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pdfPlan Deductible LPPO/RPPO Base 1
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 1 of 79
Plan Deductible LPPO/RPPO Base 2
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 2 of 79
Plan Deductible LPPO/RPPO Base 3
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 3 of 79
Plan Deductible LPPO/RPPO Base 4
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 4 of 79
Plan Deductible LPPO/RPPO Base 5
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 5 of 79
Plan Deductible LPPO/RPPO Base 6
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 6 of 79
CY 2022 PBP Data Entry System Screens
Deductible for LPPO/RPPO Mandatory Supplemental Benefits – Base 1
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 7 of 79
CY 2022 PBP Data Entry System Screens
Deductible for LPPO/RPPO Mandatory Supplemental Benefits – Base 2
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 8 of 79
Plan Deductible (In-Network)
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 9 of 79
Plan Deductible (Combined) – Base 1
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 10 of 79
Plan Deductible (Combined) – Base 2
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 11 of 79
Plan Deductible (Out-of-Network)
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 12 of 79
Plan Deductible (Non-Network)
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 13 of 79
Max Enrollee Cost Limit (In-Network)
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 14 of 79
CY 2022 PBP Data Entry System Screens
Max Enrollee Cost Limit (Combined) – Base 1
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 15 of 79
CY 2022 PBP Data Entry System Screens
Max Enrollee Cost Limit (Combined) – Base 2
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 16 of 79
Max Enrollee Cost Limit (Out-of-Network)
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 17 of 79
Max Enrollee Cost Limit (Non-Network)
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 18 of 79
Max Plan Benefit Coverage
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 19 of 79
CY 2022 PBP Data Entry System Screens
Max Plan Benefit Coverage (Non-Network)
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 20 of 79
Plan Premium/Rebate Reduction
CY 2022 PBP Data Entry System Screens
Change in variable help screen:
New language should display
“Select Yes if the Organization is using any of the MA rebates to
reduce the Part B Premium. Select No if the Organization is not.
For all other organization types, this data entry field will not be
accessible. The Indication of a Part B premium reduction will be
taken from the Bid Pricing Tool (BPT)instead.”
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 21 of 79
CY 2022 PBP Data Entry System Screens
MMP – Medicaid/plan covered cost sharing
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 22 of 79
PFFS Balance Billing
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 23 of 79
MSA Annual Deductible/Deposit
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 24 of 79
Reductions in Cost Sharing – General
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 25 of 79
Reductions in Cost Sharing #1 – Base 1
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 26 of 79
Reductions in Cost Sharing #1 – Base 2
o
CY 2022 PBP Data Entry System Screens
Every month
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 27 of 79
Reductions in Cost Sharing #2 – Base 1
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 28 of 79
Reductions in Cost Sharing #2 – Base 2
o
Softrams
CY 2022 PBP Data Entry System Screens
Every month
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 29 of 79
Reductions in Cost Sharing #3 – Base 1
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 30 of 79
Reductions in Cost Sharing #3 – Base 2
o
Softrams
CY 2022 PBP Data Entry System Screens
Every month
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 31 of 79
Combined Benefits – General
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 32 of 79
Combined Benefits #1
CY 2022 PBP Data Entry System Screens
Maximum plan benefit coverage amount periodicity:
•
•
•
•
•
•
Softrams
Every three years
Every two years
Every year
Every six months
Every three month
Other, describe
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 33 of 79
Combined Benefits #2
CY 2022 PBP Data Entry System Screens
Maximum plan benefit coverage amount periodicity:
•
•
•
•
•
•
Softrams
Every three years
Every two years
Every year
Every six months
Every three month
Other, describe
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 34 of 79
Combined Benefits #3
CY 2022 PBP Data Entry System Screens
Maximum plan benefit coverage amount periodicity:
•
•
•
•
•
•
Softrams
Every three years
Every two years
Every year
Every six months
Every three month
Other, describe
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 35 of 79
Notes
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 36 of 79
CY 2022 PBP Data Entry System Screens
Optional Supplemental – Management Screen
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 37 of 79
CY 2022 PBP Data Entry System Screens
Optional Supplemental – Label and Premium
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 38 of 79
CY 2022 PBP Data Entry System Screens
Optional Supplemental – Service Categories
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 39 of 79
Optional Supplemental – OON Step-up
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 40 of 79
Optional Supplemental – OON Optional
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 41 of 79
CY 2022 PBP Data Entry System Screens
Step-up #10b Transportation Services – Base 1
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 42 of 79
CY 2022 PBP Data Entry System Screens
Step-up #10b Transportation Services – Base 2
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 43 of 79
CY 2022 PBP Data Entry System Screens
Step-up #10b Transportation Services – Base 3
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 44 of 79
Step-up #16a Preventive Dental – Base 1
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 45 of 79
Step-up #16a Preventive Dental – Base 2
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 46 of 79
Step-up #16a Preventive Dental – Base 3
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 47 of 79
Step-up #16a Preventive Dental – Base 4
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 48 of 79
Step-up #16a Preventive Dental – Base 5
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 49 of 79
CY 2022 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 1
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 50 of 79
CY 2022 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 2
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 51 of 79
CY 2022 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 3
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 52 of 79
CY 2022 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 4
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 53 of 79
CY 2022 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 5
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 54 of 79
CY 2022 PBP Data Entry System Screens
Step-up #16b Comprehensive Dental – Base 6
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 55 of 79
Step-Up #17a Eye Exams – Base 1
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 56 of 79
Step-Up #17a Eye Exams – Base 2
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 57 of 79
Step-Up #17a Eye Exams – Base 3
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 58 of 79
Step-up #17b Eyewear – Base 1
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 59 of 79
Step-up #17b Eyewear – Base 2
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 60 of 79
Step-up #17b Eyewear – Base 3
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 61 of 79
Step-up #17b Eyewear – Base 4
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 62 of 79
Step-up #17b Eyewear – Base 5
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 63 of 79
Step-up #17b Eyewear – Base 6
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 64 of 79
Step-up #18a Hearing Exams – Base 1
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 65 of 79
Step-up #18a Hearing Exams – Base 2
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 66 of 79
Step-up #18a Hearing Exams – Base 3
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 67 of 79
Step-up #18a Hearing Exams – Base 4
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 68 of 79
Step-up #18b Hearing Aids -Base 1
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 69 of 79
Step-up #18b Hearing Aids -Base 2
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 70 of 79
Step-up #18b Hearing Aids -Base 3
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 71 of 79
Step-up #18b Hearing Aids -Base 4
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 72 of 79
Step-up #18b Hearing Aids -Base 5
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 73 of 79
CY 2022 PBP Data Entry System Screens
Step-up #7b Chiropractic Services – Base 1
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 74 of 79
CY 2022 PBP Data Entry System Screens
Step-up #7b Chiropractic Services – Base 2
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 75 of 79
CY 2022 PBP Data Entry System Screens
Step-up #7b Chiropractic Services – Base 3
Softrams
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 76 of 79
Step-up #7f Podiatry Services – Base 1
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 77 of 79
Step-up #7f Podiatry Services – Base 2
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 78 of 79
Step-up #7f Podiatry Services – Base 3
Softrams
CY 2022 PBP Data Entry System Screens
CY2022 PBP – Section D
09/15/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 79 of 79
| File Type | application/pdf |
| File Title | CY 2022 PBP Data Entry System Screens - Section D |
| Author | CMS |
| File Modified | 2020-10-14 |
| File Created | 2020-09-20 |