CMS-R-262 Benefit Details-Service Categories 1-10

The Plan Benefit Package (PBP) and Formulary Submission for Advantage (MA) Plans and Prescription Drug Plans (PDPs) (CMS-R-262) - IRA

Appendix_C_PBP2024 Benefit Details-Service Categories 1-10

OMB: 0938-0763

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1a - Inpatient Hospital-Acute - Page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1a - Inpatient Hospital-Acute - Page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1a - Inpatient Hospital-Acute - Page 3

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1a - Inpatient Hospital-Acute - Page 4

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1a - Inpatient Hospital-Acute - Page 5

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1a - Inpatient Hospital-Acute - Page 6

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1a - Inpatient Hospital-Acute - Page 7

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1a - Inpatient Hospital-Acute - Page 8

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1a - Inpatient Hospital-Acute - Page 9

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1a - Inpatient Hospital-Acute - Page 10

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1a – Additional Days for Inpatient Hospital-Acute - Page 1

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01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1a - Additional Days for Inpatient Hospital-Acute - Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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1a - Non-Medicare Covered Stay for Inpatient Hospital-Acute - Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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CY 2024 PBP Data Entry System Screens

1a - Non-Medicare Covered Stay for Inpatient Hospital-Acute – Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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CY 2024 PBP Data Entry System Screens

1a – Upgrades for Inpatient Hospital-Acute

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01/13/2023
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CY 2024 PBP Data Entry System Screens

1b - Inpatient Hospital-Psychiatric - Page 1

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01/13/2023
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1b - Inpatient Hospital-Psychiatric - Page 2

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01/13/2023
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1b - Inpatient Hospital-Psychiatric - Page 3

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01/13/2023
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1b - Inpatient Hospital-Psychiatric - Page 4

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01/13/2023
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1b - Inpatient Hospital-Psychiatric - Page 5

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01/13/2023
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1b - Inpatient Hospital-Psychiatric - Page 6

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01/13/2023
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1b - Inpatient Hospital-Psychiatric - Page 7

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01/13/2023
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1b - Inpatient Hospital-Psychiatric - Page 8

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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1b - Inpatient Hospital-Psychiatric - Page 9

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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1b - Inpatient Hospital-Psychiatric - Page 10

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1b - Additional Days for Inpatient Hospital-Psychiatric -Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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1b - Additional Days for Inpatient Hospital-Psychiatric -Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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1b - Additional Days for Inpatient Hospital-Psychiatric -Page 3

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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1b - Additional Days for Inpatient Hospital-Psychiatric - Page 4

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

1b - Non-Medicare-Covered Stay for Inpatient Hospital Psychiatric - Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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1b - Non-Medicare-Covered Stay for Inpatient Hospital Psychiatric - Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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2 - Skilled Nursing Facility - Page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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2 - Skilled Nursing Facility - Page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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2 - Skilled Nursing Facility - Page 3

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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2 - Skilled Nursing Facility - Page 4

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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2 - Skilled Nursing Facility - Page 5

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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2 - Skilled Nursing Facility - Page 6

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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2 - Skilled Nursing Facility - Page 7

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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2 - Skilled Nursing Facility - Page 8

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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2 - Additional Days for Skilled Nursing Facility -Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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2 - Additional Days for Skilled Nursing Facility -Page -2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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2 - Additional Days for Skilled Nursing Facility - Page-3

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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2 - Non-Medicare-Covered Stay for Skilled Nursing Facility -Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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2 - Non-Medicare-Covered Stay for Skilled Nursing Facility -Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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CY 2024 PBP Data Entry System Screens

3 - Cardiac and Pulmonary Rehabilitation Services

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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3-1 - Cardiac Rehabilitation Services -Page 1

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01/13/2023
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3-1 - Cardiac Rehabilitation Services -Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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3-2 - Intensive Cardiac Rehabilitation Services - Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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3-2 - Intensive Cardiac Rehabilitation Services - Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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3-3 - Pulmonary Rehabilitation Services - Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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3-3 - Pulmonary Rehabilitation Services -Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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3-4 - SET for PAD Services -Page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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3-4 - SET for PAD Services -Page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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3-1 - Additional Cardiac Rehabilitation Services - Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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3-1 - Additional Cardiac Rehabilitation Services -Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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3-2 - Additional Intensive Cardiac Rehabilitation Services -Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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3-2 - Additional Intensive Cardiac Rehabilitation Services -Page 2

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CY2024 PBP – Benefit Service Categories 1-10
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3-3 - Additional Pulmonary Rehabilitation Services -Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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3-3 - Additional Pulmonary Rehabilitation Services -Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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3-4 Additional SET for PAD Services -Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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3-4 Additional SET for PAD Services -Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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4a Emergency Services -Page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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4a Emergency Services -Page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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4b - Urgently Needed Services -Page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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4b - Urgently Needed Services -Page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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4b - Urgently Needed Services -Page 3

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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4c - Worldwide Emergency /Urgent Coverage -Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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4c - Worldwide Emergency /Urgent Coverage -Page 2

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01/13/2023
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4c1 - Worldwide Emergency Coverage

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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4c2 - Worldwide Urgent Coverage

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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4c3 - Worldwide Emergency Transportation

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5 - Partial Hospitalization -Page 1

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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5 - Partial Hospitalization -Page 2

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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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5 - Partial Hospitalization -Page 3

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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6 -Home Health Services-Page 1

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6 -Home Health Services-Page 2

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01/13/2023
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CY2024 PBP – Benefit Service Categories 1-10
01/13/2023
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6-1 Additional Hours of Care -Page 1

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6-1 Additional Hours of Care -Page 2

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6-2 Personal Care Services -Page 1

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6-3 Other 1 for Home Health Services -Page 1

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7a - Primary Care Physician Services -Page 1

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7a - Primary Care Physician Services -Page 2

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7b – Chiropractic Services -Page 1

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7b – Chiropractic Services -Page 2

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7b – Chiropractic Services -Page 3

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7b – Chiropractic Services -Page 4

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7b1 – Routine Chiropractic Care -Page 1

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7b1 – Routine Chiropractic Care -Page 2

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7b2 – Other Chiropractic Care -Page 1

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7b2 – Other Chiropractic Care -Page 2

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7c - Occupational Therapy Services -Page 1

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7c - Occupational Therapy Services -Page 2

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7c - Occupational Therapy Services -Page 3

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7d - Physician Specialist Services – Page 1

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7e - Mental Health Specialty Services -Page 1

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7e - Individual Sessions for Mental Health Specialty Services

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7e - Group Sessions for Mental Health Specialty Services

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7f - Podiatry Services -Page 1

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7f - Podiatry Services -Routine Foot Care -Page 1

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7g - Other Health Care Professional -Page 1

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7h2 - Group Sessions for Psychiatric Services

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7i - Physical Therapy and Speech -Language Pathology Services -Page 1

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7j - Additional Telehealth Benefits -Page 1

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7j - Additional Telehealth Benefits -Page 2

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7k - Opioid Treatment Program Services -Page 1

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8a - Diagnostic Procedures /Tests/Lab Services -Page 1

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9b - Ambulatory Surgical Center (ASC) Services -Page 1

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9c - Outpatient Substance Abuse -Page 1

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9d - Outpatient Blood Services

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9d - Three (3) pint Deductible Waived -Page 1

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10a - Ambulance Services

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10a1 - Ground Ambulance Services -Page 1

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10a2 - Air Ambulance Services -Page 1

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10b1 - Transportation Services -Plan Approved Health-related Location -Page 1

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