List of Changes

CY 2016 PBP/Formulary/MTMP List of Changes
CY 2016 PBP Changes
PBP General Section
1. The Notes fields have been updated so that the word “Optional,” will be deleted. An exit
validation will alert users if the Notes field (in a specific section) becomes mandatory depending
on the data entry throughout that section.
SOURCE: Internal
PBP Screen/Category: Section A-6, Section B - #1a Inpatient Hospital – Acute – Base 12, #1a
Inpatient Hospital – Acute (B Only) – Base 4, #1b Inpatient Hospital Psychiatric – Base 12, #1b
Inpatient Hospital Psychiatric (B Only) – Base 5, #2 SNF – Base 7, #2 SNF (B Only) – Base 4, #3
Cardiac and Pulmonary Rehabilitation Services – Base 4, #4a Emergency Care – Base 2, #4b
Urgently Needed Care – Base 3, #4c Worldwide Emergency Coverage – Base 3, #5 Partial
Hospitalization – Base 2, #6 Home Health Services – Base 3, #6 Home Health Services – MMP –
Base 3, #7a Primary Care Physician Services – Base 2, #7b Chiropractic Services – Base 4, #7c
Occupational Therapy Services – Base 2, #7c Occupational Therapy Services – MMP – Base 2,
#7d Physician Specialist Services – Base 2, #7e Mental Health Specialty Services – Base 3, #7f
Podiatry Services – Base 3, #7g Other Health Care Professional – Base 2, #7h Psychiatric Services
– Base 3, #7i PT and SP Services – Base 2, #7i PT and ST – MMP – Base 2, #8a Outpatient Diag
Procs/Tests/Lab Services – Base 4, #8b Outpatient Diag/Therapeutic Rad Services – Base 3, #9a
Outpatient Hospital Services – Base 3, #9b ASC Services – Base 3, #9c Outpatient Substance
Abuse – Base 3, #9d Outpatient Blood Services – Base 2, #10a Ambulance Services – Base 2,
#10b Transportation Services – Base 3, #11a DME – Base 2, #11a DME – MMP - Base 2, #11b
Prosthetic/Medical Supplies – Base 3, , #11b Prosthetic/Medical Supplies – MMP - Base 1, #11c
Diabetic Supplies and Services – Base 2, #12 End - Stage Renal Disease – Base 2, #13a
Acupuncture and Other Alternative Therapies – Base 3, #13c Meal Benefit – Base 3, #13d Other
1 – Base3, #13e Other 2 – Base 3, #13f Other 3 – Base 3, #13g Dual Eligible SNPs with Highly
Integrated Services – Base 3, #13h Additional Services – Base 26, #14a Medicare-covered
Preventive Services, #14b Annual Physical Exam – Base 3, #14c Eligible Supplemental Benefits as
Defined in Chapter 4 – Base 5, #14c Eligible Supplemental Benefits as Defined in Chapter 4 –
Base 6, #14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 7, #14d – Kidney
Disease Education Services - Base 3, #14e Diabetes Self-Management Training – Base 3, #15
Medicare Part B Rx Drugs – Notes (Optional), #16a Preventive Dental – Base 5, #16b
Comprehensive Dental – Base 6, #17a Eye Exams – Base 3, #17b Eyewear – Base 6, #18a Hearing
Exams – Base 4, #18b Hearing Aids – Base 5, #20 Outpatient Drugs – Notes (Optional); OON –
General – Notes, POS – General – Base 6, V/T – General – US – Notes, Optional Supplemental –
Label and Premium, Optional Supplemental – OON Stepup, Optional Supplemental – OON
Optional, Step Up #10b Transportation Services – Base 3, Step Up #16a Preventive Dental – Base
5, Step Up #16b Comprehensive Dental – Base 6, Step Up #17a Eye Exams – Base 3, Step Up

#17b Eyewear – Base 6, Step Up #18a Hearing Exams – Base 4, Step Up #18b Hearing Aids – Base
5, Step Up #7b Chiropractic Services – Base 4, Step Up #7f Podiatry Services – Base 3; Medicare
Rx – Notes
Document: Appendix_C_PBP_2016_ screenshots_section_a_2014_12_03.pdf,
Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Appendix_C_PBP_2016_screenshots_section_c_2014_12_02.pdf,
Appendix_C_PBP_2016_screenshots_section_d_2014_12_04.pdf,
Appendix_C_PBP_2016_screenshots_section_Rx_2014_12_02.pdf
Page(s): Appendix_C_PBP_2016_ screenshots_section_a_2014_12_03.pdf:7;
Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf: pgs. 12, 16, 28, 33, 40, 44, 48,
50, 53, 56, 58, 61, 64, 66, 70, 72, 74, 76, 79, 82, 84, 87, 89, 91, 95, 98, 101, 104, 107, 109, 111,
114, 116, 118, 121, 122, 124, 126, 129, 135, 138, 141, 144, 147, 173, 174, 177, 180, 187, 188,
189, 192, 195, 198, 204, 210, 213, 219, 223, 228, 233;
Appendix_C_PBP_2016_screenshots_section_c_2014_12_02.pdf: pgs. 3, 18;
Appendix_C_PBP_2016_screenshots_section_d_2014_12_04.pdf: pgs. 23, 25, 27, 28, 31, 36, 42,
45, 51, 55, 60, 64, 67; Appendix_C_PBP_2016_screenshots_section_Rx_2014_12_02.pdf: pg. 68
Citation: (Release 1, 12808)
Reason Why Change is Needed: These fields can sometimes be mandatory, so the word optional
was misleading.
Impact Burden: No impact
2. The PBP has been updated so hotkeys have been programmed for the navigation buttons.
Source: Internal
PBP Screen/Category: All screens
Document: Appendix_C_PBP_2016_ screenshots_section_a_2014_12_03.pdf,
Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Appendix_C_PBP_2016_screenshots_section_c_2014_12_02.pdf,
Appendix_C_PBP_2016_screenshots_section_d_2014_12_04.pdf,
Appendix_C_PBP_2016_screenshots_section_Rx_2014_12_02.pdf
Page(s): All pages
Citation: (Release 1, 12809)
Reason Why Change is Needed: Users expressed a need for an efficient way to navigate through
the PBP by keyboard.
Impact Burden: Lessens Impact
3. The separate physician/professional services questions have been removed from the PBP.
Source: Internal
PBP Screen/Category: #8a: Outpatient Diagnostic Procedures/Tests/Lab Services – Base 3
screen, #8b: Outpatient Diagnostic/Therapeutic Radiological Services – Base 2, #14e: Diabetes
Self-Management Training – Base 2, #17a: Eye Exams – Base 3, OON– Groups – Base 2, POS –
Groups – Base 2, Step Up #17a: Eye Exams – Base 3

Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Appendix_C_PBP_2016_screenshots_section_c_2014_12_02.pdf,
Appendix_C_PBP_2016_screenshots_section_d_2014_12_04.pdf,
Page(s): PBP_2016_screenshots_section_b_2014_12_04.docx: 96, 99, 194, 213;
PBP_2016_screenshots_section_c_2014_12_02.docx: 12, 28;
PBP_2016_screenshots_section_d_2014_12_04.docx: 52
Citation: (Release 2, 13947)
Reason Why Change is Needed: To ensure plans are not double charging beneficiaries for
benefits.
Impact Burden: Lessens Impact
4. Cost sharing ranges (i.e., minimum and maximum coinsurance and copayment) have been
added to every benefit within Section B screen and Optional Supplemental Step Up screen.
Source: Internal
PBP Screen/Category: #4c Worldwide Emergency/Urgent Coverage – Base 2, #5 Partial
Hospitalization – Base 1, #5 Partial Hospitalization – Base 2, #9d Outpatient Blood Services –
Base 1, #9d Outpatient Blood Services – Base 2, #10b Transportation Services – Base 2, #10b
Transportation Services – Base 3, #13a Acupuncture – Base 2, #13b OTC Items – Base 2, #13c
Meal Benefit – Base 2, #13d Other 1 – Base 2, #13e Other 2 – Base 2, #13f Other 3 – Base 2,
#13g Dual Eligible SNPs with Highly Integrated Services – Base 2, #14b Annual Physical Exam –
Base 2, #14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 5, #14c Eligible
Supplemental Benefits as Defined in Chapter 4 – Base 6, #17b eyewear – Base 4, #17b eyewear –
Base 5, #18b Hearing Aids – Base 3, #18b Hearing Aids – Base 4, Step Up #10b Transportation
Services – Base 2, Step Up #10b Transportation Services – Base 3, Step Up #17b eyewear – Base
4, Step Up #17b eyewear – Base 5, Step Up #18b Hearing Aids – Base 3, Step Up #18b Hearing
Aids – Base 4
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Appendix_C_PBP_2016_screenshots_section_d_2014_12_04.pdf,
Page(s): PBP_2016_screenshots_section_b_2014_12_04.docx: 57, 59, 60, 110, 111, 115, 116,
130, 133, 136, 139, 142, 145, 148, 179, 185, 186, 217, 218, 226, 227;
PBP_2016_screenshots_section_d_2014_12_04.docx: 30, 31, 49, 50, 58, 59
Citation: (Release 2, 14281)
Reason Why Change is Needed: To allow a plan to accurately enter a cost sharing range if that
plan offers tiered cost sharing for a benefit.
Impact Burden: Low Impact
PBP Section A
1. Tiered cost-sharing questions have been added to the Section A-6 screen.
Source: Internal
PBP Screen/Category: A-6

Document: Appendix_C_PBP_2016_ screenshots_section_a_2014_12_03.pdf,
Page(s): 6
Citation: (Release 2, 13654)
Reason Why Change is Needed: To allow plans to indicate tiered cost sharing for any benefit.
Impact Burden: Low Impact
PBP Section B
1. A Validation has been added ensuring that if a plan selects tiered cost sharing on the Section A-6
screen for any benefit, then in Section B that benefit must include a range in cost sharing.
(Release 2, 13654)
Source: Internal
PBP Screen/Category: Section A-6, #4c Worldwide Emergency/Urgent Coverage – Base 2, #5
Partial Hospitalization – Base 1, #5 Partial Hospitalization – Base 2, #9d Outpatient Blood
Services – Base 1, #9d Outpatient Blood Services – Base 2, #10b Transportation Services – Base
2, #10b Transportation Services – Base 3, #13a Acupuncture – Base 2, #13b OTC Items – Base 2,
#13c Meal Benefit – Base 2, #13d Other 1 – Base 2, #13e Other 2 – Base 2, #13f Other 3 – Base
2, #13g Dual Eligible SNPs with Highly Integrated Services – Base 2, #14b Annual Physical Exam –
Base 2, #14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 5, #14c Eligible
Supplemental Benefits as Defined in Chapter 4 – Base 6, #17b eyewear – Base 4, #17b eyewear –
Base 5, #18b Hearing Aids – Base 3, #18b Hearing Aids – Base 4
Document: Appendix_C_PBP_2016_ screenshots_section_a_2014_12_03.pdf,
Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): PBP_2016_screenshots_section_a_2014_12_03.docx: 6;
PBP_2016_screenshots_section_b_2014_12_04.docx: 57, 59, 60, 110, 111, 115, 116, 130, 133,
136, 139, 142, 145, 148, 179, 185, 186, 217, 218, 226, 227
Citation: (Release 2, 13654)
Reason Why Change is Needed: To allow a plan to accurately portray a tiered cost sharing
structure.
Impact Burden: Low Impact
B-1: Inpatient Hospital Services
1. The following questions have been added to the B-1a – Base 2 screen and B1b – Base 2 screen:
“What is your inpatient hospital benefit period?” and “Enter Other description for benefit
period:”
Source: Internal
PBP Screen/Category:
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf: 2, 18
Citation: (Release 2, 12725)
Reason Why Change is Needed: To allow plans to clarify how their benefit period is structured.
Impact Burden: Low Impact

B-2: Skilled Nursing Facility (SNF)
1. Plans will be allowed to have up to three hospital cost share tiers for In-Network Medicarecovered SNF benefits. (Release 2, 13654)
Source: Internal
PBP Screen/Category: #2 SNF – Base 2, #2 SNF – Base 3, #2 SNF – Base 5, #2 SNF – Base 6, #2
SNF – Base 7
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf: 35, 36, 38, 39, 40
Citation: (Release 2, 13654)
Reason Why Change is Needed: To allow for tiered cost sharing.
Impact Burden: Low Impact
2. The following questions have been added to the B-2 – Base 2 screen: “What is your SNF benefit
period?” and “Enter Other description for benefit period:” (Release 2, 12725)
Source: Internal
PBP Screen/Category:
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf: 35
Citation: (Release 2, 12725)
Reason Why Change is Needed: To allow plans to clarify how their benefit period is structured.
Impact Burden: Low Impact
B-7: Health Care Professional Services
1. Questions have been added to the #7b: Chiropractic Services – Base 1 screen and #13a:
Acupuncture – Base 1 screens asking if the plan offers a combined Acupuncture and
Chiropractor Services benefit. With this question a validation has been added ensuring all plans
that do combine these services must have matching maximum plan benefit amounts, number
of visits, cost sharing, and limits in both B-7b: Chiropractic Services and B-13a: Acupuncture.
Source: Internal
PBP Screen/Category:
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s):
Citation: (Release 2, 13954)
Reason Why Change is Needed: To allow plans to accurately define a combined chiropractic and
acupuncture benefit.
Impact Burden: Low Impact
B-13: Other Supplemental Services
1. Questions have been added to the #7b: Chiropractic Services – Base 1 screen and #13a:
Acupuncture – Base 1 screens asking if the plan offers a combined Acupuncture and
Chiropractor Services benefit. With this question a validation has been added ensuring all plans

that do combine these services must have matching maximum plan benefit amounts, number
of visits, cost sharing, and limits in both B-7b: Chiropractic Services and B-13a: Acupuncture.
Source: Internal
PBP Screen/Category: #7b Chiropractic Services – Base 1, #13a: Acupuncture – Base 1
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): 69,129
Citation: (Release 2, 13954)
Reason Why Change is Needed: To allow plans to accurately define a combined chiropractic and
acupuncture benefit.
Impact Burden: Low Impact
2. Five additional “Other” services have been added to Section 13h: Additional Services.
Source: Internal
PBP Screen/Category: #13h Additional Services – Base 1 through #13h Additional Services – Base
27
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): 150-176
Citation: (Release 2, 13968)
Reason Why Change is Needed: To allow MMPs to more accurately enter benefits in the PBP.
Impact Burden: Low Impact
3. The following additional options have been added to all benefit limits on the B-13h: Additional
Services:
• New unit option: Other
• New Periodicity Options: Every Session/Visit, Every Pregnancy, and Every Lifetime
With these new options, a validation rule has been added preventing a plan from entering both
“Sessions and "Visits" for unit and "Every Session/Visit" for periodicity.
Source: Internal
PBP Screen/Category: #13h Additional Services – Base 3 through #13h Additional Services – Base
11screens
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): 152-160
Citation: (Release 2, 14241)
Reason Why Change is Needed: To allow MMPs to more accurately enter benefits in the PBP.
Impact Burden: Low Impact
4. The Minimum and Maximum Patient Pay Amount fields have been updated so they are optional
fields in B-13h: Additional Services.
Source: Internal
PBP Screen/Category: #13h Additional Services – Base 17
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,

Page(s): 166
Citation: (Release 2, 13966)
Reason Why Change is Needed: To allow MMPs to more accurately enter benefits in the PBP.
Impact Burden: Lessens Impact
B-14: Preventative and Other Defined Supplemental Services
1. The list of supplemental benefits offered in B-14c: Eligible Supplemental Benefits as defined in
Chapter 4 Benefits has been updated to the following:
• Health Education
• Nutritional/Dietary Benefit
• Additional sessions of Smoking and Tobacco Cessation Counseling
• Fitness Benefit
• Enhanced Disease Management
• Telemonitoring Services
• Remote Access Technologies (including Web/Phone based technologies and Nursing
Hotline)
• Bathroom Safety Devices
• Counseling Services
• In-Home Safety Assessment
• Personal Emergency Response System (PERS)
• Medical Nutrition Therapy (MNT)
• Post discharge In-home Medication Reconciliation
• Re-admission Prevention
• Wigs for Hair Loss Related to Chemotherapy
• Weight Management Programs
• Alternative Therapies
Source: Internal
PBP Screen/Category: #14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 1
through #14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 9
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): 181-189
Citation: (Release 2, 13936 & 13934, & 13938)
Reason Why Change is Needed: Updates the list of Supplemental benefits in B-14c to match the
list of benefits in Chapter 4.
Impact Burden: Low Impact
2. Individual maximum plan benefit questions have been added for all benefits on the B14c – Base
3 through Base 4 screens.
Source: Industry
PBP Screen/Category: #14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 3, #14c
Eligible Supplemental Benefits as Defined in Chapter 4 – Base 4
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): 183-184
Citation: (Release 2, 13946)

Reason Why Change is Needed: To allow plan to more accurately enter benefits in the PBP
Impact Burden: Low Impact
3. The Notes fields is required for the following benefits if offered in Eligible Supplemental Benefits
as Defined in Chapter 4:
•
•
•
•

Nutritional/Dietary Benefit
Health Club/Fitness Classes
Telemonitoring
Remote Access Technologies (including Web/Phone based technologies and Nursing
Hotline)
• Bathroom Safety Devices
• Readmission Prevention
Source: Internal
PBP Screen/Category: #14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 1, #14c
Eligible Supplemental Benefits as Defined in Chapter 4 – Base 7, #14c Eligible Supplemental
Benefits as Defined in Chapter 4 – Base 8
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): 181, 187, 188
Citation: (Release 2, 14322)
Reason Why Change is Needed: To ensure plans explain these benefits in greater detail to CMS
Impact Burden: Low Impact
4. Plans offering Nutritional/Dietary Benefit under Eligible Supplemental Benefits as Defined in
Chapter 4 are required to indicate the number and duration of visit offered.
Source: Internal
PBP Screen/Category: #14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 1
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): 181
Citation: (Release 2, 14323)
Reason Why Change is Needed: So a plan can more accurately enter the Nutritional/Dietary
Benefit.
Impact Burden: Low Impact
5. Plans offering Additional Smoking and Tobacco Use Cessation are required to indicate the
number of visits allowed in addition to what is offered by Medicare.
Source: Internal
PBP Screen/Category: #14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 1
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): 181
Citation: (Release 2, 14323)
Reason Why Change is Needed: So a plan can more accurately enter the Additional Smoking and
Tobacco Use Cessation Benefit.

Impact Burden: Low Impact
6. Plans offering Medical Nutrition Therapy benefit are required to provide information on the
number of visits and length of sessions for both Medicare-covered diseases as well as nonMedicare covered diseases.
Source: Internal
PBP Screen/Category: #14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 1, #14c
Eligible Supplemental Benefits as Defined in Chapter 4 – Base 2
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): 181, 182
Citation: (Release 2, 14462)
Reason Why Change is Needed: So a plan can more accurately enter the Medical Nutrition
Therapy benefit.
Impact Burden: Low Impact
7. Plans offering Re-admission Prevention are required to provide more information on if they
include any other services above Meals, Medication Reconciliation, and In-Home Safety
Assessment. (Release 2, 13943)
Source: Internal
PBP Screen/Category: #14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 1, #14c
Eligible Supplemental Benefits as Defined in Chapter 4 – Base 2
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Page(s): 181, 182
Citation: (Release 2, 14462)
Reason Why Change is Needed: So a plan can more accurately enter the Re-admission
Prevention benefit.
Impact Burden: Low Impact

PBP Section C
1. The maximum plan benefit coverage validation rules have been updated for PPO plans.
Source: Industry
PBP Screen/Category: Section B - #16a Preventive Dental – Base 2, #16b Comprehensive Dental –
Base 3, #17a Eye Exams – Base 1, #17b Eyewear – Base 3, #18a Hearing Exams – Base 2, #18b
Hearing Aids – Base 2, Section C – OON – Groups - Base 1 screen
Document: Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Appendix_C_PBP_2016_screenshots_section_c_2014_12_02.pdf
Page(s): Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf: pgs. 201, 207, 211, 216,
221, 225; PBP_2016_screenshots_section_c_2014_12_02.pdf: pg. 11
Citation: (Release 1, 12825)

Reason why Change is Needed: The PBP is incorrectly enforcing the OON max plan benefit coverage
validations for PPO plans.
Impact Burden: Lessens Impact
2. A Geographic Area question has been added to the V/T – General – US screen.
Source: Internal
PBP Screen/Category: V/T – General – US
Document: Appendix_C_PBP_2016_screenshots_section_c_2014_12_02.pdf
Page(s): 29
Citation: (Release 2, 10502)
Reason why Change is Needed: Allows more detailed benefit description.
Impact Burden: Low Impact
PBP Section D
1. The 4c: Worldwide Emergency /Urgent Coverage service category has been added to the
Differential Deductible questions for LPPO/RPPO plan types.
Source: Internal
PBP Screen/Category: Plan Deductible LPPO/RPPO Base 3, Plan Deductible LPPO/RPPO Base 4
Document: Appendix_C_PBP_2016_screenshots_section_d_2014_12_04.pdf,
Page(s): 3, 4
Citation: (Release 2, 13770)
Reason Why Change is Needed: To allow a PPO plan to enter a Differential deductible for
Worldwide Emergency /Urgent Coverage.
Impact Burden: Low Impact
2. The Deductible screens have been re-ordered as follows for Network plans: Plan Deductible (InNetwork), Deductible (Combined), Deductible (Out-of-Network). (Release 2, 12642)
Source: Internal
PBP Screen/Category:
Document: Appendix_C_PBP_2016_screenshots_section_d_2014_12_04.pdf,
Page(s): 7,8,9,10
Citation: (Release 2, 12642)
Reason Why Change is Needed: To match the new order of the MOOP screens.
Impact Burden: No Impact
3. The Maximum Enrollee Out-of-Pocket (MOOP) screens have been re-ordered as follows for
Network plans: In-Network MOOP, Combined MOOP, Out-of-Network MOOP.
Source: Internal
PBP Screen/Category:
Document: Appendix_C_PBP_2016_screenshots_section_d_2014_12_04.pdf,
Page(s): 12, 13, 14, 15
Citation: (Release 2, 12642)

Reason Why Change is Needed: The new order simplifies the data entry process for the MOOP,
as it aligns the order of data entry with the policy requirements.
Impact Burden: No Impact
4. The Maximum Enrollee Out-of-Pocket (MOOP) screens have been updated as follows:
•

The question “Is your In-Network Maximum Enrollee Out-of-Pocket (MOOP) Cost at the
Voluntary or Mandatory Level?” on the Max Enrollee Cost Limit (In-Network) screen has
been disabled for Network PFFS plans.
• The question “Is your Combined (In-Network and Out-of-Network) Maximum Enrollee Outof-Pocket (MOOP) Cost at the Voluntary or Mandatory Level?” on the Max Enrollee Cost
Limit (Combined) screen has been disabled for PPO plans.
• "(Network PFFS plans only)" has been added to the end of the question Is your Combined
(In-Network and Out-of-Network) Maximum Enrollee Out-of-Pocket (MOOP) Cost at the
Voluntary or Mandatory Level?” on the Max Enrollee Cost Limit (Combined) screen.
• The term “In-Network” has been removed from the Max Enrollee Cost Limit (Non-Network)
screen.
Source: Internal
PBP Screen/Category:
Document: Appendix_C_PBP_2016_screenshots_section_d_2014_12_04.pdf,
Page(s): 12, 13, 14, 16
Citation: (Release 2, 12642)
Reason Why Change is Needed: Simplifies the data entry process for the MOOP, as it clarifies
data entry requirements for various plan types.
Impact Burden: Lessens Impact
PBP Section Rx
1. The specialty tier calculations have been updated in the PBP.
Source: Industry
PBP Screen/Category: Section Rx – Alternative – Deductible, Alternative – Retail Pharmacy
Copayment and Coinsurance – Pre-ICL, Alternative – Mail Order Copayment and Coinsurance – PreICL, Alternative – OON and LTC Copayment and Coinsurance – Pre-ICL
Document: Appendix_C_PBP_2016_screenshots_section_Rx_2014_12_02.pdf
Page(s): 29, 37-39
Citation: (Release 1, 12953)
Reason why Change is Needed: If a plan charges a deductible and does not include the specialty tier
in the deductible, then the Specialty tier should be able to have a coinsurance of 33% or less since
that tier does not apply to the deductible.
Impact Burden: Low Impact
2. The Daily Copayment fields have been removed from the Copayment and Coinsurance screens.
Source: Internal

PBP Screen/Category: Actuarially Equivalent – Retail Pharmacy Copayment and Coinsurance – PreICL, Actuarially Equivalent – Mail Order Copayment and Coinsurance – Pre-ICL, Actuarially Equivalent
– OON and LTC Copayment and Coinsurance – Pre-ICL, Actuarially Equivalent – Daily Copayment
Amount Cost Sharing – Pre-ICL, Actuarially Equivalent – Tier Cost Sharing – Post-OOP Threshold,
Alternative – Retail Pharmacy Copayment and Coinsurance – Pre-ICL, Alternative – Mail Order
Copayment and Coinsurance – Pre-ICL, Alternative – OON and LTC Copayment and Coinsurance –
Pre-ICL, Alternative – Daily Copayment Amount Cost Sharing – Pre-ICL, Alternative – MedicareMedicaid Copayment – Pre-ICL, Alternative – Medicare-Medicaid Daily Copayment Amount Cost
Sharing, Alternative – Retail Pharmacy Copayment and Coinsurance – Gap, Alternative – Mail Order
Copayment and Coinsurance – Gap, Alternative – OON and LTC Copayment and Coinsurance – Gap,
Alternative – Daily Copayment Amount Cost Sharing – Gap
Document: Appendix_C_PBP_2016_screenshots_section_Rx_2014_12_02.pdf
Page(s): 22, 23, 24, 25, 28, 37, 38, 39, 40, 47, 48, 57, 58, 59, 60
Citation: (Release 2, 11480)
Reason why Change is Needed: To eliminate plan user’s confusion of the Daily copay fields.
Impact Burden: Lessens Impact
3. A Daily Copayment Amount Cost Sharing screen has been added for the Pre-ICL and Gap phases of
the benefit which will include the following:
• Copayment amount for one month, daily supply amount for one month, and daily copay
amount for Retail, Mail Order and LTC.
• The Daily Copay amount will be calculated when a plan selects the Calculate Daily Copay
Amount Button, and can be edited to a lower amount.
Source: Internal
PBP Screen/Category: Actuarially Equivalent – Daily Copayment Amount Cost Sharing – Pre-ICL,
Alternative – Daily Copayment Amount Cost Sharing – Pre-ICL, Alternative – Daily Copayment
Amount Cost Sharing – Gap
Document: Appendix_C_PBP_2016_screenshots_section_Rx_2014_12_02.pdf
Page(s): 25, 40, 60
Citation: (Release 2, 11480)
Reason why Change is Needed: To eliminate plan user’s confusion regarding completion of the Daily
copay fields.
Impact Burden: Lessens Impact
4. A Medicare Rx – Attestation screen has been added with attestations for any plan offering
coinsurance and for any D-SNP plan that include a $0 cost share tier.
Source: Internal
PBP Screen/Category: Medicare Rx – Attestations
Document: Appendix_C_PBP_2016_screenshots_section_Rx_2014_12_02.pdf
Page(s): 67
Citation: (Release 2, 13962, 13593)

Reason why Change is Needed: To clarify to plans what their responsibility is when offering a tier $0
cost.
Impact Burden: Low Impact
508 Compliance
1. The PBP has been updated to be more compatible with the JAWS software
Source: Internal
PBP Screen/Category: All screens
Document: Appendix_C_PBP_2016_ screenshots_section_a_2014_12_03.pdf,
Appendix_C_PBP_2016_screenshots_section_b_2014_12_04.pdf,
Appendix_C_PBP_2016_screenshots_section_c_2014_12_02.pdf,
Appendix_C_PBP_2016_screenshots_section_d_2014_12_04.pdf,
Appendix_C_PBP_2016_screenshots_section_Rx_2014_12_02.pdf
Page(s): All pages
Citation: (Release 1, 12953)
Reason why Change is Needed: There is a request for the embedded table rows to correspond with
the item list number.
Impact Burden: Lessens Impact.
Formulary Changes
1. Change: Quantity_Limit_YN field has been replaced with Quantity_Limit_Type. Permissible values
are:
•
•
•

0 = Quantity Limits Do Not Apply
1 = Daily Quantity Limit
2 = Quantity Limit Over Time

Source: Industry Feedback/plan oversight
Document: CY2016 Plan Formulary Submission File Record Layout
Page: 1
Reg Citation: 42 CFR 423.120
Reason why change is needed: Allow plans to submit drug information for non-standard durations,
i.e., other than amount per day.
Impact on Burden to plans: None.
2. Change: Quantity_Limit_Amount field. Changed permissible values to:
• If the Quantity_Limit_Type = 0 (No Limits), leave this field blank.
• If the Quantity_Limit_Type = 1 (Daily QL), enter the quantity limit unit amount per day for a
given prescription. The units for this amount must be defined by a unit of measure e.g.
number of tablets, milliliters, grams, etc.

•

If the Quantity_Limit_Type = 2 (QL Over Time), enter the quantity limit unit amount for a
given time period. The units for this amount must be defined by a unit of measure e.g.
number of tablets, milliliters, grams, etc.
• The maximum number of decimal points that will be accepted is 5, i.e., “9.99999.”
• The maximum number that will be accepted is “9999.99.”
Source: Industry Feedback/plan oversight
Document: CY2016 Plan Formulary Submission File Record Layout
Page: 1
Reg Citation: 42 CFR 423.120
Reason why change is needed: Allow plans to submit drug information for non-standard durations,
i.e., other than amount per day.
Impact on Burden to plans: None.
3. Change: Quantity_Limit_Days field. Changed permissible values to:
• If the Quantity_Limit_Type field is 0 (No Limits), then leave this field blank.
• If the Quantity_Limit_Type Type is 1 (Daily QL), then enter 1 in this field.
• If the Quantity_Limit_Type field is 2 (QL Over Time), then enter the time period in days
associated to the quantity limit.
• If the Quantity_Limit_Type field is 2 , the minimum number that will be accepted is 2 and the
maximum number that will be accepted is “999”
Source: Industry Feedback/plan oversight
Document: CY2016 Plan Formulary Submission File Record Layout
Page: 1
Reg Citation: 42 CFR 423.120
Reason why change is needed: Allow plans to submit drug information for non-standard durations,
i.e., other than amount per day.
Impact on Burden to plans: None.
MTMP Changes
1. A Plan user may see the error message “Quarterly cannot be selected for Frequency for Targeting
because Incurred one-twelfth of specified annual cost threshold ($3,138) in previous month is
selected for Specific Threshold and Frequency in previous page” when the “Next” button is clicked
on the /edit/EditPageB.asp (Targeting) page that “Quarterly” for the Frequency for Targeting and
other required option(s) for Data Evaluated for Targeting are selected if “Incurred one-twelfth of
specified annual cost threshold ($3,138) in previous month” is selected for Specific Threshold and
Frequency on the /edit/EditPageA_3.asp (Incurred Cost for Covered Part D Drugs) page.
Source: Internal
Document: CY 2016 MTMP Baseline Document
Page(s): 51
Citation: Lessons Learned

Reason Why Change is Needed: To meet the business requirements when a Plan selects a onetwelfth specified annual cost threshold, the option for quarterly frequency cannot be selected
per Business Owner
Impact Burden: No Impact
2. A Plan user may select Pharmacy intern under the direct supervision of a pharmacist and/or
Pharmacy technician under the In-house staff’s list for Provider of MTM Services.
Page: /edit/EditPageE.asp
Source: Internal
Document: CY 2016 MTMP Baseline Document
Page(s): 53 - 60
Citation: Lessons Learned
Reason why changes is needed: Requirement of Addition of Pharmacy intern as a selection for
In-House staff per Business Owner
Impact Burden: No Impact
3. The user will see the following areas grayed out when a related selection has NOT been populated
on a previous page:
• Plan Sponsor Pharmacist under the Qualified Provider of Interactive, Person-to-Person CMR
with written summaries’ selection list grayed-out (not available for selection) if Pharmacist
is NOT selected.
• MTM Vendor In-house Pharmacist under the Qualified Provider of Interactive, Person-toPerson CMR with written summaries’ selection list grayed-out (not available for selection) if
In-house Pharmacist under the Name of Name of vendor’s selection list for Outside
personnel\ Medication Therapy Management vendor for Provider of MTM Services is NOT
selected.
• Physician under the Qualified Provider of Interactive, Person-to-Person CMR with written
summaries’ selection list grayed-out (not available for selection) if Physician under the Inhouse staff’s selection list for Provider of MTM Services is NOT selected.
• Registered Nurse under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list grayed-out (not available for selection) if Registered
Nurse under the In-house staff’s selection list for Provider of MTM Services is NOT selected.
• Licensed Practical Nurse under the Qualified Provider of Interactive, Person-to-Person
CMR with written summaries’ selection list grayed-out (not available for selection) if
Licensed Practical Nurse under the In-house staff’s selection list for Provider of MTM
Services is NOT selected.
• Nurse Practitioner under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list grayed-out (not available for selection) if Nurse
Practitioner under the In-house staff’s selection list for Provider of MTM Services is NOT
selected.

•

Physician’s Assistant under the Qualified Provider of Interactive, Person-to-Person CMR

with written summaries’ selection list grayed-out (not available for selection) if Physician’s
Assistant under the In-house staff’s selection list for Provider of MTM Services is NOT
selected.
• Pharmacy intern under the direct supervision of a pharmacist under the Qualified
Provider of Interactive, Person-to-Person CMR with written summaries’ selection list grayedout (not available for selection) if Pharmacy intern under the direct supervision of a
pharmacist under the In-house staff’s selection list for Provider of MTM Services is NOT
selected
Page: /edit/EditPageE.asp
Source: Internal
Document: CY 2016 MTMP Baseline Document
Page(s): 53 - 60
Citation: Lessons Learned
Reason why change is needed: Users should not be able to select these services on the second
page if they were not previously selected.
Impact Burden: No Impact
4. A Plan user may select Pharmacy intern under the direct supervision of a pharmacist and/or
Pharmacy technician under the Outside personnel’s selection list for Provider of MTM Services and
under each Name on the PBM selection.
Page: /edit/EditPageE.asp (Resources) page.
Source: Internal
Document: CY 2016 MTMP Baseline Document
Page(s): 53 - 60
Citation: Lessons Learned
Reason why changes is needed: Requirement of Addition of Pharmacy intern as a selection for
Outside personnel per Business Owner
Impact Burden: Low Impact
5. A Plan user may select Pharmacy intern under the direct supervision of a pharmacist and/or
Pharmacy technician under each Name of vendor’s selection list for Outside personnel\ Disease
Management vendor and for Outside personnel\ Medication Therapy Management vendor for
Provider of MTM Services
Page: /edit/EditPageE.asp (Resources) page.
Source: Internal
Document: CY 2016 MTMP Baseline Document
Page(s): 53 - 60
Citation: Lessons Learned
Reason why changes is needed: Requirement of Addition of Pharmacy intern as a selection for
each Name of vendor’s selection list for Outside personnel\ Disease Management vendor for
Provider of MTM Services per Business Owner

Impact Burden: Low Impact
6. A Plan user may select Disease Management Pharmacist and/or Pharmacy intern under the direct
supervision of a pharmacist under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list
Page: /edit/EditPageE.asp (Resources) page.
Source: Internal
Document: CY 2016 MTMP Baseline Document
Page(s): 53 - 60
Citation: Lessons Learned
Reason why changes is needed: Requirement of Addition of Disease Management Pharmacist
Pharmacy intern as a selection under the Qualified Provider of Interactive, Person-to-Person
CMR with written summaries’ selection list per Business Owner
Impact Burden: No Burden on Impact
7. The user will see the following areas grayed out when a related selection has NOT been populated
on a previous page:
• Local Pharmacist under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list grayed-out (not available for selection) if Local Pharmacist
under the Outside personnel’s selection list for Provider of MTM Services is NOT selected.
• Long Term Care (LTC) Consultant Pharmacist under the Qualified Provider of Interactive,
Person-to-Person CMR with written summaries’ selection list grayed-out (not available for
selection) if Long Term Care (LTC) Consultant Pharmacist under the Outside personnel’s
selection list for Provider of MTM Services is NOT selected.
• Plan Benefit Manager (PBM) Pharmacist under the Qualified Provider of Interactive,
Person-to-Person CMR with written summaries’ selection list grayed-out (not available for
selection) if Pharmacist under the Name of PBM’s selection list for Outside personnel\ PBM
for Provider of MTM Services is NOT selected
• MTM Vendor Local Pharmacist under the Qualified Provider of Interactive, Person-toPerson CMR with written summaries’ selection list grayed-out (not available for selection) if
Local Pharmacist under the Name of Name of vendor’s selection list for Outside
personnel\ Medication Therapy Management vendor for Provider of MTM Services is NOT
selected.
• Disease Management Pharmacist under the Qualified Provider of Interactive, Person-toPerson CMR with written summaries’ selection list grayed-out (not available for selection) if
Pharmacist under the Name of Name of vendor’s selection list for Outside personnel\
Disease Management vendor for Provider of MTM Services is NOT selected
• Hospital Pharmacist under the Qualified Provider of Interactive, Person-to-Person CMR
with written summaries’ selection list grayed-out (not available for selection) if Hospital
Pharmacist under the Outside personnel’s selection list for Provider of MTM Services is
NOT selected.

•

•

•

•

•

•

•

•

•

•

Physician under the Qualified Provider of Interactive, Person-to-Person CMR with written

summaries’ selection list grayed-out (not available for selection) if Physician under the
Name of PBM’s selection list for Outside Personnel/PBM for Provider of MTM Services is
NOT selected
Registered Nurse under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list grayed-out (not available for selection) if Registered
Nurse under the Name of PBM’s selection list for Outside Personnel/PBM for Provider of
MTM Services is NOT selected
Licensed Practical Nurse under the Qualified Provider of Interactive, Person-to-Person
CMR with written summaries’ selection list grayed-out (not available for selection) if
Licensed Practical Nurse under the Name of PBM’s selection list for Outside
Personnel/PBM for Provider of MTM Services is NOT selected
Nurse Practitioner under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list grayed-out (not available for selection) if Nurse
Practitioner under the Name of PBM’s selection list for Outside Personnel/PBM for Provider
of MTM Services is NOT selected
Physician’s Assistant under the Qualified Provider of Interactive, Person-to-Person CMR
with written summaries’ selection list grayed-out (not available for selection) if Physician’s
Assistant under the Name of PBM’s selection list for Outside Personnel/PBM for Provider of
MTM Services is NOT selected
Pharmacy intern under the direct supervision of a pharmacist under the Qualified
Provider of Interactive, Person-to-Person CMR with written summaries’ selection list grayedout (not available for selection) if Pharmacy intern under the direct supervision of a
pharmacist under the Name of PBM’s selection list for Outside Personnel/PBM for Provider
of MTM Services is NOT selected
Physician under the Qualified Provider of Interactive, Person-to-Person CMR with written
summaries’ selection list grayed-out (not available for selection) if Physician under the
Name of vendor’s selection list for Outside Personnel/Disease Management vendor for
Provider of MTM Services is NOT selected
Registered Nurse under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list grayed-out (not available for selection) if Registered
Nurse under the Name of vendor’s selection list for Outside Personnel/Disease
Management vendor for Provider of MTM Services is NOT selected
Licensed Practical Nurse under the Qualified Provider of Interactive, Person-to-Person
CMR with written summaries’ selection list grayed-out (not available for selection) if
Licensed Practical Nurse under the Name of vendor’s selection list for Outside
Personnel/Disease Management vendor for Provider of MTM Services is NOT selected.
Nurse Practitioner under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list grayed-out (not available for selection) if Nurse
Practitioner under the Name of vendor’s selection list for Outside Personnel/Disease
Management vendor for Provider of MTM Services is NOT selected

•

•

•

•

•

•

•

•

•

•
•

Physician’s Assistant under the Qualified Provider of Interactive, Person-to-Person CMR

with written summaries’ selection list grayed-out (not available for selection) if Physician’s
Assistant under the Name of vendor’s selection list for Outside Personnel/Disease
Management vendor for Provider of MTM Services is NOT selected
Pharmacy intern under the direct supervision of a pharmacist under the Qualified
Provider of Interactive, Person-to-Person CMR with written summaries’ selection list grayedout (not available for selection) if Pharmacy intern under the direct supervision of a
pharmacist under the Name of vendor’s selection list for Outside Personnel/Disease
Management vendor for Provider of MTM Services is NOT selected
Physician under the Qualified Provider of Interactive, Person-to-Person CMR with written
summaries’ selection list grayed-out (not available for selection) if Physician under the
Name of vendor’s selection list for Outside Personnel/ Medication Therapy Management
vendor for Provider of MTM Services is NOT selected
Registered Nurse under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list grayed-out (not available for selection) if Registered
Nurse under the Name of vendor’s selection list for Outside Personnel/ Medication Therapy
Management vendor for Provider of MTM Services is NOT selected
Licensed Practical Nurse under the Qualified Provider of Interactive, Person-to-Person
CMR with written summaries’ selection list grayed-out (not available for selection) if
Licensed Practical Nurse under the Name of vendor’s selection list for Outside Personnel/
Medication Therapy Management vendor for Provider of MTM Services is NOT selected
Nurse Practitioner under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list grayed-out (not available for selection) if Nurse
Practitioner under the Name of vendor’s selection list for Outside Personnel/ Medication
Therapy Management vendor for Provider of MTM Services is NOT selected
Physician’s Assistant under the Qualified Provider of Interactive, Person-to-Person CMR
with written summaries’ selection list grayed-out (not available for selection) if Physician’s
Assistant under the Name of vendor’s selection list for Outside Personnel/ Medication
Therapy Management vendor for Provider of MTM Services is NOT selected
Pharmacy intern under the direct supervision of a pharmacist under the Qualified
Provider of Interactive, Person-to-Person CMR with written summaries’ selection list grayedout (not available for selection) if Pharmacy intern under the direct supervision of a
pharmacist under the Name of vendor’s selection list for Outside Personnel/ Medication
Therapy Management vendor for Provider of MTM Services is NOT selected
Physician under the Qualified Provider of Interactive, Person-to-Person CMR with written
summaries’ selection list grayed-out (not available for selection) if Physician under the
Outside Personnel’s selection list for Provider of MTM Services is NOT selected.
Registered Nurse under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list grayed-out (not available for selection) if Registered Nurse
under the Outside Personnel’s selection list for Provider of MTM Services is NOT selected
Licensed Practical Nurse under the Qualified Provider of Interactive, Person-to-Person CMR
with written summaries’ selection list grayed-out (not available for selection) if Licensed

Practical Nurse under the Outside Personnel’s selection list for Provider of MTM Services is
NOT selected
• Nurse Practitioner under the Qualified Provider of Interactive, Person-to-Person CMR with
written summaries’ selection list grayed-out (not available for selection) if Nurse
Practitioner under the Outside Personnel’s selection list for Provider of MTM Services is
NOT selected
• Physician’s Assistant under the Qualified Provider of Interactive, Person-to-Person CMR
with written summaries’ selection list grayed-out (not available for selection) if Physician’s
Assistant under the Outside Personnel’s selection list for Provider of MTM Services is NOT
selected
• Pharmacy intern under the direct supervision of a pharmacist under the Qualified Provider
of Interactive, Person-to-Person CMR with written summaries’ selection list grayed-out (not
available for selection) if Pharmacy intern under the direct supervision of a pharmacist
under the Outside Personnel’s selection list for Provider of MTM Services is NOT selected
Screen/category: /edit/EditPageE.asp (Resources) page.
Source: Internal
Document: CY 2016 MTMP Baseline Document
Page(s): 53 - 60
Citation: Lessons Learned
Reason why changes is needed: Requirement to gray out option for sections if not previously
selected on Page E per Business Owner
Impact Burden: No Impact
8. The fees displayed on page F will be changed and directly correspond to the selections made on
page E.
Screen/Category: /edit/EditPageF.asp
Source: Internal
Document: CY 2016 MTMP Baseline Document
Page(s): 21 – 51
Citation: Lessons Learned
Reason why changes is needed: To meet the requirements and business needs of Business
Owner
Impact Burden: Low Impact