Crosswalk

CY 2019 PBP/Formulary List of Changes

CY 2019 PBP Changes
PBP Section A

1. If a plan selects “Yes” to the question “Is your organization filing a standard bid for Section B of the
PBP?” on the Section A-5 screen the “Other Medicare-covered Preventive Services” in 14e1: Other
Medicare-covered Services will be populated with a 20% coinsurance.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section A-5
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_a_and_upload_2017_11_17.pdf,
APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): APPENDIX_C_PBP_2019_ screenshots_section_a_and_upload_2017_11_17.pdf Pg. 5,
APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf Pg. 199
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure accurate cost sharing is entered for “Other Medicarecovered Preventive Services” in 14e1: Other Medicare-covered Services are being included.
IMPACT BURDEN: No impact
2. The question “Enrollee Type:” will be disabled on the Section A-1 screen for MSAs.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section A-1
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_a_and_upload_2017_11_17.pdf
PAGE(S): Pg. 1
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure MSAs are not able to select “Part B only” for their Enrollee
Type.
IMPACT BURDEN: Lessens impact
3. The Standard Bid Service Category picklists have been updated by listing each benefit from Sections
B-9a: Outpatient Hospital Services and B-14e: Other Medicare-covered Preventive Services.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section A-5, Section A-6
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_a_and_upload_2017_11_17.pdf
PAGE(S): Pgs. 5,6
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure Standard Bids correctly reflect benefit authorizations,
referrals, and tiered cost sharing.
IMPACT BURDEN: Low impact
PBP Section B

B-1: Inpatient Hospital Services

1. If a plan offers Additional Days at a cost for any given tier, the followings questions will be enabled:

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•

"What is your Inpatient Hospital-Acute benefit period?" will be enabled on the B1a Inpatient
Hospital-Acute – Base 12 screen.

•

"What is your Inpatient Hospital Psychiatric benefit period?" will be enabled on the B1b
Inpatient Hospital Psychiatric – Base 12 screen.

SOURCE: Industry
PBP SCREEN/CATEGORY: Section B-1a: Inpatient Hospital-Acute – Base 12, Section B-1b: Inpatient
Hospital Psychiatric – Base 12
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): Pgs. 12, 28
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure plans can indicate the hospital benefit period for
Additional days.
IMPACT BURDEN: Reduces impact
2. The question, “Do you charge cost sharing on the day of discharge?” has been added for B-Only
plans to the B1a Inpatient Hospital-Acute (B Only) – Base 3 and B1b Inpatient Hospital Psychiatric (B
Only) – Base 4 screens.
SOURCE: Industry
PBP SCREEN/CATEGORY: Section B-1a: Inpatient Hospital-Acute (B Only) – Base 3, Section B-1b:
Inpatient Hospital Psychiatric (B Only) – Base 4
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): Pgs. 15, 32
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure consistent data entry between plans that include both A
and B services or only include B-only services.
IMPACT BURDEN: Reduces impact

B-2: Skilled Nursing Facility (SNF)

1. If a plan offers Additional Days at a cost for any given tier, the question, "What is your SNF benefit
period?" will be enabled on the B2 SNF – Base 10 screen. (Release 2, Requirement 22370)
SOURCE: Industry
PBP SCREEN/CATEGORY: Section B-2: SNF – Base 10
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): Pg. 43
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure plans can indicate the hospital benefit period for
Additional days.
IMPACT BURDEN: Reduces impact
2. The following questions have been updated, on the B2 SNF (B Only) – Base 1 screen:
•

“Is a hospital stay required before admission to a SNF?” has been updated to “Do you allow
less than 3 day Inpatient hospital stay prior to SNF admission?”

•

“Indicate number of days required for hospital stay:” has been updated to “Indicate the
Number of Hospital Days Required Prior to SNF Admission (0-2).”

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SOURCE: Industry
PBP SCREEN/CATEGORY: Section B-2: SNF (B Only) – Base 1
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): Pg. 44
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure consistent data entry between plans that include both A
and B services or only include B-only services.
IMPACT BURDEN: Reduces impact

B-4: Emergency Care/Urgently Needed Services

1. Service Category B-4a: Emergency Care has been renamed B-4a: Emergency Care/Post-Stabilization
Care.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B-4a: Emergency Care/Post-Stabilization Care
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): Pgs. 52, 53
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To accurately reflect the Service Category.
IMPACT BURDEN: No impact

B-9: Outpatient Services

1. Medicare-covered Outpatient Hospital Services has been separated into “Medicare-covered
Outpatient Hospital Services” and “Medicare-covered Observation Services” with each benefit
having separate data entry fields for Coinsurance, Copayment, Deductible, Maximum Enrollee Outof-Pocket Cost, Referral, and Authorization.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B-9a: Outpatient Hospital Services
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): Pgs. 101, 102
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To provide benefit clarity within the Service Category.
IMPACT BURDEN: Low impact

B-10: Ambulance/Transportation Services

1. Medicare-covered Ambulance Services has been separated into “Medicare-covered Ground
Ambulance Services” and “Medicare-covered Air Ambulance Services” with each benefit having
separate data entry fields for Coinsurance, Copayment, Deductible, and Maximum Enrollee Out-ofPocket Cost.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B-10a: Ambulance Services
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): Pgs. 112, 113
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To provide benefit clarity within the Service Category.
IMPACT BURDEN: Low impact
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B-13: Other Supplemental Services

1. A validation has been added to ensure a plan may not enter more than “24” for the question,
“Indicate numerical limit on the (service).” if the plan selects the following for that service:
•

“Hours” for the question, “Indicate units a limit will be provided for (service):”

•

“Every day” for the question, “Select limit on services periodicity for (service).”

SOURCE: Internal
PBP SCREEN/CATEGORY: Section B-13h: Additional Services - Base 3 – 16
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): Pgs. 153-166
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure a plan does not enter more than 24 hours in a day.
IMPACT BURDEN: Reduces impact
2. The following new question and attestation have been added to the B13b OTC Items – Base 1
screen.
•

“Are you offering Nicotine Replacement Therapy (NRT) as a Part C OTC benefit?”

•

“The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC
or formulary drugs.” (Release 2, Requirement 23816)

SOURCE: Internal
PBP SCREEN/CATEGORY: Section B-13b: OTC Items – Base 1
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): Pg. 133
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To provide benefit clarity for the OTC benefit.
IMPACT BURDEN: Low impact

B-14: Preventive and Other Defined Supplemental Services

1. The cost sharing fields for Remote Access Technologies (including Web/Phone based technologies
and Nursing Hotline) have been separated into minimum and maximum coinsurance and copayment
fields for Remote Access Technologies (Web/Phone based technologies) and Remote Access
Technologies (Nursing Hotline). (Release 2, Requirement 22380)
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B-14c: Eligible Supplemental Benefits as Defined in Chapter 4 – Base 7,
8
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): Pgs. 191, 192
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To allow plans to provide more accurate cost sharing for Remote
Access Technologies.
IMPACT BURDEN: Reduces impact

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2. The following benefits have been added to Section B-14e: Other Medicare-covered Preventive
Services:
•

Medicare-covered Barium Enemas,

•

Medicare-covered Digital Rectal Exams, and

•

Medicare-covered EKG following Welcome Visit

Note: Separate Maximum Enrollee Out-of-Pocket Cost, Coinsurance, Deductible, Copayment,
Authorization, Referral and Notes fields have been added for each benefit. (Release 2, Requirement
23862)
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B-14: Other Medicare-covered Preventive Services
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf
PAGE(S): Pgs. 199-202
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To provide benefit clarity within the Service Category.
IMPACT BURDEN: Low impact

B-19: VBID/MA Uniformity Flexibility

1. Section B-19: Value Based Insurance Design (VBID) Model Test has been renamed B-19: VBID/MA
Uniformity Flexibility and updated to allow plans to include MA Uniformity Flexibility (UF) along with
the already existing VBID benefit.
Note: If a plan includes both UF and VBID benefits, they will be able to note whether a package is a
UF or VBID package.
In addition to updating existing VBID screens to reflect the inclusion of MA UF data entry, the
following new screen, question, and Disease States have been added:
•

Section B-19: VBID/MA Uniformity Flexibility screen

•

“Does your plan include MA Uniformity Flexibility with reductions in cost or additional
benefits?”

•

Five new “Other” Disease States have been added as possible selections for the question,
“Which disease states does this benefit apply? (Select all that apply).”

Note: If a plan selects “Other” 1-5, individual description textboxes will be enabled.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section B-19: VBID/MA Uniformity Flexibility
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_b_VBID_UF_2017_11_21.pdf
PAGE(S): Pgs. 1-178
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To allow plans to include their MA Uniformity Flexibility benefits.
IMPACT BURDEN: Medium impact

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PBP Section C
1. The Medicare-covered Service Category picklists have been updated by listing each benefit from
Sections B-9a: Outpatient Hospital Services, B-10a: Ambulance Services, and B-14e: Other Medicarecovered Preventive Services.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section C: OON/POS
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_c_2017_11_16.pdf
PAGE(S): Pgs. 2, 11, 13-14, 16-17, 27
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure consistent data entry of benefits.
IMPACT BURDEN: Reduces impact
2. The Non-Medicare-covered Service Category picklists have been updated by listing each benefit
from Section B-14c: Eligible Supplemental Benefits as Defined in Chapter 4.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section C: OON/POS
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_c_2017_11_16.pdf
PAGE(S): Pgs. 2, 11, 13-14, 27
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure consistent data entry of benefits.
IMPACT BURDEN: Low impact
Section D

1. If a plan offers a Plan Deductible, a new validation has been implemented to ensure two or more
Service Categories are selected to apply to that Plan Deductible.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section D: Plan Deductible
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_d_2017_11_17.pdf
PAGE(S): Pgs. 1-2, 9-13
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure a plan includes more than one Service Category for a Planlevel Deductible, when a Plan Deductible is offered.
IMPACT BURDEN: No impact
2. The Medicare-covered Service Category picklists for Deductible and Maximum Enrollee Out-ofPocket Cost have been updated to list each benefit from Sections B-9a: Outpatient Hospital Services,
and B-10a: Ambulance Services. (Release 2, Requirement 23775, 24350)
SOURCE: Internal
PBP SCREEN/CATEGORY: Section D: Plan Deductible/Max Enrollee Cost Limit
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_d_2017_11_17.pdf
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PAGE(S): Pgs. 1, 3, 5-6, 10-18
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure consistent data entry of benefits.
IMPACT BURDEN: Low impact
3. The Non-Medicare-covered Service Category picklists for Maximum Plan Benefit Coverage,
Maximum Enrollee Out-of-Pocket Cost, and PFFS Balance Billing have been updated to list each
individual benefit from Section B-14c: Eligible Supplemental Benefits as Defined in Chapter 4.
(Release 2, Requirement 23817)
SOURCE: Internal
PBP SCREEN/CATEGORY: Section D: Max Enrollee Cost Limit/Max Plan Benefit Coverage/PFFS Balance
Billing
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_d_2017_11_17.pdf
PAGE(S): Pgs. 14-20, 23
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure consistent data entry of benefits.
IMPACT BURDEN: Low impact
PBP Section Rx

1. If a plan includes a “Supplemental” drug tier, the answer, “Excluded Drugs Only” will be prepopulated for the question, “Tier Includes (select only one for each tier):” on the Alternative – Tier
Type and Cost Share Structure – Pre-ICL screen. (Release 2, Requirement 23951)
SOURCE: Internal
PBP SCREEN/CATEGORY: Section Rx: Alternative – Tier Type and Cost Share Structure – Pre-ICL
DOCUMENT: APPENDIX_C_PBP_2019_ screenshots_section_Rx_2017_11_17.pdf
PAGE(S): Pg. 32
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To ensure plan users designate “Supplemental” drug tiers as
“Excluded Drugs Only”.
IMPACT BURDEN: Lessens impact
2. The Non-Extended Day Supply Tier Coverage screen and question, “Which drugs are NOT offered at
an Extended Day Supply (select only one for each tier):” have been removed from the PBP.
SOURCE: Internal
PBP SCREEN/CATEGORY: Section Rx: Non-Extended Day Supply Tier Coverage, Non-Extended Day Supply
Tier Coverage – MMP
DOCUMENT: N/A
PAGE(S): N/A
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: The screen became unnecessary with the exclusion of the Nonextended Day Supply Supplemental Formulary File upload.
IMPACT BURDEN: Significant Reduction to impact
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Technical
1. The PBP software has been updated to reflect an improved processing efficiency and program
speed.
SOURCE: Internal
PBP SCREEN/CATEGORY: N/A
DOCUMENT: N/A
PAGE(S): N/A
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To quicken the user’s data entry process.
IMPACT BURDEN: Lessens impact

Formulary Changes

1. CMS is proposing additional 2019 Tier Model options.
SOURCE: Internal
DOCUMENT: Appendix_C_FormularyProposed_Tier_Models.exe
PAGE(S): N/A
CITATION: 42 CFR 423.120
REASON WHY CHANGE IS NEEDED: This will help organizations to more accurately select tier models
IMPACT BURDEN: No impact
2. CMS is proposing the use of an OTC reference file for CY 2019. This involves the submission of a
proxy RXCUI, in lieu of the current comprehensive NDC format.
SOURCE: Internal
DOCUMENT: Appendix_C_Formulary_CY2019_OTC_Record_Layout.pdf
PAGE(S): N/A
CITATION: 42 CFR 423.120
REASON WHY CHANGE IS NEEDED: This will significantly reduce the size of the OTC supplemental files
and streamline both the submission and review.
IMPACT BURDEN: Reduces impact
3. CMS will no longer be collecting the Non-Extended Day Supply (NDS) supplemental file.
SOURCE: Internal
DOCUMENT: N/A
PAGE(S): N/A
CITATION: 42 CFR 423.120
REASON WHY CHANGE IS NEEDED: Operationally challenging. Burden of maintaining the supplemental
files by Part D sponsors and CMS outweighs benefit.
IMPACT BURDEN: Reduces impact
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4. CMS will now be collecting an upload of responses to what comprehensive strategies an
organization is using to combat the opioid crisis
SOURCE: Internal
DOCUMENT: Appendix_C_CY2019_Formulary_Opiod Strategy Layout_final
PAGE(S): N/A
CITATION: 42 CFR 423.120
REASON WHY CHANGE IS NEEDED: In light of the public health emergency, to better understand how
organizations are responding to the opioid crisis. Information will be used for policy development and
dissemination of best practices.
IMPACT BURDEN: Increases impact

MTMP Changes

1. Updates the annual cost threshold amount/ percentage and increases the characters limit from 50
to 500 characters the “Formula” and “Other” fields on the Incurred Cost for Covered Part D Drugs
page.
SOURCE: CMS, Internal
DOCUMENT: Appendix_C_MTMP_508Screenshots_09072017.pdf
PAGE(S): 1
CITATION: Lessons Learned
REASON WHY CHANGE IS NEEDED: To meet the business needs and give users the ability to enter more
information if necessary.
IMPACT BURDEN: No impact
2. Updates the annual cost threshold amount/ percentage on the Incurred Cost for Covered Part D
Drugs page.
SOURCE: CMS Internal
DOCUMENT: Appendix_C_MTMP_508Screenshots_09072017.pdf
PAGE(S): 1
CITATION: Lessons Learned
REASON WHY CHANGE IS NEEDED: To meet the business needs, and make field current.
IMPACT BURDEN: No impact
3. Changes the text at the top on the attestation page to read “Your data will not be submitted until
you click the “Attest” button located at the bottom of this page.” Note: Currently the text reads
“Your data has not been submitted” in red.
SOURCE: CMS, Internal
DOCUMENT: Appendix_C_MTMP_508Screenshots_09072017
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PAGE(S): 2
CITATION: Lessons Learned
REASON WHY CHANGE IS NEEDED: To meet business and plan user needs and explain what is necessary
to submit the data.
IMPACT BURDEN: No impact

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