Services screen: “Does the plan pay for Part D drug home infusion services and supplies as a Medicaid benefit?”
SOURCE: Industry
PBP SCREEN/CATEGORY: Section B – 15 Home Infusion Bundled Services Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 170
CITATION: Section 1115A of the Social Security Act, codified at 42 U.S.C. 1315a
REASON WHY CHANGE IS NEEDED: This is a new question only asked of MMP plan types. MMPs have different bundled benefits as required under the MMP financial alignment.
IMPACT ON BURDEN: No Impact, as MMPs are exempt from PRA approval.
The authorization and referral questions have been removed from 16a: Preventive Dental.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B – 16a – Preventive Dental – Base 5 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 175
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Plan users are not permitted to require authorization or referral for preventive dental.
IMPACT ON BURDEN: Lessens Impact
The authorization and referral questions have been removed from 17a: Eye Exams and 17b: Eyewear.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section B – 17a – Eye Exams – Base 3 Screen, 17b – Eye Wear – Base 5 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_b_2012_12_03.doc
PAGE(s): 184, 189
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Plan users are not permitted to require authorization or referral for this benefit.
IMPACT ON BURDEN: Lessens Impact
8a: Outpatient Diagnostic Procedures/Tests/Lab Services has been divided into the following two separate picklist items in every OON and POS Medicare-covered Service picklist: “8a1: Medicare-covered Diagnostic Procedures/Tests,” and “8a2: Medicare-covered laboratory services.”
SOURCE: Industry
PBP SCREEN/CATEGORY: Section C- OON – General Base 2 Screen, OON – Groups – Base 1 Screen, POS – General – Base 1 Screen, POS – General – Base 2 Screen, POS – General – Base 4, POS – General – Base 5, POS – Groups – Base 1
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_c_2012_12_03.doc
PAGE(s): 2, 11, 13-14, 16-17, 27
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To allow for more accurate data entry of the benefit design.
IMPACT ON BURDEN: Low Impact
Point of Service
HMO, HMO-POS, and PSO plans that offer an Optional Supplemental benefit will be able to offer the same benefit as part of an optional POS benefit.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section C- POS- General- Base 1 Screen, Section C- POS- General- Base 2 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_c_2012_08_23.doc
PAGE(s): 13, 14
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To allow for more accurate data entry of the benefit design.
IMPACT ON BURDEN: Lowers Impact
LPPO and RPPO plans may offer an annual plan level deductible if they choose to offer any deductible at all. There are new deductible screens for these plans, which will allow LPPO and RPPO plans to enter their deductible as follows:
All OON Medicare-covered services must be included in the deductible, except for 14a: Preventive Services, which may be excluded.
14a: Medicare-covered Zero Cost-Sharing Preventive Services may NOT be included in the deductible.
If a plan offers a Medicare-covered deductible in 1a: Inpatient Hospital-Acute and/or 1b: Inpatient Hospital Psychiatric within Section B, then that In-Network service category must be included in the annual deductible.
Differential deductibles may be applied to In-Network services. If any differential deductibles are entered, they must be included where no single differential deductible can be greater than the plan-level deductible amount and if a plan selects to use the 2014 rates any differential deductibles chosen can not exceed the anticipated 2014 rates that will be released in the Trustee's Report.
If Medicare-defined cost sharing is chosen in Section(s) 1a: Inpatient Hospital-Acute or 1b: Inpatient Hospital Psychiatric for either In-Network or Out-of-Network (Sections B or C), then the plan will not be allowed to choose the "Part B Deductible amount only” in Section D.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section D - Plan Deductible LPPO/RPPO Base 1 Screen, Plan Deductible LPPO/RPPO Base 2 Screen, Plan Deductible LPPO/RPPO Base 3 Screen, Plan Deductible LPPO/RPPO Base 4 Screen, Plan Deductible LPPO/RPPO Base 5 Screen, Plan Deductible LPPO/RPPO Base 6 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_d_2012_12_03.doc
PAGE(s): 1-6
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To allow for more accurate data entry of the benefit design, as specified in the regulation and statue. PBP did not previously accommodate this level of data entry.
IMPACT ON BURDEN: Medium Impact
The following questions have been added for MMPs, so they can differentiate between the provider of certain benefits (Medicaid, the plan, or both) on the new MMP – Medicaid plan covered cost sharing screen:
“Do you offer any Non-Medicare benefits (i.e., services not covered by Medicare or Medicaid)?”
“Select all of the service categories that include services covered under Medicaid:”
“Select all of the service categories that include plan-covered supplemental benefit (i.e., services not covered by Medicare or Medicaid)”
SOURCE: Internal
PBP SCREEN/CATEGORY: Section D – MMP – Medicaid/plan covered cost sharing Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_d_2012_12_03.doc
PAGE(s): 22
CITATION: Section 1115A of the Social Security Act, codified at 42 U.S.C. 1315a
REASON WHY CHANGE IS NEEDED: To allow for more accurate data entry of the benefit design for MMPs, which are newer plan types and previously did not complete data entry in the PBP.
IMPACT ON BURDEN: No Impact, as MMPs are exempt from PRA approval.
A deductible question has been added for each optional supplemental package on the Optional Supplemental – Label and Premium screen.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section D – Optional Supplemental – Label and Premium Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_d_2012_12_03.doc
PAGE(s): 25
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To allow for more accurate data entry of the benefit design. This previously had to be entered in a free-form textbox.
IMPACT ON BURDEN: Lessen Impact
PPO and Network PFFS plans that offer an Optional Supplemental benefit In-Network must answer "Yes" to the question "Does this category include OON Benefits?" on the Optional Supplemental – OON Step Up or Optional Supplemental – OON Optional screen for that specific category.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section D – Optional Supplemental – OON Step up Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_d_2012_12_03.doc
PAGE(s): 27
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Ensuring consistent data entry throughout the PBP software.
IMPACT ON BURDEN: No Impact
The following LTC attestation has been added to the Medicare Rx General 1 screen, which must be completed by all plans that offer Part D:
“Unless sponsor’s compliance is waived by the regulation, by checking the box below[sponsor] attests that it will comply with 42 CFR § 423.154 beginning January 1, 2013 regarding the appropriate dispensing of prescription drugs in long-term care (LTC) facilities. This section requires, among other things:
1) that certain drugs be dispensed to Part D enrollees in no greater than 14-day increments;
2) that the use of uniform dispensing techniques as defined by each of the LTC facilities be permitted;
3) that information be collected and reported in a form and manner specified by CMS on the dispensing methodology used for each applicable dispensing event and on the nature and quantity of unused brand and generic drugs dispensed to Part D enrollees in LTC facilities;
4) that the total cost-sharing for a Part D drug to which the LTC dispensing requirements apply must be no greater than the total that would be imposed if the requirements did not apply; and
5) that the terms and conditions offered by the sponsor to a network pharmacy must include provisions that address the disposal of drugs that have been dispensed to Part D enrollees in LTC facilities but not used and returned to the pharmacy, including whether credit and ruse is authorized.”
SOURCE: Internal
PBP SCREEN/CATEGORY: Medicare Rx – General 1 Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 1
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To clarify the LTC rules and regulations.
IMPACT ON BURDEN: Low Impact
A validation has been added preventing a plan with 5 tiers from selecting “Injectable" or "Specialty" for the 3rd radio button down for the Meaningful benefit tier. Instead they will have to choose the 5th or 6th radio button.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section Rx- Medicare RX – Tier 5 Model Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 7
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To allow proper SB sentences to generate.
IMPACT ON BURDEN: No Impact
The Tier Name(s) chosen on the Medicare Rx – Tier 2,3,4, etc Model screen will now show on all following screens where tier information is to be filled out.
SOURCE: Internal
PBP SCREEN/CATEGORY: Medicare Rx – Actuarially Equivalent – Tier Type and Cost Share Structure – Pre-ICL Screen, Actuarially Equivalent – Tier Locations – Pre-ICL Screen, Actuarially Equivalent – Retail Pharmacy Location Supply – Pre-ICL Screen, Actuarially Equivalent – Mail Order Location Supply – Pre-ICL Screen, Actuarially Equivalent – OON and LTC Location Supply – Pre-ICL Screen, Actuarially Equivalent – Retail Pharmacy Copayment and Coinsurance – Pre-ICL Screen, Actuarially Equivalent – Mail Order Copayment and Coinsurance – Pre-ICL Screen, Actuarially Equivalent – OON and LTC Copayment and Coinsurance – Pre-ICL Screen, Actuarially Equivalent – Tier Type – Post-OOP Threshold Screen, Actuarially Equivalent – Tier Cost Sharing – Post-OOP Threshold Screen, Alternative– Tier Type and Cost Share Structure – Pre-ICL Screen, Alternative– Tier Locations – Pre-ICL Screen, Alternative– Retail Pharmacy Location Supply – Pre-ICL Screen, Alternative– Mail Order Location Supply – Pre-ICL Screen, Alternative– OON and LTC Location Supply – Pre-ICL Screen, Alternative– Retail Pharmacy Copayment and Coinsurance – Pre-ICL Screen, Alternative– Mail Order Copayment and Coinsurance – Pre-ICL Screen, Alternative– OON and LTC Copayment and Coinsurance – Pre-ICL Screen, Alternative– Medicare-Medicaid Tier Type – Pre-ICL Screen, Alternative– Medicare-Medicaid Tier Locations – Pre-ICL Screen, Alternative– Medicare-Medicaid Retail Pharmacy Location Supply – Pre-ICL Screen, Alternative– Medicare-Medicaid Mail Order Location Supply – Pre-ICL Screen, Alternative– Medicare-Medicaid OON and LTC Location Supply – Pre-ICL Screen, Alternative– Medicare-Medicaid Copayment – Pre-ICL Screen, Alternative– Tier Type and Cost Share Structure – Gap Screen, Alternative– Tier Coverage – Gap Screen, Alternative– Tier Locations – Gap Screen, Alternative– Retail Pharmacy Location Supply – Gap Screen, Alternative– Mail Order Location Supply – Gap Screen, Alternative– OON and LTC Location Supply – Gap Screen, Alternative– Retail Pharmacy Copayment and Coinsurance – Gap Screen, Alternative– Mail Order Copayment and Coinsurance – Gap Screen, Alternative– OON and LTC Copayment and Coinsurance – Gap Screen, Alternative– Tier Type – Post-OOP Threshold Screen, Alternative– Tier Cost Sharing Post-OOP Threshold Screen, Alternative– Tier Type and Cost Share Structure Post-OOP Medicare-Medicaid Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 17-24, 26-27, 31-38, 40-45, 48-56, 58-59, 61
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To ensure more accurate data entry, and to help the users.
IMPACT ON BURDEN: Lessens Impact
MMPs have a new Alternative – Pre-ICL Medicare-Medicaid screen that includes the following questions:
“How do you apply your cost sharing before the Out-of-Pocket Threshold?”
“Will any of your tiers apply only the LIS cost sharing values?”
“Indicate each tier for which your cost sharing will be only the LIS cost sharing values:”
“Is there an annual Maximum Enrollee Out-of-Pocket Cost?”
“You must include all non-Part D covered prescription drugs and Medicaid-required OTC drugs and items on an Additional Demonstration Drug (ADD) file in a flat file which must be uploaded through the Formulary Submission Module by Friday, June 7th, 2012, at 12:00 pm Eastern Time. All OTC drugs that are being offered at $0 to the beneficiary, paid for through plan administrative costs and used in a formal step therapy protocol to obtain a formulary drug must still be placed on the OTC supplemental file.”
SOURCE: Internal
PBP SCREEN/CATEGORY: Medicare Rx – Alternative – Pre-ICL Medicare-Medicaid Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 39
CITATION: Section 1115A of the Social Security Act, codified at 42 U.S.C. 1315a
REASON WHY CHANGE IS NEEDED: To accommodate the new MMP type and ensure they offer the required Part D benefits.
IMPACT ON BURDEN: No Impact, as MMPs are exempt from PRA approval.
The Tier Type and Cost-Share Structure screen will be enabled for all BA, AE, and EA plans, even if “Medicare-defined Part D Coinsurance Amount” or “No cost sharing” is selected. The validations for the questions on this screen are as follows:
BA, AE, and EA plans will all fill out the question “Tier Drug Type(s)” for each tier offered.
BA and AE plans must choose “Part D Drugs Only” for the question “Tier Includes” for every tier offered.
If a plan offers Medicare Defined Cost Sharing, then “Coinsurance” must be chosen for the question “Indicate the type of cost sharing structure” for every tier offered.
If a plan offers $0 Cost Sharing, then “Copayment” must be chosen for the question “Indicate the type of cost sharing structure” for every tier offered.
SOURCE: Internal
PBP SCREEN/CATEGORY: Actuarially Equivalent – Tier Type and Cost Share Structure – Pre-ICL Screen, Alternative – Tier Type and Cost Share Structure – Pre-ICL Screen,
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 17, 31
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Certain plan types were able to bypass certain screens in CY2013, and did not complete necessary PBP data entry.
IMPACT ON BURDEN: Medium Impact
MMPs have a new Tier Type and Cost Share Structure screen that includes the following questions:
“Tier Drug Type(s) (select all that apply):”
“Tier includes (select only one for each tier):”
SOURCE: Internal
PBP SCREEN/CATEGORY: Alternative – Medicare-Medicaid Tier Type– Pre-ICL Screen,
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 40
CITATION: Section 1115A of the Social Security Act, codified at 42 U.S.C. 1315a
REASON WHY CHANGE IS NEEDED: To match the tier models that MMPs are required to offer.
IMPACT ON BURDEN: No Impact, as MMPs are exempt from PRA approval.
All the Location and Supply screens have been updated by combining the In-Network Preferred and Non-Preferred fields as well as the Mail Order Preferred and Non-Preferred fields.
SOURCE: Internal
PBP SCREEN/CATEGORY: Actuarially Equivalent – Tier Locations – Pre-ICL Screen, Actuarially Equivalent – Retail Pharmacy Location Supply – Pre-ICL Screen, Actuarially Equivalent – Mail Order Location Supply – Pre-ICL Screen, Alternative– Tier Locations – Pre-ICL Screen, Alternative– Retail Pharmacy Location Supply – Pre-ICL Screen, Alternative– Mail Order Location Supply – Pre-ICL Screen,
Alternative– Medicare-Medicaid Tier Locations – Pre-ICL Screen, Alternative– Medicare-Medicaid Retail Pharmacy Location Supply – Pre-ICL Screen, Alternative– Medicare-Medicaid Mail Order Location Supply – Pre-ICL Screen, Alternative– Tier Locations – Gap Screen, Alternative– Retail Pharmacy Location Supply – Gap Screen, Alternative– Mail Order Location Supply – Gap Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 18-20, 32-34, 41-43, 50-52
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To ensure more accurate data entry and for ease of data entry.
IMPACT ON BURDEN: Lessens Impact
The Long Term Care Brand and Generic fields have been combined into one “Long Term Care" field for location, supply, and cost sharing and the location and supply fields for Long Term Care Other Day Supply have been deleted on the Tier Locations and OON and LTC Location Supply screens.
SOURCE: Internal
PBP SCREEN/CATEGORY: Medicare Rx –Actuarially Equivalent – Tier Locations – Pre-ICL Screen, Actuarially Equivalent – OON and LTC Location Supply – Pre-ICL Screen, Actuarially Equivalent – OON and LTC Copayment and Coinsurance – Pre-ICL Screen, Alternative– Tier Locations – Pre-ICL Screen, Alternative– OON and LTC Location Supply – Pre-ICL Screen, Alternative– OON and LTC Copayment and Coinsurance – Pre-ICL Screen, Alternative– Medicare-Medicaid Tier Locations – Pre-ICL Screen, Alternative– Medicare-Medicaid OON and LTC Location Supply – Pre-ICL Screen, Alternative– Medicare-Medicaid Copayment – Pre-ICL Screen, Alternative– Tier Locations – Gap Screen, Alternative– OON and LTC Location Supply – Gap Screen, Alternative– OON and LTC Copayment and Coinsurance – Gap Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 18, 21, 24, 32, 35, 38, 41, 44-45, 50, 53, 56
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To ensure more accurate data entry and for ease of data entry.
IMPACT ON BURDEN: Lessens Impact
A validation has been added that will alert a plan to that they have required a deductible for a tier that they have indicated will have $0 cost sharing.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section Rx-Actuarially Equivalent-Retail Pharmacy Copayment and Coinsurance – Pre-ICL Screen, Section Rx-Actuarially Equivalent-Mail Order Copayment and Coinsurance – Pre-ICL Screen, Section Rx-Actuarially Equivalent-OON and LTC Copayment and Coinsurance – Pre-ICL Screen, Section Rx-Alternative – Deductible Screen, Section Rx-Alternative- Retail Pharmacy Copayment and Coinsurance – Pre-ICL Screen, Section Rx-Alternative- Mail Order Copayment and Coinsurance – Pre-ICL Screen, Section Rx-Alternative- OON and LTC Copayment and Coinsurance – Pre-ICL Screen,
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 22-24, 28, 36-38
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To ensure more accurate data entry, specifically that the plan wishes to offer a deductible on a tier in which no cost sharing was indicated.
IMPACT ON BURDEN: Low Impact
The following changes have been made to the Copayment and Coinsurance screens:
“$” has been added to the top of the copay column.
“%” has been added to the top of the coinsurance columns.
The “Daily ($) copay” field is now mandatory for any tier that has a copay. The “Daily ($) copay” may not be higher than the 1 month supply amount divided by the actual number of days entered for that 1 month supply amount.
“Average Expected Cost Sharing” has been changed to “Average Expected Copay Equivalent.”
The “Average Expected Copay Equivalent” is mandatory for every tier (except for specialty tiers where it is optional) that offers coinsurance.
A validation has been added if Average Expected Copay Equivalent is equal to or less than the coinsurance amount entered for that tier.
(Release 4, 6713) (Release 4, 6715)
SOURCE: Internal
PBP SCREEN/CATEGORY: Actuarially Equivalent – Retail Pharmacy Copayment and Coinsurance – Pre-ICL Screen, Actuarially Equivalent – Mail Order Copayment and Coinsurance – Pre-ICL Screen, Actuarially Equivalent – OON and LTC Copayment and Coinsurance – Pre-ICL Screen, Alternative– Retail Pharmacy Copayment and Coinsurance – Pre-ICL Screen, Alternative– Mail Order Copayment and Coinsurance – Pre-ICL Screen, Alternative– OON and LTC Copayment and Coinsurance – Pre-ICL Screen, Alternative– Medicare-Medicaid Copayment – Pre-ICL Screen, Alternative– Retail Pharmacy Copayment and Coinsurance – Gap Screen, Alternative– Mail Order Copayment and Coinsurance – Gap Screen, Alternative– OON and LTC Copayment and Coinsurance – Gap Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 22-24, 36-38, 45, 54-56
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To clarify the data entry items and to ensure proper data entry.
IMPACT ON BURDEN: Low Impact
MMPs have a new cost sharing screen that will allow an MMP to offer a minimum and maximum copay range instead of the cost sharing screens other Part D plans see.
SOURCE: Internal
PBP SCREEN/CATEGORY: Medicare Rx – Alternative – Medicare-Medicaid Copayment – Pre-ICL Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 45
CITATION: Section 1115A of the Social Security Act, codified at 42 U.S.C. 1315a
REASON WHY CHANGE IS NEEDED: Allows data entry to reflect true benefit design. MMPs may have ranges and previously could only enter a single value.
IMPACT ON BURDEN: No Impact, as MMPs are exempt from PRA approval.
A validation has been added ensuring that if a plan’s Network includes Mail Order Pharmacy and only a Vaccine and/or Injectable tier is offered with additional Gap coverage, that tier will not be required to include Mail Order Pharmacy.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section Rx-Alternative-Tier Locations – Pre-ICL Screen, Section Rx-Alternative-Tier Locations – Gap Screen
DOCUMENT: PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 27, 38
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: Allows data entry to reflect true benefit design
IMPACT ON BURDEN: Low Impact
MMPs have a new Alternative-OOP threshold screens which have the following questions:
“How do you apply your cost sharing beyond the Medicare-defined Part D Annual Out-of-Pocket Threshold?”
“Minimum and Maximum Copayment” for each Tier
SOURCE: Industry
PBP SCREEN/CATEGORY: Section Rx- Alternative – Medicare-Medicaid Post-OOP Threshold Screen, Alternative – Tier Type and Tier Cost Sharing Post-OOP Medicare-Medicaid Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_Rx_2012_12_03.doc
PAGE(s): 60-61
CITATION: Section 1115A of the Social Security Act, codified at 42 U.S.C. 1315a
REASON WHY CHANGE IS NEEDED: Allows data entry to reflect true benefit design for MMP plans, which are newer plan types that previously were not accommodated in the PBP.
IMPACT ON BURDEN: No Impact, as MMPs are exempt from PRA approval.
The following message has been added after a plan selects the “Upload Plan(s)” button on the PBP Plan Upload screen: “Your plans have been successfully uploaded into the PBP and are now ready to upload through HPMS. A zip file containing these plans has been created and is located in your PBP directory. The default database directory is: C: \PBP2014. The name of the zip file is PBPUPLOD2014.ZIP.” (Release 1, 5013)
SOURCE: Industry
PBP SCREEN/CATEGORY: PBP Plan Upload Screen
DOCUMENT: Appendix_C_PBP_2014_screenshots_section_a_2012_12_03.doc
PAGE(s): 8
CITATION: 42 CFR 423.272
REASON WHY CHANGE IS NEEDED: To alert plan users that their data is ready to be uploaded to the HPMS
IMPACT ON BURDEN: No Impact
Formulary Changes
No changes to submission
MTMP Changes
On the EditPageE.asp page, a Plan user may enter up to 5 “Name of PBM” if Outside personnel and PBM are selected.
SOURCE: CMS, Lessons Learned
DOCUMENT: Appendix_C_CY 2014 MTMP - Review Tool Page Mockup 08292012.docx
PAGE(s): 1
CITATION: 42 CFR 423.153
REASON WHY CHANGE IS NEEDED: To better serve users
IMPACT ON BURDEN: No impact
On the EditPageE.asp page, a Plan user may select In-house Pharmacists, Local Pharmacists, Physician, Registered Nurse, Licensed Practical Nurse, Nurse Practitioner, Physician's Assistant, and up to 10 “Other” fields with information entered for each “Other” field selected for each “Name of PBM” is selected.
SOURCE: CMS, Lessons Learned
DOCUMENT: Appendix_C_CY 2014 MTMP - Resources Page Mockup 08282012.docx
PAGE(s): 1
CITATION: 42 CFR 423.153
REASON WHY CHANGE IS NEEDED: To better serve users
IMPACT ON BURDEN: No impact
On the EditPageE.asp page, a Plan user may enter up to 5 “Name of Vendor” if Outside personnel and Medication Therapy Management Vendor are selected.
SOURCE: CMS, Lessons Learned
DOCUMENT: Appendix_C_CY 2014 MTMP - Resources Page Mockup 08282012.docx
PAGE(s): 1
CITATION: 42 CFR 423.153
REASON WHY CHANGE IS NEEDED: To better serve users
IMPACT ON BURDEN: No impact
On the EditPageE.asp page, a Plan user may select In-house Pharmacists, Local Pharmacists, Physician, Registered Nurse, Licensed Practical Nurse, Nurse Practitioner, Physician's Assistant, and up to 10 “Other” fields with information entered for each “Other” field selected for each “Name of Vendor” is selected.
SOURCE: CMS, Lessons Learned
DOCUMENT: Appendix_C_CY 2014 MTMP - Resources Page Mockup 08282012.docx
PAGE(s): 1
CITATION: 42 CFR 423.153
REASON WHY CHANGE IS NEEDED: To better serve users
IMPACT ON BURDEN: No impact
On the EditPageF.asp page, for the option “Fees priced out separately,” a Plan user may select “Fees priced out separately - Associates one fee table with all PBMs/MTMs” or “Fees priced out separately – Associates a fee table for each PBM/MTM.”
SOURCE: CMS, Lessons Learned
DOCUMENT: Appendix_C_CY 2014 MTMP - Fees Page Mockup 08302012.docx
PAGE(s): 1
CITATION: 42 CFR 423.153
REASON WHY CHANGE IS NEEDED: To better serve users
IMPACT ON BURDEN: No impact
On the EditPageF.asp page, a fee table will be displayed if a Plan user selected the option “Fees priced out separately - Associates one fee table with all PBMs/MTMs”
SOURCE: CMS, Lessons Learned
DOCUMENT: Appendix_C_CY 2014 MTMP - Fees Page Mockup 08302012.docx
PAGE(s): 1
CITATION: 42 CFR 423.153
REASON WHY CHANGE IS NEEDED: To better serve users
IMPACT ON BURDEN: No impact
On the EditPageF.asp page, each Name of PBM and or Name of Vendor entered in EditPageE.asp page will be displayed with a fee table if a Plan user selected the option “Fees priced out separately – Associates a fee table for each PBM/MTM.”
SOURCE: CMS, Lessons Learned
DOCUMENT: Appendix_C_CY 2014 MTMP - Fees Page Mockup 08302012.docx
PAGE(s): 1
CITATION: 42 CFR 423.153
REASON WHY CHANGE IS NEEDED: To better serve users
IMPACT ON BURDEN: No impact
On the EditVerify.asp page, the information selected and entered in EditPageE.asp page and EditPageF.asp page will be displayed.
SOURCE: CMS, Lessons Learned
DOCUMENT: Appendix_C_CY 2014 MTMP - Verification Page Mockup 08272012.docx
PAGE(s): 1
CITATION: 42 CFR 423.153
REASON WHY CHANGE IS NEEDED: To better serve users
IMPACT ON BURDEN: No impact
12/04/2012 CY2014
PRA PBP - List of Changes Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | PBP-SB 2006 SOFTWARE ENHANCEMENTS |
| Author | Terese R. Deutsch |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |