The "sometimes" would not be used to describe separate patient encounters with different providers.

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1 CMS Responses to Questions from Organizations (CY 2013) PBP/Data Entry 1. Q. In Section B 8a & 8b of the PBP, can CMS clarify under what circumstance is it asking if a separate physician/professional service cost share applies? A. For CY 2013, the options for the question, "Indicate whether a separate physician/professional service cost share applies" have been changed to "Sometimes" and "No" for B8a and B8b, therefore the "Yes" option is no longer available. The cost sharing a plan enters in the data fields should be inclusive of all cost sharing an enrollee will pay, but if the plan chooses "sometimes" as their option, then there should be a note entered explaining when the "sometimes" would occur. For additional information, the PBP variable help, which is available when right clicking on the variable question, reads as follows: Some plans may require that an enrollee pay two separate cost shares if this service is received as part of a primary care or specialist office visit. Examples 1) there may be a general $5 primary care physician office visit copayment required in addition to a $10 copayment for receiving this specific service if it is part of the same patient encounter; or 2) there may be a general $10 specialist office visit copayment required in addition to a $15 copayment for receiving this specific service if it is part of the same patient encounter. (NOTE: The information provided for this field is used to create sentences in the Summary of Benefits. Please refer to the PBP/SB Crosswalk for further details.) The "sometimes" would only be used if a plan sometimes requires an enrollee to pay two separate cost shares if the service is received as part of a primary care or specialist office visit. As stated before the "sometimes" situation will need to be described in the notes. The "sometimes" would not be used to describe separate patient encounters with different providers. 2. Q. Can CMS provide clarification on yearly vs. three year designation of benefits, specifically related to Hearing Aid benefits? Typically benefits include $1,000 plan coverage limit for hearing aids every three years or $500 limit/year (dollar allowance in the bid is driven by the type of designation) A. CMS encourages plans to design benefits packages based on one contract year to minimize potential beneficiary confusion; however, in section 90.2 of the Medicare Managed Care Manual, plan enrollees may be offered supplemental multi year benefits. Plans may offer a yearly allowance or can offer, for example, the enrollee an allowance of up to $1000 for a hearing aid every three years. Please see reference guidance: Medicare Managed Care Manual 90.2 Multi Year Benefits (Rev. 97, Issued: , Effective: 1

2 , Implementation: ) Supplemental multi year benefits are services that are provided to a plan s Medicare enrollees over a period exceeding one year. We understand that some benefits are appropriately offered over multiple years, but encourage plans to limit offerings to one contract year where possible. 3. Q. The Call Letter and Final Rule mention that MA plans are allowed to limit DME to certain providers or brands. What if the MA plan does not want to limit the DME providers or brands, but wants to offer lower cost sharing for using preferred providers or brands? Is this type of benefit allowed for all categories of DME? A. Within the DME service category, a plan may offer lower cost sharing for supplies purchased from a preferred manufacturer, as long as all plan enrollees have access to the preferred manufacturer and the benefit is transparent to the beneficiary. 4. Q. What is the best way for a MA plan to enter the following information about our Dental benefits into PBP for 2013? Oral exams and prophylaxis are covered once every 6 months with max coverage amount of $100. X rays are covered once every year with a max coverage amount of $50. The data entry screens will not allow for the x rays to be separated out. What are CMS suggestions on how to enter the periodicity and maximum plan benefit coverage amount for these benefits when they are not the same? A. Once the benefits and periodicity data entry screens are completed, it would be recommended to enter $150 in the box labeled: Indicate Maximum Plan Benefit Coverage amount. The $150 amount would incorporate both amounts for the exam, prophylaxis and x rays. Then in the Notes field, describe in further detail that the $100 applies to the oral exams and prophylaxis which are covered every 6 months, and the $50 applies to x rays that are covered once a year with a max coverage of $ Q. Is there a cost sharing limit for plans charging coinsurance for outpatient psychiatric and mental health specialty services (7e and 7h)? A. The coinsurance reduction described in your question is related to Original Medicare s approach to aligning professional cost sharing over time. The CY 2013 Medicare Advantage limits for mental health services in 7e and 7h remain consistent with last year (i.e., $40 copayment / 50% coinsurance) as described in the CY 2013 Call Letter (page 93) and Chapter 4 of the Medicare Managed Care Manual (50.1). 6. Q. Will CMS be providing additional guidance on the new PBP change to allow tiering of hospital cost sharing tiers for Inpatient Hospital Acute and IP Hospital Psychiatric? A. CMS issued on April 12, 2012 an HPMS Memo titled, Contract Year 2013 Medicare Advantage Bid Review and Operations Guidance. On page 10 of this guidance you will find inpatient hospital information pertaining to Sections B1a and 1b of the PBP. 2

3 CMS revised the PBP to enable data entry for tiered inpatient hospital cost sharing to ensure benefit and cost sharing transparency for beneficiaries. The revised PBP will include data entry fields for up to three tiers of cost sharing for inpatient acute and inpatient mental health service categories. MAOs must continue to ensure their tiered cost sharing is not discriminatory and provides beneficiaries with equal access to quality hospitals. The additional data entry fields will decrease the need for notes entry explaining inpatient hospital tiers and enable generation of accurate and meaningful summary of benefit sentences, thus ensuring the benefit is transparent to beneficiaries. Additional information can also be found in Chapter 4 of the Managed Care Manual. 7. Q. Can MA and MAPD plans offer different (lower) cost sharing for procedures performed at an Ambulatory Surgical Center (ASC) versus procedures performed in an outpatient facility/hospital setting? Would CMS consider this tiering? A. When a plan offers different cost sharing at different places of service, CMS does not consider this to be tiering. CMS has allowed plans to charge cost sharing that reflects differences in the facility costs of the various sites. Variation related to facility/place of service: Enrollee cost sharing varies depending on the facility or place of service in which the service is furnished. CMS has not defined a limited set of service categories that may be offered at different sites or what that cost sharing may be but, plans commonly charge different cost sharing for physical therapy/occupational therapy/speech language pathology, outpatient surgery and imaging services (therapeutic and diagnostic). These services may be furnished in the outpatient department of a hospital, ambulatory surgical centers, and freestanding imaging facilities or to some extent, in physician offices. The total cost sharing, including that attributable to the facility in which services are furnished, is included in a plan s PBP entry of required cost sharing and meets CMS standards. A range of cost sharing is allowed in order to capture those variations. We have not seen variation in cost sharing based on where services are furnished as a violation of the uniformity requirement because it may be argued that the cost sharing for the service itself is the same across all sites, and the difference in cost sharing is due to the overhead costs for the facility/place of service. The cost sharing is fairly transparent because the PBP value entered by the plan reflects the cost sharing range and the MOC reports the highest value. 8. Q. Table VI 4 of the CY 2013 Call Letter indicates a cost share limit for Part B chemotherapy drugs of 20% or $75. Does this limit simply mean that the plan can choose a copayment of $50 or a coinsurance of 20% for this benefit? Or does it mean that if, for instance, the plan employs a coinsurance of 20%, or the plan needs to limit the member's out of pocket amount to no more than $75? A. Consistent with past years, where CMS lists both a coinsurance and copayment amount as the cost sharing standard for a particular service category in Table VI 4 of the Call Letter, it means that plans have a choice and may choose either type of cost sharing and may choose any amount up to and including the amounts listed. 3

4 9. Q. In the PBP Software Section D one can select what service categories the Part B Deductible applies to. PBP Category 4 (ER) is not available for selection which would imply that the Part B Deductible does not apply to ER. However in the Medicare & You Manual on Page 43, it states that the Part B Deductible does apply to Emergency Department Services (see attachment). This seemingly contradicts the PBP Software and we were hoping that you could help us understand why the PBP software doesn't allow the selection of ER for the Part B Deductible. A. Consistent with last year, cost sharing cannot exceed $65 per visit for emergency services. A deductible cannot be applied to section 4a (Emergency Care) of the PBP. This limit to enrollees for emergency department services is determined annually by CMS. Guidance pertaining to emergency services can be found in CFR These services are defined as emergency services covered inpatient and outpatient services that are furnished by a provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition. MA organizations are financially responsible for emergency and urgently needed services. 10. Q. In section C of the PBP software, Can PPO plans create a separate OON Group for Preventive Services? However, some of the Preventive Services OON pull a copayment and some pull a coinsurance. Is it correct to list both in the PBP? The SB sentence doesn't clearly state for the members which services would be subject to which cost share. For example, it could show $20 $40 copay [or 0 30%]. Is it then appropriate to clarify in the Evidence of Coverage? A.Yes, that is correct. You also need to specify which services have the copayment and which have coinsurance in the Notes section. You also need to further explain in the EOC OR in SB Section III. 11. Q. In Section B of the PBP won't allow the plan to select coverage for Non Medicare items unless at least one Mandatory enhanced benefit is offered. This is only happening on Employer Group PBP's as we file the standard 20% for all items. Please advise how a MA plan should correct this? A. If a MA plan does NOT offer ANY enhanced benefits within Section B, the plan will not be able to select "Yes" to the question "Does the In Network Maximum Enrollee Out of Pocket Cost apply to all In Network Non Medicare covered plan services" on the Max Enrollee Cost Limit (In Network) screen. Since the plan offers the "Standard bid" within Section B, you do not offer any enhanced benefits In Network. The plan will need to deselect "In Network Non Medicare covered benefits" from the question "Select the benefits that apply to the In Network Maximum Enrollee Out of Pocket cost" on the Max Enrollee Cost Limit (In Network) screen. Then the plan will be able to exit with validation correctly. 12. Q. In regards to the LPPO deductible on Page 116 of the 2013 Final Call Letter, can CMS clarifying if the following scenarios are permissible? All scenarios assume that there is no deductible on in network preventive services and other specific services. Scenario 1 4

5 Combined deductible of $400 with $0 deductible on in network services (i.e., single deductible applies to out of network only). Scenario 2 Combined deductible of $400. In network deductible is capped at $200 and can satisfy by deductibles paid on in network and/or out of services with remaining $200 applicable to out ofnetwork services only. Scenario 3 Combined deductible of $400 with deductible cap of $100 on Part B in network services. A. The scenarios provided have one common feature, for the deductible to be applied specifically to either in network or out of network services. In Chapter 4, section 50.1 and 50.3 of the Medicare Managed Care Manual new guidance is available. As stated in the Call Letter dated April 2, 2012, All PPO plans (local and regional) that choose to apply a deductible must establish a single deductible that applies to all Part A and B services, both in and out of network (OON combined). PPOs may not apply a separate deductible amounts for in network and OON services. PPO plans (local and regional) may elect to exclude any or all in network Part A or B services from the deductible. Scenario 1 Combined deductible of $400 with $0 deductible on in network services (i.e., single deductible applies to out of network only). Response: Yes. Single combined deductible: If an MA PPO wishes, in one of its plan packages, to offer a deductible for Original Medicare services, either in network or out of network, then the RPPO may: Offer a single combined deductible for all Original Medicare services, whether in network or outof network; Offer separate deductibles for specific Original Medicare in network services, provided the plan also offers a single combined deductible for all Original Medicare services, both in and out ofnetwork, towards which the separate deductibles for specific in network Original Medicare services count; and Not offer a separate deductible for out of network Original Medicare services. Scenario 2 Combined deductible of $400. In network deductible is capped at $200 and can be satisfied by deductibles paid on in network and/or out of services with remaining $200 applicable to out ofnetwork services only. Response: Yes, the plan can have a single combined $400 in and out of network deductible. In this example the enrollee may meet the limit by spending $200 in network and $200 out ofnetwork or by spending $400 out of network. A plan may have a $400 limit in in network out ofpocket expenditures and a combined in network/out of network limit of $400. Scenario 3 Combined deductible of $400 with deductible cap of $100 on Part B in network services. Response: Yes, This scenario is acceptable. 5

6 13. Q. If an MAO is approved by CMS for a partial county for an expansion county in the PBP, does this show with the county name and (partial) after that specific county? A. Yes, that is correct; it will show the county and show that it is a partial county. 14. Q. If an MAO is looking at offering a Narrow Network option to a small targeted service area which is part of their existing area, does the MAO file as a separate PBP? If the MAO has segments and would potentially only offer, can they select only those counties that would fall into the Network from a filing perspective which would then pull into this specific PBP (assuming they will be able to include/exclude counties through HPMS). If the MAO currently has segments can they potentially only offer this in one segment for Is this something that can be done with the existing functionality in HPMS to pull down into our PBP? A. If a plan wants to provide a specific plan, that plan needs to be a different plan ID. The new plan ID does NOT have to be a segmented plan. This provider specific plan indicator is at the PLAN level, so it would make the most sense to break out. Supplemental Benefits 1. Q. Can a Medicare Advantage plan cover driving evaluations done by an occupational therapist? Does Original Medicare pay for this service as of 3/2011? Is there CMS guidance that describes coverage for this service? A. In the case of Occupational Therapy driving evaluations, this would appear to be a MAC local coverage determination. The NCD or benefit policy manuals do not have guidance specifically on OT driving evaluations, but several older LCDs have discussed the topic. CMS would recommend contacting the local MAC with jurisdiction in the MAO s service area to see if there is a current LCD on the topic. 2. Q. Can an MAO offer a card with an annual allowance for a specified amount that allows members to pay for services they need to stay healthy? A. This is not an acceptable supplemental benefit. The card itself is a mechanism for enrollees to access the plan specified non Medicare covered benefits and is not a benefit itself. Further, if the plan is covering all of the non Medicare covered services that enrollees can purchase with the debit card, they simply should offer those services as the supplemental benefits. 3. Q. Chapter 4 of the managed care manual allows MAOs to offer medically necessary transportation as a supplemental benefit. Can CMS confirm if this definition includes transportation to provide MA members access to CMS approved benefits that are provided outside of physician offices, hospitals and other traditional medical facilities. For example, are plans permitted to provide transportation to providers of covered benefit including pharmacies to access covered drugs, gym facilities to access covered fitness benefits, and providers of visions, dental, hearing and other supplemental benefits? 6

7 A.MAOs are allowed to offer medically necessary transportation as a supplemental benefit. A plan may provide transportation to locations where their enrollees can access their health benefits. The plan must arrange transportation exclusively to these places. Transportation should not consist of items or services that can be used for other non medical transportation (e.g., a free train or bus pass). 4. Q. The final call letter provides MAOs with an opportunity to offer telemonitoring services as a supplemental benefit for enrollees with specific health conditions (e.g., hypertension or chronic heart failure). Please clarify if MAOs are permitted to offer these benefits to subsets of the enrollees with the particular condition(s) based on clinical need. For example, can the plan offer telemonitoring services only to high risk CHF members post hospital discharge vs. all CHF members in the plan? A. Yes, the plan may target in home telemonitoring to specific subgroups of enrollees based on a specific health condition or on the severity of a specific health condition and based on clinical need. In addition to providing telemonitoring services that are consistent with the description provided in the CY 2013 Call Letter (page 103), it must ensure that its marketing materials make clear that not all enrollees will be monitored in this way by the plan. And, although CMS is discouraging excessive and extraneous notes in the PBP, if the enrollee group targeted for the services is a subset of all enrollees with a particular health condition, the plan should explain in the notes field for CMS review, how it will identify enrollees who are eligible for in home monitoring. 5. Q. Does the annual screening Pap smear/pelvic exams as a supplemental benefit get entered in the PBP? A. Yes, if a plan is going to offer an annual Pap smear/pelvic exam as a supplemental benefit to their enrollees, then this benefit must be entered in the PBP. The plan may use the "Other" categories at Section B 13d, e, or f. 6. Q. POS benefits are now defined as mandatory supplemental benefits in the Medicare Managed Care Manual. I don't understand the rationale that underlies why CMS would deem an out ofnetwork outpatient surgery that would normally be a Medicare covered service as a mandatory supplemental benefit (and non Medicare covered). I believe the Medicare covered determination for all other Medicare Advantage benefits are based on the type of service rather than the network status of the provider. Please help me understand why the determination for POS benefits is on a different basis than for all other benefits. A. HMOs cover all Parts A and B benefits, but may also offer a POS as a mandatory or optional supplemental benefit. This supplemental benefit may not be offered by any other plan type. The POS supplemental benefit provides coverage for some plan covered services outside of the HMO s network. Chapter 4 in the Medicare Managed Care Manual provides additional details on this supplemental benefit. 7

8 1) HMO enrollees have CHOICE. They can choose to receive the Medicare covered surgery IN NETWORK in which case it would be classified as A/B, or they can choose to receive the Medicare covered surgery OUT OF NETWORK in which case it would be covered by the POS benefit. NOTE: If the plan does not offer a POS benefit it does not have to cover this surgery since the enrollee has CHOSEN not to work through the network of plan providers. 2) COST SAVINGS IN NETWORK The correct statement is that HMOs are required to provide IN NETWORK all Part A and B services. There is no requirement to provide A/B services out of network. By contrast, Fee For Service provides coverage throughout the country. In exchange for the more restrictive network the HMO may provide services at a reduced cost. Further, each Medicare Advantage Organization can use this information to evaluate the advantages and/or disadvantages of offering an HMO, HMO POS, Local PPO, and/or Regional PPO. HMOs and PPOs (both local and regional) are types of coordinated care plans, while the POS benefit is considered a supplemental benefit covering health services not covered by Medicare. The POS benefit can be offered as either an optional or mandatory supplemental benefit. As discussed below an HMO that elects to offer a POS benefit has more discretion than a PPO regarding the conditions of any out of network coverage it elects to offer its enrollees. A PPO is a type of MA coordinated care plan that under the statute and MA regulations (see 42 CFR section 422.4(a)(1)(v)) is required to cover all medically necessary Part A and B services and supplemental benefits both in network and through out of network providers. In addition, the regulations specifically prohibit a PPO from imposing any prior notification or authorization requirements on an enrollee s right to obtain medically necessary care from a non contract provider. An HMO is a type of MA coordinated care plan that is required to furnish access to all plan covered services (i.e. Parts A and B and supplemental benefits) through a network of contracted providers (see 42 CFR section 422.4(a)(1)(iii)(A)). Unlike a PPO an HMO plan is not required to cover any outof network services with the exception of emergency or urgently needed services. However, an HMO can elect to offer a supplemental POS benefit by which it offers its enrollees the option to receive specified services out of network subject to certain conditions (see 42 CFR section ). The out of network services offered by an HMO POS can range from one service to all services and may impose limitations on geographic area and/or providers, as long as the benefit is transparent to beneficiaries. Subject to CMS approval an HMO could impose prior authorization requirements for POS benefits. An HMO can also specify what services it will cover out of network under its POS benefit. 7. Q. Why did CMS elect to put POS plans at a competitive disadvantage vs. PPO plans by declaring that their out of network benefits must be considered mandatory supplemental benefits? 8

9 A. HMO plans are required to establish a network of contracted providers that furnish plan covered services (i.e. Parts A & B and supplemental benefits). In addition, the network must meet Medicare access and availability requirements. Except for emergency and urgently needed services an HMO plan can restrict its enrollees to its contracted provider network. POS is an option that allows an HMO to give its enrollees a wider choice of providers by allowing them to obtain specified services from non contract providers. This is called a POS benefit and can be offered as either a mandatory or optional supplemental benefit. The POS benefit can help an HMO compete with PPO plans by giving its enrollees more out of network choices then they would otherwise have. Indeed, an HMO could elect to offer an HMO with a POS benefit that covered all its services out of network making the HMO function much like a PPO plan. Bid Guidance 1. Q. Where can an MAO find specific documentation regarding the PMPM AE Cost Sharing Maximums for the 2013 bids in the Rate Announcement? A. Please review pages 8 through 9 (Per Member Per Month Actuarial Equivalent Cost Sharing Maximums) in the April 12, 2012 HPMS Memo from Danielle Moon entitled: Contract Year 2013 Medicare Advantage Bid Review and Operations Guidance. 9