Overview of PBP Changes and OOPC Tool - CMS Drug _ Health by pptfiles

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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




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       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.”




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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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