CMS-R-262 CY 2016 PBP Data Entry System Screens (section D)

Plan Deductible LPPO/RPPO Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 1 of 67

Plan Deductible LPPO/RPPO Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 2 of 67

Plan Deductible LPPO/RPPO Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 3 of 67

Plan Deductible LPPO/RPPO Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 4 of 67

Plan Deductible LPPO/RPPO Base 5

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 5 of 67

Plan Deductible LPPO/RPPO Base 6

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 6 of 67

Plan Deductible (In-Network)

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 7 of 67

Plan Deductible (Combined) – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 8 of 67

Plan Deductible (Combined) – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 9 of 67

Plan Deductible (Out-of-Network)

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 10 of 67

Plan Deductible (Non-Network)

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 11 of 67

Max Enrollee Cost Limit (In-Network)

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 12 of 67

CY 2016 PBP Data Entry System Screens

Max Enrollee Cost Limit (Combined) – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 13 of 67

CY 2016 PBP Data Entry System Screens

Max Enrollee Cost Limit (Combined) – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 14 of 67

Max Enrollee Cost Limit (Out-of-Network)

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 15 of 67

Max Enrollee Cost Limit (Non-Network)

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 16 of 67

Max Plan Benefit Coverage

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 17 of 67

CY 2016 PBP Data Entry System Screens

Max Plan Benefit Coverage (Non-Network)

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 18 of 67

Plan Premium/Rebate Reduction

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 19 of 67

CY 2016 PBP Data Entry System Screens

MMP – Medicaid/plan covered cost sharing

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 20 of 67

PFFS Balance Billing

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 21 of 67

MSA Annual Deductible/Deposit

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 22 of 67

Notes

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 23 of 67

CY 2016 PBP Data Entry System Screens

Optional Supplemental – Management Screen

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 24 of 67

CY 2016 PBP Data Entry System Screens

Optional Supplemental – Label and Premium

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 25 of 67

CY 2016 PBP Data Entry System Screens

Optional Supplemental – Service Categories

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 26 of 67

Optional Supplemental – OON Stepup

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 27 of 67

Optional Supplemental – OON Optional

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 28 of 67

CY 2016 PBP Data Entry System Screens

Step Up #7b Chiropractic Services – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 29 of 67

CY 2016 PBP Data Entry System Screens

Step Up #7b Chiropractic Services – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 30 of 67

CY 2016 PBP Data Entry System Screens

Step Up #7b Chiropractic Services – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 31 of 67

CY 2016 PBP Data Entry System Screens

Step Up #7b Chiropractic Services – Base 4

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 32 of 67

Step Up #7f Podiatry Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 33 of 67

Step Up #7f Podiatry Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 34 of 67

Step Up #7f Podiatry Services – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 35 of 67

CY 2016 PBP Data Entry System Screens

Step Up #10b Transportation Services – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 36 of 67

CY 2016 PBP Data Entry System Screens

Step Up #10b Transportation Services – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 37 of 67

CY 2016 PBP Data Entry System Screens

Step Up #10b Transportation Services – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 38 of 67

Step Up #16a Preventive Dental – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 39 of 67

Step Up #16a Preventive Dental – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 40 of 67

Step Up #16a Preventive Dental – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 41 of 67

Step Up #16a Preventive Dental – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 42 of 67

Step Up #16a Preventive Dental – Base 5

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 43 of 67

CY 2016 PBP Data Entry System Screens

Step Up #16b Comprehensive Dental – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 44 of 67

CY 2016 PBP Data Entry System Screens

Step Up #16b Comprehensive Dental – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 45 of 67

CY 2016 PBP Data Entry System Screens

Step Up #16b Comprehensive Dental – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 46 of 67

CY 2016 PBP Data Entry System Screens

Step Up #16b Comprehensive Dental – Base 4

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 47 of 67

CY 2016 PBP Data Entry System Screens

Step Up #16b Comprehensive Dental – Base 5

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 48 of 67

CY 2016 PBP Data Entry System Screens

Step Up #16b Comprehensive Dental – Base 6

Fu Associates, Ltd.

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 49 of 67

Step Up #17a Eye Exams – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 50 of 67

Step Up #17a Eye Exams – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 51 of 67

Step Up #17a Eye Exams – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 52 of 67

Step Up #17b Eyewear – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 53 of 67

Step Up #17b Eyewear – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 54 of 67

Step up #17b Eyewear – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 55 of 67

Step Up #17b Eyewear – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 56 of 67

Step Up #17b Eyewear – Base 5

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 57 of 67

Step Up #17b Eyewear – Base 6

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 58 of 67

Step Up #18a Hearing Exams – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 59 of 67

Step Up #18a Hearing Exams – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 60 of 67

Step Up #18a Hearing Exams – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 61 of 67

Step Up #18a Hearing Exams – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 62 of 67

Step Up #18b Hearing Aids – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 63 of 67

Step Up #18b Hearing Aids – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 64 of 67

Step Up #18b Hearing Aids – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 65 of 67

Step Up #18b Hearing Aids – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 66 of 67

Step Up #18b Hearing Aids – Base 5

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section D
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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