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pdfPlan Deductible LPPO/RPPO Base 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 1 of 77
Plan Deductible LPPO/RPPO Base 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 2 of 77
Plan Deductible LPPO/RPPO Base 3
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 3 of 77
Plan Deductible LPPO/RPPO Base 4
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 4 of 77
Plan Deductible LPPO/RPPO Base 5
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 5 of 77
Plan Deductible LPPO/RPPO Base 6
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 6 of 77
CY 2021 PBP Data Entry System Screens
Deductible for LPPO/RPPO Mandatory Supplemental Benefits – Base 1
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 7 of 77
CY 2021 PBP Data Entry System Screens
Deductible for LPPO/RPPO Mandatory Supplemental Benefits – Base 2
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 8 of 77
Plan Deductible (In-Network)
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 9 of 77
Plan Deductible (Combined) – Base 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 10 of 77
Plan Deductible (Combined) – Base 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 11 of 77
Plan Deductible (Out-of-Network)
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 12 of 77
Plan Deductible (Non-Network)
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 13 of 77
Max Enrollee Cost Limit (In-Network)
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 14 of 77
CY 2021 PBP Data Entry System Screens
Max Enrollee Cost Limit (Combined) – Base 1
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 15 of 77
CY 2021 PBP Data Entry System Screens
Max Enrollee Cost Limit (Combined) – Base 2
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 16 of 77
Max Enrollee Cost Limit (Out-of-Network)
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 17 of 77
Max Enrollee Cost Limit (Non-Network)
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 18 of 77
Max Plan Benefit Coverage
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 19 of 77
CY 2021 PBP Data Entry System Screens
Max Plan Benefit Coverage (Non-Network)
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 20 of 77
Plan Premium/Rebate Reduction
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 21 of 77
CY 2021 PBP Data Entry System Screens
MMP – Medicaid/plan covered cost sharing
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 22 of 77
PFFS Balance Billing
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 23 of 77
MSA Annual Deductible/Deposit
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 24 of 77
Reductions in Cost Sharing #1 – Base 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 25 of 77
Reductions in Cost Sharing #1 – Base 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 26 of 77
Reductions in Cost Sharing #2 – Base 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 27 of 77
Reductions in Cost Sharing #2 – Base 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 28 of 77
Reductions in Cost Sharing #3 – Base 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 29 of 77
Reductions in Cost Sharing #3 – Base 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 30 of 77
Combined Benefits #1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 31 of 77
Combined Benefits #2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 32 of 77
Combined Benefits #3
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 33 of 77
Notes
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 34 of 77
CY 2021 PBP Data Entry System Screens
Optional Supplemental – Management Screen
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 35 of 77
CY 2021 PBP Data Entry System Screens
Optional Supplemental – Label and Premium
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 36 of 77
CY 2021 PBP Data Entry System Screens
Optional Supplemental – Service Categories
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 37 of 77
Optional Supplemental – OON Step-up
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 38 of 77
Optional Supplemental – OON Optional
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 39 of 77
CY 2021 PBP Data Entry System Screens
Step-up #10b Transportation Services – Base 1
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 40 of 77
CY 2021 PBP Data Entry System Screens
Step-up #10b Transportation Services – Base 2
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 41 of 77
CY 2021 PBP Data Entry System Screens
Step-up #10b Transportation Services – Base 3
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 42 of 77
Step-up #16a Preventive Dental – Base 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 43 of 77
Step-up #16a Preventive Dental – Base 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 44 of 77
Step-up #16a Preventive Dental – Base 3
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 45 of 77
Step-up #16a Preventive Dental – Base 4
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 46 of 77
Step-up #16a Preventive Dental – Base 5
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 47 of 77
CY 2021 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 1
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 48 of 77
CY 2021 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 2
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 49 of 77
CY 2021 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 3
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 50 of 77
CY 2021 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 4
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 51 of 77
CY 2021 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 5
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 52 of 77
CY 2021 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 6
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 53 of 77
Step-Up #17a Eye Exams – Base 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 54 of 77
Step-Up #17a Eye Exams – Base 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 55 of 77
Step-Up #17a Eye Exams – Base 3
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 56 of 77
Step-up #17b Eyewear – Base 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 57 of 77
Step-up #17b Eyewear – Base 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 58 of 77
Step-up #17b Eyewear – Base 3
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 59 of 77
Step-up #17b Eyewear – Base 4
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 60 of 77
Step-up #17b Eyewear – Base 5
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 61 of 77
Step-up #17b Eyewear – Base 6
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 62 of 77
Step-up #18a Hearing Exams – Base 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 63 of 77
Step-up #18a Hearing Exams – Base 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 64 of 77
Step-up #18a Hearing Exams – Base 3
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 65 of 77
Step-up #18a Hearing Exams – Base 4
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 66 of 77
Step-up #18b Hearing Aids -Base 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 67 of 77
Step-up #18b Hearing Aids -Base 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 68 of 77
Step-up #18b Hearing Aids -Base 3
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 69 of 77
Step-up #18b Hearing Aids -Base 4
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 70 of 77
Step-up #18b Hearing Aids -Base 5
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 71 of 77
CY 2021 PBP Data Entry System Screens
Step-up #7b Chiropractic Services – Base 1
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 72 of 77
CY 2021 PBP Data Entry System Screens
Step-up #7b Chiropractic Services – Base 2
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 73 of 77
CY 2021 PBP Data Entry System Screens
Step-up #7b Chiropractic Services – Base 3
Softrams
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 74 of 77
Step-up #7f Podiatry Services – Base 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 75 of 77
Step-up #7f Podiatry Services – Base 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 76 of 77
Step-up #7f Podiatry Services – Base 3
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section D
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 77 of 77
| File Type | application/pdf |
| File Title | CY 2021 PBP Data Entry System Screens |
| Author | Softrams |
| File Modified | 2019-12-09 |
| File Created | 2019-12-09 |