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Overview of CY 2012 PBP
Changes and OOPC Tool
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This
information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and
must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure
may result in prosecution to the full extent of the law.
1
PBP 2012 Training Agenda
Objective: Focus on CY 2012 Technical Changes
• Describe Key PBP CY 2012 Software Changes
• Describe Key SB CY 2012 Changes
• CMS List of Contacts
2
PBP CY 2012
Section A
Changes
3
Section A – A5
Plans must differentiate, for Sections B, C, and D
(by section), whether they are submitting a
“Standard Bid” or a “Fee-for-Service (FFS) Bid” by
answering Yes/No questions on the Section A-5
screen
If the standard bid question is answered yes for
Section B, then the organization will offer the
following benefits and this will be reflected in the
Summary of Benefits:
0% coinsurance for home health and preventive services
40% coinsurance for outpatient mental health care
20% coinsurance for all other services
4
Section A – A5
If the standard bid question is answered yes for
Section C, then the organization will offer the
following benefits, as applicable :
OON Benefit:
FFS cost sharing for Inpatient and SNF
Three groupings
0% coinsurance for home health and preventive
services
40% coinsurance for outpatient mental health care
20% coinsurance for all other services
US V/T:
Not offered
5
Section A – A5 (Cont.)
Section C Data Entry, continued
POS Benefit:
Offered as a mandatory supplemental benefit
Includes all PBP service categories
No Max Plan Benefit Coverage Amount, Max Enrollee
OOP amount or Deductible
No authorization/referral
FFS cost sharing for Inpatient and SNF
Three groupings –
0% coinsurance for home health and preventive
services
40% coinsurance for outpatient mental health care
20% coinsurance for all other services
6
Section A – A5 (Cont.)
If the standard bid question is answered yes for Section
D, then the organization will offer the following benefits,
as applicable :
Deductible:
Combined deductible for those plans that have the
combined deductible option; for those plan that do not
have the combined deductible option (e.g. HMO), In-
network only deductible
Changes the Medicare-defined Part B deductible
amount
Applies to all PBP service categories except PBP B1,
B2, B6, and B14
Max Enrollee Cost Limit:
$6700 in-network for all Medicare covered
benefits/$10,000 Catastrophic (as applicable)
Max Plan Benefit Coverage:
Not Offered
7
PBP CY 2012
Section B
Changes
8
Section B – Cost Share Limits
CY 2012 Limits
# Parts A and B Services PBP Location Voluntary MOOP Mandatory MOOP
x In-network MOOP Amount Section D $3,400 $6,700
x Combined IN and OON MOOP Amount Section D $5,100 $10,000
1 Inpatient – 60 Days 1a N/A $3,935
2 Inpatient – 10 Days 1a $2,231 $1,785
3 Inpatient – 6 Days 1a $2,016 $1,613
4 Mental Health Inpatient-60 Days 1b $2,471 $1,977
5 Mental Health Inpatient-15 Days 1b $1,796 $1,437
6 SNF-First 20 days 2a $100/day $50/day
7 SNF-Days 21-100 2a $146/day $146/day
8 Home Health 6a 20% or $30 co-pay none
9 Primary Care Visit 7a $35 co-pay $35 co-pay
10 Chiropractic Visit 7b $20 co-pay $20 co-pay
11 Specialist Visit 7d $50 co-pay $50 co-pay
12 Professional Mental Health Visit 7e & 7h $40 co-pay $40 co-pay
13 Therapeutic Radiological Services 8b 20% or $60 co-pay 20% or $60 co-pay
14 DME-Equipment 11a N/A 20%
15 DME-Prosthetics 11b N/A 20%
16 DME-Medical Supplies 11b N/A 20%
17 DME-Diabetes Supplies 11c N/A 20% or $10 co-pay
18 DME-Diabetic Shoes or Inserts 11c N/A 20% or $10 co-pay
19 Renal Dialysis 12 20% or $30 co-pay 20% or $30 co-pay
20 Part B Drugs-Chemotherapy 15 20% or $75 co-pay 20% or $75 co-pay
21 Part B Drugs-Other 15 20% or $50 co-pay 20% or $50 co-pay
22 Emergency Room Limit 4a $65
NOTE: THE TABLE ABOVE IS FROM THE 2012 DRAFT CALL LETTER.
9
Section B – 3
Section B-3: Cardiac and Pulmonary
Rehabilitation Services
The Comprehensive Outpatient Rehabilitation Facility
(CORF) benefit, which previously resided in Section
B-3, has been removed from the PBP software
The Cardiac Rehabilitation Services benefit, which
previously resided in Section B-9d, is now located in
Section B-3 and is expanded
10
Section B – 14
Section B-14: Preventive Services
The Preventive Services Section has been revised to
include Medicare-covered preventive services that must be
offered at zero dollar cost sharing
As a result, the number of sub-categories within the section
has been reduced from ten (10) to the following five (5):
14a: Medicare-covered $0 Cost Sharing Preventive Services
– An attestation statement and the list of Medicare-covered
preventive services that are offered at $0 cost sharing are
added to the beginning of Section B-14a.
14b: Supplemental Preventive Health Benefits
14c: Supplemental Education and Wellness Programs
14d: Kidney Disease Education Services (new)
14e: Diabetes Self-Management Training
11
Section B – 14a
Medicare-covered Zero Cost-Sharing Preventive Services:
Abdominal Aortic Aneurysm Screening
Bone Mass Measurement
Cardiovascular Screening
Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam)
Colorectal Cancer Screening
Diabetes Screening
Influenza Vaccine
Hepatitis B Vaccine
HIV Screening
Breast Cancer Screening (Mammogram)
Medical Nutrition Therapy Services
Personalized Prevention Plan Services (Annual Wellness Visits)
Pneumococcal Vaccine
Prostate Cancer Screening – Prostate Specific Antigen (PSA) test only
Smoking Cessation (counseling to stop smoking)
Welcome to Medicare Physical Exam (initial preventive physical exam)
12
Section B – 14b
Section B-14b: Supplemental Preventive Health Benefits
An on-screen label has been added to the base 1 screen that states:
“You should only use these supplemental benefits for OTHER
IMMUNIZATIONS not covered by Original Medicare. You may
charge co-pays for these other immunizations. NOTE: Medicare-
covered preventive services are always plan covered when
medically necessary, and consequently they are not appropriate
as a supplemental benefit.”
Section B-14b now consists of the following enhanced benefits:
Other Immunizations
This is the only enhanced benefit that data should be entered
Additional Physical Exams
Additional Pap Smears
Additional Pelvic Exams
Additional Prostate Exams
Additional Colorectal Exams
Additional Mammography Exams
13
Section B – 14d and 14e
Section B-14d: Kidney Disease Education Services
Section B-14d now includes Medicare-covered Kidney
Disease Education Services with no enhanced benefits,
along with minimum/maximum cost sharing data entry
Section B-14e: Diabetes Self-Management Training
Diabetes Self-Management Training (previously named
Diabetes Monitoring) has been moved from Section B-
14i to Section B-14e
14
PBP 2012
Section C
Changes
15
Section C – OON and V/T
Out-of-Network
The Out-of-Network data entry has been updated so
that an organization can enter the maximum benefit
coverage amount for non-Medicare benefits
Visitor Travel:
All PBP data entry for US V/T has been removed
except for the following 2 questions: ‘Do you offer a
US V/T program?’ AND ‘Select the type of benefit for
the US V/T program.’
16
PBP 2012
Section D
Changes
17
Section D – Plan Level Deductible
All of the non-Medicare picklists in Section D have
been updated to include all of the PBP categories
with a supplemental component
On the Plan Deductible (Combined) and (In-
Network) screens, an edit rule has been added to
ensure that Section B-14a cannot be selected in the
picklist for Combined and/or In-Network Deductible
18
Section D
CY 2012 Voluntary and Mandatory MOOP Amounts
By Plan Type
TABLE
Plan Type Voluntary Mandatory
HMO $3,400 $6,700
HMO POS $3,400 In-network $6,700 In-network
Local PPO $3,400 In-network $6,700 In-network and
and $5,100 Catastrophic* $10,000 Catastrophic*
Regional PPO $3,400 In-network $6,700 In-network
and $5,100 Catastrophic* and $10,000 Catastrophic*
PFFS (full network) $3,400 In- and out-of-network $6,700 In- and out-of-network
PFFS (partial network) $3,400 In- and out-of-network $6,700 In- and out-of-network
PFFS (non-network) $3,400 $6,700
* Catastrophic MOOP is inclusive of in-and-out-of-network Parts A and B Services
NOTE: THE TABLE ABOVE IS FROM THE 2012 DRAFT CALL LETTER AND MAY
CHANGE. PLEASE REFERENCE THE FINAL CALL LETTER FOR THE FINAL VALUES.
19
PBP 2012
Section Rx
Changes
20
Section Rx
The supplemental formulary file upload date has been updated to
June 13, 2011 throughout the PBP Rx section to reflect the CY2012
deadline
Any plan that is participating in Puerto Rico’s Platino Program may
not submit an Enhanced Alternative (EA) Plan in 2012
As stated in the 2012 Call Letter, the PBP and formulary upload will
continue to accept 6 formulary tiers. CMS will only allow a 6th tier if:
it is an excluded-drug-only tier;
a tier that provides a meaningful benefit offering such as a $0 vaccine-only tier,
or a $0 or low cost-sharing tier for special needs plans (SNP) targeting specific
conditions (e.g., $0 diabetic drug tier);
or an injectable drug tier with cost-sharing that is at or below the cost sharing
for specialty tier drugs in the other five tiers
Plans will have the ability to enter excluded drug cost-sharing pre-ICL
and in the catastrophic phase, even if choosing Medicare-defined cost
sharing for all other tiers
21
Section Rx
2012 Tier Label
2012 Tier
2012 Tier 2012 Model
Structure Option Code Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Optional Tier 6*
Either Generic or Either Brand or
2 Tier A 2A Preferred Generic Preferred Brand --- --- --- ---
Either Generic or Either Brand or
3 Tier A 3A Preferred Generic Preferred Brand Specialty Tier --- --- ---
Either Generic or
3 Tier B 3B Preferred Generic Preferred Brand Non-Preferred Brand --- --- ---
Either Generic or
4 Tier A 4A Preferred Generic Preferred Brand Non-Preferred Brand Specialty Tier --- ---
Non-Preferred
4 Tier B 4B Preferred Generic Generic Preferred Brand Non-Preferred Brand --- ---
Non-Preferred
5 Tier A 5A Preferred Generic Generic Preferred Brand Non-Preferred Brand Specialty Tier optional
Non-Preferred
5 Tier B 5B Preferred Generic Generic Preferred Brand Non-Preferred Brand Injectables optional
Non-Preferred
5 Tier C 5C Preferred Generic Generic Preferred Brand Injectables Specialty Tier optional
Either Generic or
5 Tier D 5D Preferred Generic Preferred Brand Non-Preferred Brand Injectables Specialty Tier optional
NOTE: THE TABLE ABOVE IS FROM THE 2012 DRAFT CALL LETTER.
PLEASE REFER TO THE FINAL CALL LETTER TIER MODEL STRUCTURE.
22
Section Rx –
New Exit Validation Rules
Excluded drug only tiers must be the highest numbered tier offered
If additional generic gap coverage is offered, then the coinsurance cannot be
greater than or equal to the standard benefit for CY2012 of 86%
Exception: In the case of a ‘lesser of’ cost-sharing scenario, the coinsurance can be
equal to 86%
Duplicative tier names are not allowed
Tier 1 must include the term ‘generic’ in the tier label (with or without the
qualifier preferred)
If two or more tier labels include the term ‘generic’, then:
At least one tier label must include the term ‘preferred generic’ and one label must
include the term ‘non-preferred generic’
The separate ‘preferred generic’ tier must be a lower tier number than the tier with
the ‘non-preferred generic’ label
If two or more tier labels include the term ‘brand’, then:
At least one tier label must include the term ‘preferred brand’ and one must include
the term ‘non-preferred brand’
The separate ‘preferred brand’ tier must be a lower tier number than the tier with the
‘non-preferred brand’ label
23
Summary of Benefits
CY2012 Changes
24
SB – General
The Summary of Benefits (SB) is revised to include the Medicare-Covered
Preventive Services that must be offered at zero dollar cost share in one
section
As a result, the SB categories are renamed and reordered from SB-22 through
the end of the SB. The following are the new SB categories from SB-22 on:
SB-22: Cardiac and Pulmonary Rehabilitation Services
SB-23: Preventive Services and Wellness/Education Programs
SB-24: Kidney Disease and Conditions
SB-25: Outpatient Prescription Drugs
SB-26: Dental Services
SB-27: Hearing Services
SB-28: Vision Services
SB – Over-the-Counter (OTC) Items
SB – Transportation
SB – Acupuncture
SB – Point of Service
SB – Optional Benefits
25
SB – General
The following categories have been removed, and the Medicare-covered and
enhanced components of these benefits are now located in SB-23:
Bone Mass Measurement
Colorectal Screening Exams
Immunizations
Breast Cancer Screening (Mammograms)
Cervical and Vaginal Cancer Screening (Pap Smears and Pelvic Exams)
Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only)
Physical Exams
Health and Wellness Education
The following is a new SB category with data that previously resided in SB-17,
and now provides more cost sharing data:
SB-22: Cardiac and Pulmonary Rehabilitation Services
The following is a new SB category with data that previously resided in SB-34:
SB – Over-the-Counter Items
26
SB – Introduction
All SB-Introductions have been updated
In all SB-Introductions, the following sentence under
“WHAT ARE MY PROTECTIONS IN THIS PLAN?”
has been updated from 60 days to 90 days:
“If a plan decides not to continue, it must send you a
letter at least 90 days before your coverage will end.”
27
PBP & SB Contacts
28
PBP/SB Contact List
PBP Software Technical Issues:
– Sara Silver 410-786-3330 sara.silver@cms.hhs.gov
– Lucia Patrone 410-786-8621 lucia.patrone@cms.hhs.gov
PBP/HPMS Technical Help Desk:
– Help Desk 800-220-2028 hpms@cms.hhs.gov
MA Benefit Operations & Policy Issues (MA PBP):
– Dale Summers (Ops) 410-786-5135 dale.summers2@cms.hhs.gov
– Marty Abeln (Policy) 410-786-1032 marty.abeln@cms.hhs.gov
– Russell Hendel (Policy) 410-786-0329 russell.hendel@cms.hhs.gov
– Heather Hostetler (Policy) 410-786-4515 heather.hostetler@cms.hhs.gov
MA Marketing Operations & Policy Issues (MA SB):
– Elizabeth Jacob 410-786-8658 elizabeth.jacob2@cms.hhs.gov
– Lisa Littleaxe 214-767-6470 lisa.littleaxe@cms.hhs.gov
Part D Benefit Operations & Policy Issues (Part D PBP):
– Rosalind Abankwah 410-786-2012 rosalind.abankwah@cms.hhs.gov
– Frank Tetkoski 410-786-5233 frank.tetkoski@cms.hhs.gov
– Kathleen Flannery 410-786-6722 kathleen.flannery@cms.hhs.gov
Part D Marketing Operations & Policy Issues (Part D SB):
– Rosalind Abankwah 410-786-2012 rosalind.abankwah@cms.hhs.gov
– Christine Hinds 410-786-4578 christine.hinds@cms.hhs.gov
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