Plan Benefit Package (PBP) CY 2021 Software Changes - HPMS
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Plan Benefit Package (PBP) CY 2021 Software Changes
PBP CY 2021 Training Agenda Objective: Focus on CY 2021 Technical Changes • Describe Key PBP Software Changes • Describe Key MMP Changes • Describe Key VBID/MA Uniformity Flexibility/SSBCI changes • Describe Part D Payment Modernization Model Additions
PBP CY 2021 General Changes
PBP CY 2021 General Changes • The Copy Plan (from Previous Year) function has been updated based on changes made to the PBP in the current year.
PBP CY 2021 Section A Changes
PBP CY 2021 Section A • There were no changes to the PBP Section A for CY 2021.
PBP CY 2021 Section B Changes
Updated Section B – Cost-Share Limits
Service Category PBP Location Voluntary MOOP Mandatory MOOP
Inpatient Hospital – Acute - 60 Days 1a N/A $4,816
Inpatient Hospital – Acute - 10 Days 1a $2,783 $2,226
Inpatient Hospital – Acute - 6 Days 1a $2,524 $2,019
Inpatient Hospital Psychiatric - 60 Days 1b $3,408 $2,726
Inpatient Hospital Psychiatric - 15 Days 1b $2,339 $1,871
SNF-First 20 days 2 $20/day $0/day
SNF-Days 21-100 2 $184/d $184/d
Cardiac Rehabilitation Services 3 $50 $50
Intensive Cardiac Rehabilitation Services 3 $100 $100
Pulmonary Rehabilitation Services 3 $30 $30
Supervised exercise therapy (SET) for $30 $30
3
Symptomatic peripheral artery disease (PAD)
Emergency / Post Stabilization Services 4a $120 $90
Urgently Needed Services 4b $65 $65
Partial Hospitalization 5 $55/day $55/day
Home Health 6a 20% or $35 0% or $0
Primary Care Physician 7a $35 $35Updated Section B – Cost-Share Limits 2
Service Category PBP Location Voluntary MOOP Mandatory MOOP
Chiropractic Care 7b $20 $20
Occupational Therapy 7c $40 $40
Physician Specialist 7d $50 $50
Psychiatric and Mental Health Specialty Services 7e & 7h $40 $40
Physical Therapy and Speech-language Pathology 7i $40 $40
Therapeutic Radiological Services 8b 20% or $60 20% or $60
DME-Equipment 11a N/A 20%
DME-Prosthetics 11b N/A 20%
DME-Medical Supplies 11b N/A 20%
DME-Diabetes Monitoring Supplies 11c N/A 20% or $10
DME-Diabetic Shoes or Inserts 11c N/A 20% or $10
12 20% or $30 20% or $30
Dialysis Services
Part B Drugs-Chemotherapy 15 20% or $75 20% or $75
Part B Drugs-Other 15 20% or $50 20% or $50Section B-4 • Service Category B4 has been renamed to “Emergency/Urgently Needed Services” and the Benefit B4a has been renamed to “Emergency/Post- Stabilization Services.” The "Indicate Maximum per visit amount" question has had the cost-sharing validation implemented.
Section B-7 B-7j: Additional Telehealth • The B7j Additional Telehealth Benefits question has been revised to read “Select the Medicare-covered benefits that may have Additional Telehealth Benefits available.” B-7k: Opioid Treatment Program Services • Service Category B7k has been renamed to “Opioid Treatment Program Services.”
Section B-13 • The notes for B13d, B13e, B13f and B13g (when they are applicable) will now be required when the benefits in these sections are offered.
Section B-14 B-14c: Other Defined Supplemental Benefits • A mandatory question has been added to indicate type of Fitness Benefit offered for the B14c4 Fitness Benefit category. • The B14c8 benefit category name has been changed to "Home and Bathroom Safety Devices and Modifications."
Sections B-15 and B-20 • "Medicare Part B Chemotherapy Drugs" has been changed to "Medicare Part B Chemotherapy/Radiation Drugs.”
PBP CY 2021 Section C Changes
Section C • Section C – Plans can now offer Remote Access Technologies in OON or POS even if not offered in B14c but B7j is offered in section B. • Section C – Plans can no longer select 14e6 Other Medicare Covered Preventive Services in Section C if there is no B14e6 data entered in Section B. • Section C OON and POS groups– Plans are now required to enter a note if a copay and coinsurance is offered OR a range in either copay/coinsurance is entered. • The OON and POS Medicare service category picklists have been updated to remove B7j Additional Telehealth.
PBP CY 2021 Section D Changes
Section D – Continued 1
• Combined Benefits screens have been added to allow
plans to combine supplemental benefits into up to
three groups. These screens will allow the plan to offer
groups of supplemental benefits together with a single
maximum plan benefit amount and will also require the
plan to designate if the enrollee must select one or
more of the benefits (as opposed to having access to all
of the combined benefits selected).
• Note: If the plan offers combined benefits in these
screens, the plan must first offer them in Section B.
Each benefit may only be offered in one combined
supplemental benefit package.Section D – Continued 2 • Part C Reductions in Cost Sharing (RICS) screens have been added for plans to enter reduced cost sharing for A/B and/or supplemental benefits in the base bid (applicable to all enrollees unlike Section 19 which are benefits offered to unique populations). • Plans can now select 19a or 19b in the Non-Medicare covered picklists for plan-level MOOP. • B7j Additional Telehealth has been removed from Optional Supplemental benefits picklists.
PBP CY 2021 Section Rx Changes
Section Rx • The validation requiring that the retail 3-month day supply value must be the same across all offered tiers has been removed. The range must still be between 90 and 102 days, inclusive. • Language updates were made throughout the section to clarify and simplify the terminology. • Section Rx data entry screens have been updated.
Medicare-Medicaid Plans CY 2021 PBP Changes
MMP – PBP (Section Rx)
• The edit rules for maximum cost-sharing amounts for MMPs drug
tiers have been updated as follows:
• For a Generic only tier: The Maximum allowable copay is
$3.70.
• For a Brand only tier: The Maximum allowable copay is $9.20.
• For a Non-Medicare drugs only tier: No validations.
• For a Combination (Brand & Generic) tier: The Maximum
allowable copay is $9.20.
• For a Combination (Medicare & Non-Medicare drugs) tier:
The Minimum and Maximum copay must both be $0.VBID/UF/SSBCI CY 2021 PBP Changes
VBID/UF/SSBCI – PBP (Section B-19) • An option for VBID plans to offer a VBID Hospice benefit has been added. Screens to capture these benefits have been added in B19c. • A screen for VBID plans to outline the components of their Wellness and Health Care Planning (WHP) programs offered to enrollees has been added. • On the B19a and B19b Package Information screens, the prerequisite question option has been changed “participation in a wellness or care management program” to “participation in a care management program.” • The list of other VBID interventions (in addition to WHP) for selection in B19a and B19b has been revised to “Value-Based Design Flexibilities by Condition or Socioeconomic Status” and “Medicare Advantage Rewards and Incentives Programs.” “Telehealth Networks” has been removed from the list of interventions.
VBID/UF/SSBCI – PBP (Section B-19) – Continued 1 • New VBID Rewards and Incentives screens have been added. • An on-screen label has been added instructing users to go to Section Rx to enter VBID Part D Rewards and Incentives. • The notes fields required for VBID packages offering Medicare Advantage Rewards and Incentives Programs or Telehealth Networks have been removed. • The 19a and 19b VBID Disease State screens have been renamed to be VBID Target Population screens. The questions on these screens have been updated to separate chronic condition(s) from socioeconomic status in specifying targeting methodology and to gather additional information on disease state requirements as well as estimated enrollees to be targeted and engaged to receive model benefits. The questions “Does the enrollee need to have all diseases selected to qualify? Y/N” and “Does the enrollee need to have a combination of diseases selected to qualify? Y/N” have been added to these screens for all VBID packages.
VBID/UF/SSBCI – PBP (Section B-19) – Continued 2 • In Section 19b, 13i the benefit “Transitional/Temporary Supports” has been renamed “General Supports for Living.” • In Section 19b, PPO plans are required to select "Yes" to the question "Do the benefits in this package apply to OON/POS?"
VBID – PBP (Section Rx) • New Part D Rewards and Incentives screens have been added. • The questions on the VBID Package Setup screen have been updated to separate chronic condition(s) from socioeconomic status in specifying targeting methodology and to gather additional information on estimated enrollees to be targeted and engaged to receive model benefits. • The question “Is any of the cost-sharing reduction contingent upon participation with a high-value pharmacy network?” has been removed from the VBID Package Setup screen.
Part D Payment Modernization • The PBP software has been updated to include new screens for Part D Payment Modernization Model plans to describe their model flexibilities.
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