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 changes in Medicare coverage 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 statutory changes impacting 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 statutory changes impacting 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 changes in CMS policy. CMS is collecting information for certain benefit categories in the PBP to improve the level of detail available for beneficiary education tools, like Plan Finder and to make CMS 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 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 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 changes in existing CMS policy. In CY 2019, CMS expanded the scope of primarily health related supplemental benefits by reinterpreting existing policy to include Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, In-Home Support Services, and Support for Caregivers of Enrollees. Entry is optional for those plans that choose to offer these benefits.
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 potential changes in Medicare coverage policy. “Other Medicare-covered preventive services” was originally included to account for new Medicare-covered preventive services that may become covered benefits during the contract year. As a Medicare-covered 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 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 is collecting this information to improve the level of detail available for beneficiary education tools, like Plan Finder and to make CMS benefit review more efficient and effective.
Impact to Burden: Potential Low to no impact
10. 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 changes in CMS policy guidance. In CY 2019, CMS reinterpreted the existing uniformity requirements. 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
11. 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
12. 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 statutory 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. This entry is optional for those organizations that wish to offer these benefits.
Impact to Burden: Low impact
13. 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 is collecting this information to improve the level of detail available for beneficiary education tools, like Plan Finder and to make CMS benefit review more efficient and effective.
Impact to Burden: Medium impact
14. 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
15. 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
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-11 |