Crosswalk

Burden Change

Reason for Change

Type of Change

2022 (new version)

2021 (old version)

Enrollment K. Of the total reported in A, the number of
Enrollment K. Of the total reported in A, the number of
enrollment requests received from an applicant through an agent enrollment requests received from an applicant through an
broker.
agent or broker.

Rev Provide technical clarification.

No

Section V. Coverage Determinations Redeterminations, and
Reopenings

Section V. Coverage Determinations Redeterminations
(including At–Risk Redeterminations under a Drug
Management Program), and Reopenings

Rev Provide technical clarification.

No

CD/RD: Title 42, Part 423, Subpart M describes Part D sponsors’
requirements for coverage determinations (including formulary
and tier exceptions, and exceptions to established drug utilization
management programs) and redeterminations, including
timeframes for standard and expedited requests. Part B vs. Part
D coverage determinations and redeterminations should be
included in this reporting. Sponsors should report data based on
the date the enrollee/enrollee’s representative is notified in writing
of the coverage determination or redetermination decision. A
sponsor’s complete decision includes making the determination,
appropriately notifying the enrollee of the determination, and
authorizing coverage or sending payment, where applicable.

Rev Provide technical clarification.
CD/RD: The requirements relating to coverage
determinations (including formulary and tier exceptions,
and exceptions to established drug utilization management
programs) and redeterminations, including timeframes for
standard and expedited requests are described in Title 42,
Part 423, Subpart M. Sponsors will be responsible for
reporting several data elements related to coverage
determinations and redeterminations, including. Part B vs.
Part D coverage determinations and redeterminations.
Sponsors should report data based on the date the
enrollee/enrollee’s representative is notified in writing of the
coverage determination or redetermination decision. A
sponsor’s complete decision includes making the
determination, appropriately notifying the enrollee of the
determination, and authorizing coverage or sending
payment, where applicable.

No

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Resignation.

N/A

Add Provide technical clarification.
CD/RD: Sponsors must also report data relating to
redeterminations of at-risk determinations made under a
plan sponsor’s drug management program pursuant to the
rules at 42 CFR §423.153(f), including the number of
requests and the disposition. At-risk redeterminations may
involve decisions about:
• Being identified as an at-risk beneficiary for prescription
drug misuse or abuse;
• Having a limitation, or the continuation of a limitation, on
access to coverage for frequently abused drugs (i.e., an
enrollee specific point-of-sale (POS) edit or the selection of
a prescriber and/or pharmacy for purposes of lock-in);
• Sharing information for subsequent Part D plan
enrollments.
Sponsors should report data based on the date the
enrollee/enrollee’s representative is notified in writing of the
at-risk redetermination decision.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Resignation.

No