List of Changes (Crosswalk)

CY 2020 PBP/MTMP/Formulary List of Changes
CY 2020 PBP Changes
Landing Page
1. The PBP software landing page has been updated to reflect the CY 2020 year changes.
Source: Internal
PBP Screen/Category: Landing Page
Document: APPENDIX_C_PBP2020_Screenshots_SectionA_Upload_2018_12_12.pdf
Page(s): Page 9
Citation: 42 CFR 422.256
Reason why change is needed: To update the year reference throughout the software.
Impact to Burden: No impact
Section A
1. The PBP software has been updated to populate the referral questions for B1a, B1b, and B2
when standard bid is selected for Section B in Section A.
Source: Internal
PBP Screen/Category: Section A-5
Document: APPENDIX_C_PBP2020_Screenshots_SectionA_Upload_2018_12_12.pdf
Page(s): Page 5
Citation: 42 CFR 422.256
Reason why change is needed: To fix a problem with the CY2019 PBP population of standard bid
for these categories.
Impact to Burden: Lessens impact
Section B
1. The PBP software will be updated to include new Supervised Exercise Therapy (SET) for
Symptomatic Peripheral Artery Disease (PAD) SET for PAD Medicare and Non Medicare covered
services in Section B3. The on screen note from the CY 2019 PBP Software will be removed.
Source: CMS Policy
PBP Screen/Category: Section B3 Cardiac and Pulmonary Rehabilitation Services
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 48-51
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. CMS determined
that the National Coverage Determination (NCD) requiring coverage of supervised exercise
therapy (SET) for symptomatic peripheral artery disease (PAD) was a significant cost under 42
C.F.R. § 422.109(a)(2). Beginning CY 2019, MAOs had to account for these items and services in

their bids as a basic Medicare-covered benefit. Cost sharing requirements for SET for PAD are
also anticipated for CY 2020 (see Draft 2020 Call Letter). Therefore, separate SET for PAD cost
sharing data fields are necessary in the PBP software.
Impact to Burden: Low impact
2. The PBP software will be updated to include a new Medicare-covered B7j: Additional Telehealth
section. It will allow plan users to offer Additional Telehealth services for any Medicare-covered
benefit. Although it is a Medicare-covered benefit, it will be optional for plans.
Source: CMS Policy
PBP Screen/Category: Section B7j Additional Telehealth
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 94-96
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. Telehealth
Proposed Rule – Citation: 83 FR 54982. Section 50323 of the Bipartisan Budget Act of 2018 (Pub.
L. 115-123) created a new section 1852(m) of the Social Security Act (the Act), which allows MA
plans to provide “additional telehealth benefits” to enrollees starting in plan year 2020 and treat
them as basic benefits for purposes of bid submission and payment by CMS. Therefore, a new
service category was created in the 2020 PBP for “Additional Telehealth.”
Impact to Burden: Medium impact
3. The PBP software has been updated to include a new Medicare-covered B7k: Opioid Treatment
Services section. It will be mandatory for plans.
Source: CMS Policy
PBP Screen/Category: Section B7k Opioid Treatment Services
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 97-98
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. Section 2005 of the
Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients
and Communities Act (Public Law No. 115-271) establishes opioid use disorder treatment
services furnished by Opioid Treatment Programs (OTPs) as a Medicare Part B service beginning
in 2020. Therefore, a new service category was created in the 2020 PBP for “Opioid Treatment
Services.”
Impact to Burden: Medium impact
4. The PBP software has been updated to add to Rideshare Services to PBP category B10b
Transportation for Plan-approved Location and Any Health-related Location
Source: CMS Policy
PBP Screen/Category: B10b Transportation Services
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf

Page(s): Page 120
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. CMS leadership and
management instructed us to provide plans with the ability to select certain benefits in the PBP
for: (1) internal management reporting, (2) potential use in press information, and (3) the ability
to use information on Medicare Plan Finder to allow informed decision making by
beneficiaries. In addition, this information makes benefit review more efficient and effective.
Impact to Burden: No impact
5. The PBP software has been updated to allow SNP plans to select B14b Annual Physical Exam as a
supplemental benefit.
Source: CMS Policy
PBP Screen/Category: B14b Annual Physical Exam
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 187-189
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. Over the past
several years, CMS has sought to improve care coordination and enhance the experience of care
for beneficiaries, particularly those that are a part of the SNP population. We believe that
specialized, targeted care through supplemental benefit offerings is one way to achieve this
goal. Beginning CY 2020, SNPs may offer the Physical Exam supplemental benefit, therefore a
change to the PBP was necessary to allow SNP plan types to offer the benefit.
Impact to Burden: No impact
6. The PBP software has been updated to change the name of Section B14c to "Other Defined
Supplemental Benefits"
Source: CMS Policy
PBP Screen/Category: Section 14c Other Defined Supplemental Benefits
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 190-204
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. This change aligns
PBP data entry expectations and instructions with existing Chapter 4 benefits guidance, several
HPMS benefits guidance memos issued over the past 12 months, expected benefit policies that
will be communicated in the CY 2020 Final Call Letter.
Impact to Burden: No impact
7. The PBP software has been updated to include new supplemental benefits in 14c. They are
Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, In-Home Support
Services, and Support for Caregivers of Enrollees.
Source: CMS Policy

PBP Screen/Category: Section B19 VBID/UF/SSBCI
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 190-204
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. In CY 2019, CMS
expanded the scope of primarily health related supplemental benefits to include Therapeutic
Massage, Adult Day Health Services, Home-Based Palliative Care, In-Home Support Services, and
Support for Caregivers of Enrollees. CMS leadership and management instructed us to provide
plans with the ability to select these benefits in the PBP for: (1) internal management reporting,
(2) potential use in press information, and (3) the ability to use information on Medicare Plan
Finder to allow informed decision making by beneficiaries. In addition, this information makes
benefit review more efficient and effective.
Impact to Burden: Medium impact
8. The PBP software will be updated to make the “Other Medicare-covered preventive services”
benefit optional in Section B14e. A new N/A option is available in response to the authorization
question in this section. If the plan does not offer Other Medicare-covered preventive services,
they can choose N/A.
Source: CMS Policy
PBP Screen/Category: Section B14e Other Medicare-covered Preventive Services
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 210
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. “Other Medicarecovered preventive services” was originally included to account for new Medicare-covered
preventive services that may become covered benefits during the contract year. As a Medicarecovered benefit, the PBP required data entry in CY 2019. For CY 2020, CMS acknowledges that
this benefit is “optional” and does not require plans to enter data.
Impact to Burden: Lowers impact
9. The PBP software will be updated to include a new Step Therapy Question for Part B plans
offering a drug benefit in Section B15. The plan must then indicate if the benefit steps up in any
of the following ways: Part B to Part B, Part B to Part D, Part D to Part B.
Source: CMS Policy
PBP Screen/Category: Section B15 Medicare Part B Rx Drugs
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 213
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. Part B Step Therapy
Proposed Rule – Citation: 83 FR 62152. The rule proposes requirements under which MA plans
may apply step therapy as a utilization management tool for Part B drugs. In the proposed rule,
CMS reaffirms MA plans' existing authority to implement appropriate utilization management

and prior authorization programs for managing Part B drugs to reduce costs for both
beneficiaries and the Medicare program. CMS leadership and management instructed us to
provide plans with the ability to select whether or not they are offering Part B Step Therapy in
the PBP for: (1) internal management reporting, (2) potential use in press information, and (3)
the ability to use information on Medicare Plan Finder to allow informed decision making by
beneficiaries. In addition, this information makes benefit review more efficient and effective.
Impact to Burden: Potential Low to no impact
10. The PBP software will be updated to include minimum and maximum coinsurance and
copayment range fields for office visits in Section B16a.
Source: Internal
PBP Screen/Category: Section B16a Preventive Dental Base 3 and Base 4
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 218 and Page 219
Citation: 42 CFR 422.256
Reason why change is needed: Based on discussion after CMS review of bids for CY2019.
Impact to Burden: Low impact
11. The PBP software will be updated to include new questions regarding disease states for UF
plans. The questions are “Does the enrollee need to have all diseases selected to qualify? Y/N”
and “Does the enrollee have to have a combination of diseases selected to qualify? Y/N” will be
added for all packages in 19a and 19b.
Source: CMS Policy
PBP Screen/Category: Section 19a Reduced Cost Sharing for VBID/UF/SSBCI – Disease States: UF
and Section 19b Additional Benefits for VBID/UF- Disease States: UF
Document: APPENDIX_C_PBP2020_Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Page 5 and Page 63
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. In CY 2019, CMS
reinterpreted the uniformity requirement in the MA regulations at §422.100(d). Under the
reinterpretation, MA plans providing access to services (or specific cost sharing and/or
deductibles for services or items) that is tied to disease state in a manner that ensures that
similarly situated individuals are treated uniformly will be considered consistent with the
uniformity requirement in the MA regulations at §422.100(d). At the time, plans were instructed
to enter separate “MA Uniformity Flexibility” benefit packages for each disease state even if the
benefits being offered in each package were the same. This was consistent with VBID data
entry. CMS determined for CY 2020 that plans may more efficiently enter the benefit packages
if they could combine multiple diseases into a single or fewer packages. Therefore, CMS added
these questions to address plans wishing to offer the same benefit package to multiple disease
states.
Impact to Burden: Low impact

12. The PBP software has been updated to include new VBID Interventions for selection in B19a and
B19b. They are Social Determinants of Health-based Supplemental Benefits, Medicare
Advantage Rewards and Incentives Programs, Wellness and Health Care Planning, Telehealth
Networks, and Medical Device Coverage.
Source: CMS Policy
PBP Screen/Category: Section 19 VBID/MA Uniformity Flexibility/SSBCI
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Page 1
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. This is the current
rule based on updates to the VBID model for 2020.
Impact to Burden: Low impact
13. The PBP software has been updated expand Section B19 to include the option to select Special
Supplemental Benefits for the Chronically Ill (SSBCI). All MA and SNP plans besides Cost plans
can offer SSBCI. Only one SSBCI package is allowed in 19a. Only one SSBCI package is allowed in
19b. SSBCI Packages do not select disease states.
Source: CMS Policy
PBP Screen/Category: Section B19 VBID/UF/SSBCI
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Pages 1, 3, and 61
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. The Bipartisan
Budget Act of 2018 (Public Law No. 115-123) amended section 1852(a) of the Act to expand the
supplemental benefits that may be offered by Medicare Advantage organizations, referred to as
Special Supplemental Benefits for the Chronically Ill (SSBCI). SSBCI include supplemental
benefits that are not primarily health related and/or offered non-uniformly to eligible
chronically ill enrollees. It was necessary to expand PBP section B19 to allow plans to enter
SSBCI benefit packages, including cost sharing and prerequisites for obtaining the benefits.
Impact to Burden: Low impact
14. The PBP software has been updated to include a new benefit for plans offering Special
Supplemental Benefits for the Chronically Ill (SSBCI) in Section B19b. They will have the ability
to select new 13i Non-Primarily Health Related Benefits for the Chronically Ill. That section
includes Home-Delivered Meals (beyond limited basis), Transportation for Non-Medical Needs,
Food and Produce, Pest Control, and three other categories to be defined by the plan.
Source: CMS Policy
PBP Screen/Category: Section 19b Additional Benefits for VBID/UF/SSBCI
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Pages 65 and 139-160
Citation: 42 CFR 422.256

Reason why change is needed: To address regulatory changes in CMS policy. Legislation, 2018
BBA, & Policy Guidance, 2020 Call Letter. CMS leadership and management instructed us to
provide plans with the ability to select certain benefits in the PBP for: (1) internal management
reporting, (2) potential use in press information, and (3) the ability to use information on
Medicare Plan Finder to allow informed decision making by beneficiaries. In addition, this
information makes benefit review more efficient and effective.
Impact to Burden: Medium impact
15. The PBP software will be updated to remove restrictions on which Supplemental Benefits can be
included in a 19b package for UF plans. All UF plans will now be able to offer 14c Health
Education, 14c Medical Nutrition Therapy, and 14c Enhanced Disease Management. C-SNP
plans will still be prevented from offering Enhanced Disease Management.
Source: CMS Policy
PBP Screen/Category: Section 19b Additional Benefits for VBID/UF
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Page 164
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. In CY 2019, CMS
policy was that plans may not offer MA Uniformity Flexibility (UF) benefits for 14c Health
Education, 14c Medical Nutrition Therapy, and 14c Enhanced Disease management as MA UF
benefits because the benefits, as defined in Chapter 4 of the MMCM, could be offered to
enrollees with certain disease states as part of the base bid. CMS subsequently determined that
this limited plans in their ability to prescribe certain prerequisites available under MA UF for
benefit eligibility. Therefore, these benefits were reinstated as MA UF benefits in the 2020 PBP.
Impact to Burden: Low impact
16. Section B19b of the PBP software will be updated to change the text of the question “Is there a
maximum aggregate amount of reduced cost sharing?” to “Is there a maximum benefit
amount?”
Source: CMS Policy
PBP Screen/Category: Section 19b Additional Benefits for VBID/UF – Base 3 (Retroactive
Reimbursement)
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Page 67
Citation: 42 CFR 422.256
Reason why change is needed: To clarify the question in the PBP
Impact to Burden: No impact
Section D
1. The PBP software has been updated to reflect the CY2020 year change in the Section D
LPPO/RPPO deductible instructions.

Source: Internal
PBP Screen/Category: Section D: Plan Deductible
Document: APPENDIX_C_PBP2020_ Screenshots_SectionD_2018_12_12.pdf
Page(s): Page 1
Citation: 42 CFR 422.256
Reason why change is needed: To update the year references throughout the software.
Impact to Burden: No impact
2. The PBP software has been updated to require all EGWP plans, except for MSA EGWP Plans, to
enter responses to “Are you using any of your plan’s MA rebates to reduce the Part B
Premium?” and “Indicate the Part B Premium reduction amount:" premium amounts in Section
D since they do not submit a BPT with their bid.
Source: CMS Policy
PBP Screen/Category: Section D Plan Premium/Rebate Reduction
Document: APPENDIX_C_PBP2020_ Screenshots_SectionD_2018_12_12.pdf
Page(s): Page 21
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy. This is a policy
proposed in the CY2020 Advance Notice, which is currently in a 30-day public comment
period. The final policy will be announced in the CY2020 Rate Announcement, expected to be
published April 1, 2019.
Impact to Burden: Low impact

Section Rx
1. The PBP software will be updated to include the following new question regarding indication
based coverage: “Will your plan be limiting on-formulary coverage of drugs to certain
indications (i.e., are you implementing indication-based formulary design)?”
Source: CMS Policy
PBP Screen/Category: Section Rx, Medicare Rx General Screen 2
Document: APPENDIX_C_PBP2020_ Screenshots_SectionRx_2018_12_12.pdf
Page(s): Page 2
Citation: HPMS Memorandum “Indication-Based Formulary Design Beginning in Contract Year
(CY) 2020”, dated August 29, 2018
Reason why change is needed: To address new CMS Policy.
Impact to Burden: Low impact
2. The PBP software will be updated to include new guidance on entering Out-of-Network cost
sharing in Section Rx.
Source: CMS Policy

PBP Screen/Category: Section Rx, Actuarially Equivalent Characteristics Screen and AlternativeDeductible Screen
Document: APPENDIX_C_PBP2020_ Screenshots_SectionRx_2018_12_12.pdf
Page(s): Page 15 and 29
Citation: 42 CFR 422.256
Reason why change is needed: To clarify existing CMS policy.
Impact to Burden: No impact

CY 2020 MTMP Changes
1. There is a requirement to update the Verify Submission page to display the following message:
“Your data will not be submitted until you click the “Submit’ button at the bottom of the page”
Source: Internal
MTMP Screen/Category: CY 2020 MTMP - Enter/Edit Verify Submission Page
Document: Appendix_C_MTMP CY2020 Enhancements Mockups.pdf
Page(s): Page 1
Citation: Lessons learned
Reason why change is needed: To meet the business needs
Impact to Burden: No impact

CY 2020 Formulary Changes
1. CMS will be collecting a new Indication-Based Coverage Supplemental File. This file will be
submitted only by plans that specify they are providing indication-based coverage on the
formulary. The submission will include the affected RxCUIs and the applicable indication
code(s). CMS will provide a reference file of indication-based coverage codes.
Source: Internal
Formulary Screen/Category: Indication-Based Coverage File Record Layout
Document: Appendix_C_Formulary_IndicationBasedCoverage_Record_Layout.pdf
Page(s): Page 1
Citation: 42 CFR 423.120
Reason why change is needed: In order to allow plans to implement the formulary design that
was announced in the August 29, 2018 HPMS memorandum titled “Indication-Based Formulary
Design Beginning in Contract Year (CY) 2020”
Impact to Burden: Low impact

2. CMS has updated the layout for the Opioid Strategy submission. Some questions were removed
or clarified and additional questions or details were added to some sections to provide more
clear instructions to Sponsors.
Source: Internal

Formulary Screen/Category: Opioid Strategy Layout
Document: Appendix_C_CY2020_Formulary_Opioid Strategy Layout
Pages(s): Page 1-3
Citation: 42 CFR 423.120
Reason why change is needed: The changes were made as a result of CMS’ review of the CY2019
submissions.
Impact to Burden: No impact
3. CMS has updated the Excluded Drug file layout. The NDC field has been replaced with RxCUI.
Source: Internal
Formulary Screen/Category: Excluded Drugs File Record Layout
Document: Appendix_C_CY2020_EXC_Record_Layout
Pages(s): Page 1
Citation: 42 CFR 423.120
Reason why change is needed: The changes were made to reduce the burden for sponsors and
streamline CMS’ review of the files.
Impact to Burden: Lessens impact
4. CMS has updated the Prior Authorization File Layout. These two new fields have been added:
PA_Indication_Indicator: This field must be populated with one of the values below. This field is used to
describe the indications for which the PA will be approved.
1 = All FDA-approved Indications. This value cannot be used if the drug that requires PA is
subject to Indication-Based Coverage (IBC).
2 = Some FDA-approved Indications Only. This value is to be submitted for drugs that are subject
to IBC.
3 = All Medically-accepted Indications. Drugs for which the PA will be approved for all Part D
medically-accepted indications (FDA-approved and compendia-supported) should be submitted
with a 3.
4 = All FDA-approved Indications, Some Medically-accepted Indications. If the PA will only be
approved for specific off-label uses, a 4 should be submitted. The additional off-label uses
should be submitted in the subsequent Off-Label Uses field.
Off-label_Uses:
o CHAR Required only if a 4 is entered for PA_Indication_Indicator
o Max length = 3000
o Enter the specific off-label uses for which the PA will be approved. This field must not
contain any FDA-approved indications.
Source: Internal
Formulary Screen/Category: Prior Authorization File Layout
Document: Appendix_C_CY2020_PA_Record_Layout

Pages(s): Page 1-2
Citation: 42 CFR 423.120
Reason why change is needed: The changes were made to collect data for the new indication
based coverage data.
Impact to Burden: Low Impact.
5. CMS has created a new PA/ST change request file layout.
Source: Internal
Formulary Screen/Category: PA/ST Criteria Change Request Record Layout
Document: Appendix_C_CY2020_PAST_Criteria_Change_Request_Record_Layout
Pages(s): Page 1-2
Citation: 42 CFR 423.120
Reason why change is needed: The change is being made to make the PA/ST update process
more efficient for plans.
Impact to Burden: Lessens impact