Plan Benefit Package (PBP) CY 2021 Software Changes PBP CY 2021 - - PowerPoint PPT Presentation

Plan Benefit Package (PBP) CY 2021 Software Changes

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 Training Agenda

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 General Changes

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 Symptomatic peripheral artery disease (PAD) 3 $30 $30 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 $35

Updated 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 Dialysis Services 12 20% or $30 20% or $30 Part B Drugs-Chemotherapy 15 20% or $75 20% or $75 Part B Drugs-Other 15 20% or $50 20% or $50

Section 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

• f 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.