CMS-R-262 CY 2017 PBP Data Entry System Screens - Section D

Plan Deductible LPPO/RPPO Base 1

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible LPPO/RPPO Base 2

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible LPPO/RPPO Base 3

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible LPPO/RPPO Base 4

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible LPPO/RPPO Base 5

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible LPPO/RPPO Base 6

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2017 PBP Data Entry System Screens

Deductible for LPPO/RPPO Mandatory Supplemental Benefits – Base 1

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 7 of 69

CY 2017 PBP Data Entry System Screens

Deductible for LPPO/RPPO Mandatory Supplemental Benefits – Base 2

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 8 of 69

Plan Deductible (In-Network)

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible (Combined) – Base 1

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible (Combined) – Base 2

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible (Out-of-Network)

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible (Non-Network)

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 13 of 69

Max Enrollee Cost Limit (In-Network)

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2017 PBP Data Entry System Screens

Max Enrollee Cost Limit (Combined) – Base 1

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 15 of 69

CY 2017 PBP Data Entry System Screens

Max Enrollee Cost Limit (Combined) – Base 2

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 16 of 69

Max Enrollee Cost Limit (Out-of-Network)

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 17 of 69

Max Enrollee Cost Limit (Non-Network)

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 18 of 69

Max Plan Benefit Coverage

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 19 of 69

CY 2017 PBP Data Entry System Screens

Max Plan Benefit Coverage (Non-Network)

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 20 of 69

Plan Premium/Rebate Reduction

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 21 of 69

CY 2017 PBP Data Entry System Screens

MMP – Medicaid/plan covered cost sharing

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 22 of 69

PFFS Balance Billing

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 23 of 69

MSA Annual Deductible/Deposit

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Notes

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2017 PBP Data Entry System Screens

Optional Supplemental – Management Screen

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 26 of 69

CY 2017 PBP Data Entry System Screens

Optional Supplemental – Label and Premium

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 27 of 69

CY 2017 PBP Data Entry System Screens

Optional Supplemental – Service Categories

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 28 of 69

Optional Supplemental – OON Optional

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 29 of 69

Optional Supplemental – OON Step-up

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 30 of 69

CY 2017 PBP Data Entry System Screens

Step-up #7b Chiropractic Services – Base 1

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 31 of 69

CY 2017 PBP Data Entry System Screens

Step-up #7b Chiropractic Services – Base 2

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 32 of 69

CY 2017 PBP Data Entry System Screens

Step-up #7b Chiropractic Services – Base 3

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 33 of 69

CY 2017 PBP Data Entry System Screens

Step-up #7b Chiropractic Services – Base 4

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 34 of 69

Step-up #7f Podiatry Services – Base 1

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 35 of 69

Step-up #7f Podiatry Services – Base 2

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 36 of 69

Step-up #7f Podiatry Services – Base 3

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2017 PBP Data Entry System Screens

Step-up #10b Transportation Services – Base 1

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 38 of 69

CY 2017 PBP Data Entry System Screens

Step-up #10b Transportation Services – Base 2

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 39 of 69

CY 2017 PBP Data Entry System Screens

Step-up #10b Transportation Services – Base 3

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 40 of 69

Step-up #16a Preventive Dental – Base 1

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 41 of 69

Step-up #16a Preventive Dental – Base 2

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #16a Preventive Dental – Base 3

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #16a Preventive Dental – Base 4

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #16a Preventive Dental – Base 5

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2017 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 1

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 46 of 69

CY 2017 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 2

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 47 of 69

CY 2017 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 3

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2017 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 4

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 49 of 69

CY 2017 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 5

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2017 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 6

Fu Associates, Ltd.

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 51 of 69

Step-up #17a Eye Exams – Base 1

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17a Eye Exams – Base 2

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17a Eye Exams – Base 3

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17b Eyewear – Base 1

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17b Eyewear – Base 2

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17b Eyewear – Base 3

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17b Eyewear – Base 4

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17b Eyewear – Base 5

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 59 of 69

Step-up #17b Eyewear – Base 6

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 60 of 69

Step-up #18a Hearing Exams – Base 1

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 61 of 69

Step-up #18a Hearing Exams – Base 2

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 62 of 69

Step-up #18a Hearing Exams – Base 3

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 63 of 69

Step-up #18a Hearing Exams – Base 4

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 64 of 69

Step-up #18b Hearing Aids – Base 1

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 65 of 69

Step-up #18b Hearing Aids – Base 2

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 66 of 69

Step-up #18b Hearing Aids – Base 3

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 67 of 69

Step-up #18b Hearing Aids – Base 4

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 68 of 69

Step-up #18b Hearing Aids – Base 5

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section D
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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