CMS Responses to Previously Asked Questions

Transcription

1 PBP/Data Entry CMS Responses to Previously Asked Questions 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. 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.) 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. 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 benefit packages based on one contract year to minimize potential beneficiary confusion; however, according to 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 30.1 Multi Year Benefits 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. 1

2 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 an MA plan to enter the following information about their Dental benefits into PBP? 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 Medicare Advantage limits for mental health services in 7e and 7h remain consistent with last year (i.e., $40 copayment / 50% coinsurance). 6. Q. Will CMS be providing additional guidance on tiering of hospital cost sharing for Inpatient Hospital Acute and IP Hospital Psychiatric? A. 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 includes 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 provide beneficiaries with equal access to quality hospitals. The additional data entry fields decrease the need for notes 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 be found in Chapter 4 of the Managed Care Manual. 2

3 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. The 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, 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. 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 the Medicare & You Manual states that the Part B Deductible does apply to Emergency Department Services 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. 3

4 10. Q. In section C of the PBP software, can PPO plans create a separate OON Group for Preventive Services? However, some of the OON Preventive Services require a copayment and some require 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 provide clarification 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. 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 an MA plan should correct this? A. If an 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, can CMS clarify 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: 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 of-network 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. 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 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. 4

5 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 out-of 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 of-network, 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 of-network 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 of-network or by spending $400 out of network. A plan may have a $400 limit on in network out of-pocket 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. 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, it will show the county and indicate 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, can they select only those counties that would fall into the Network from a filing perspective which would then pull into the 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? 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 it out. 15. Q. On screen A-5 it asks if the plan is filing a standard bid. When the plan indicates the answer yes, it then asks if the plan requires any referrals or prior authorizations and wants the plan to pick from a list of categories. How does the plan answer this question when there are multiple EGWP s under a single contract/plan and the requirements certainly may be different from one EGWP to the next? A. If any of the employer plans require authorization or referrals, the plan should indicate the 5

6 requirement in the PBP software when submitting the bid. 16. Q. For an HMO plan that has a mandatory In-network Maximum Enrollee Out-of-Pocket Cost Amount of $5,000, there was an error message that the copay must be less than $50 for the first 20 days. The plan wants to offer a benefit at $0 for days 1-6, $70 for days 7-25 and $0 for days If the plan takes the days 7-20 at $70 per day and adds the $0 for days 1-6 and divide by 20 days, this is $49 which is less than the maximum. Why is there an edit that will not allow this scenario since it is actuarially equivalent? A. Medicare cost sharing requirements for SNF are separated into two periods: days 1-20 and days Whereas there is no cost sharing during the first 20 days of a covered SNF stay under Original Medicare, MA plans and 1876 cost plans may charge some cost sharing during the first 20 days. However, because cost sharing for the overall SNF benefit (i.e., days 1 to 100) is subject to the actuarial equivalence test, plans must offset any cost sharing charged in the first 20 days by limiting cost sharing for days 21 through 100 to amounts that are low enough to satisfy those criteria. Please refer to the annual Call Letter for a description of the Per Member Per Month Actuarial Equivalence requirements. 17. Q. In the Original Medicare column of the PBP, the description of Medicare-covered chiropractic services includes manual manipulation of the spine performed by a chiropractor or other qualified provider. Is it CMS expectation that other qualified provider provision applies to the health plan specific column? If so, can CMS clarify what other qualified providers would mean for purposes of Medicare-covered chiropractic services? A. For chiropractic services, the services are to be provided by a State-licensed chiropractor who provides services within the States licensure and practice guidelines. 18. Q. In the past the MAO would have included glaucoma screening within the vision benefit as a range to accommodate zero copay. Can the MAO remove the glaucoma screening from the vision benefit since it is a preventive service? A. Glaucoma screening is and has been a preventive benefit and the cost sharing for the benefit needs to be captured in the PBP in the vision section (B-17). The only preventive benefits that do NOT need to be captured in the respective PBP data entry areas are the $0 cost share preventive benefits, since these are captured under B-14A. Glaucoma screening is not a $0 cost share preventive service, so the cost sharing that the plan is charging needs to be captured in B Q. Regarding the Emergency copay limit of $65, does this apply as a blanket copay to encompass facility, professional, and diagnostic test costs? Or, does it only apply to the facility fee, allowing for cost sharing of 20% or less on the professional and diagnostic tests and related fees? A. A plan may charge up to $65 for an emergency room (ER) visit. The amount the plan charges for an ER visit should encompass all services that are necessary to evaluate and stabilize the enrollee s emergency medical condition. The plan may not charge an ER copay in addition to other charges for each individual service an enrollee is provided during their ER visit. 6

7 20. Q. An MAO would like to offer their members a gym membership at any of their network facilities. The member will incur an annual $20 activation fee regardless of which facility they choose to attend. After the member has paid the $20, the cost of the membership will be covered for the year. How does the MAO show that this activation is not a recurring cost for the member? Where does the MAO put the $20 fee into the PBP? A. The plan would enter $20 in the data entry field at 14c and then explain more clearly in the notes section: the $20 is an activation fee regardless of which facility the enrollee chooses to attend. Once the activation fee of $20 is paid, the cost of the membership will be covered by the plan for the year. 21. Q. An MAO would like to add an optional supplemental dental benefit to their plans. Only those who choose the benefit and pay the additional premium will have access to dental benefits other than the Medicare covered dental. Should section 16 of the PBP remain grayed out? Should the MAO just enter the data in Section D-Optional Supplemental Benefits screen? The service specific premium is grayed out and we need that to be an active field. A. Section B16 of the PBP will need to be completed, Section B is where the plan indicates they are offering an optional supplemental benefit and all data fields will be filled out. Section D will need to be completed as well. 22. Q. Although the enrollees in our D-SNP pay nothing out-of-pocket because the State pays those costs, in the PBP are we still required to enter what the cost sharing would be if the State was not paying, or what the enrollee would pay in cases that the enrollee loses his/her Medicaid eligibility? A. Yes. The cost sharing amounts that enrollees would be responsible to pay if the State were not paying cost sharing for them must be entered in the PBP. The fact that the State pays the cost sharing does not mean those amounts were not charged for services provided; or that the services received by the dual-eligible enrollee were fully paid by your plan. In order for your plan to accurately reflect in the PBP and BPT the plan costs of providing services, the PBP and BPT must reflect pricing and cost sharing that are consistent. If a plan enters $0 cost sharing in the PBP because the State will pay the cost sharing amounts for enrollees, it is creating a PBP that may contain benefits not intended to be covered by the MA plan. In that situation, the PBP indicates that the plan is responsible for paying cost sharing. Also, by entering in the PBP $0 cost sharing for services that do, in fact, incur cost sharing charges that are paid for by the State, the plan is entering non-ma plan benefits in its PBP; the payments made by the State to cover enrollees cost sharing are the benefit that result in $0 cost sharing. The plan may not claim a State benefit, or any benefit not provided by the MA plan, in the PBP. D-SNPs that are All Dual, Full Dual, and Dual Eligible Subset will receive Summary of Benefit sentences that say, $0 or $XX for Medicare-covered service categories, where the $XX represents the cost sharing entered by the organization for the given service category. 23. Q. Please confirm where OON cost sharing that is not in the data entry must be noted - In Section B, Section C, or both? A. All OON cost sharing notes must be entered in Section C of the PBP. 7

8 24. Q. Please explain the rules that apply to LPPOs and RPPOs that choose to charge a deductible. Additionally, are these rules contradictory to each other? For example, if a plan chooses to charge a $500 deductible for a local PPO plan, based on rule #1, the $500 deductible must be a combined deductible for in-and out-network services. However, based on the rule #2, the plan could exclude all in-network Part A and Part B services from the deductible. This basically creates a $0 deductible for in-network services and $500 deductible for OON services, which is not allowed by the rule #1. Could CMS explain how a MAO should apply the new rules in the benefit design of PPO plans?: All PPO plans that choose to apply a deductible must establish a single deductible that applies to all Part A and Part B services, both in-and out-of network (OON) combined. PPOs may not apply separate deductible amounts for in-network and OON services. However, PPO plans may elect to exclude any or all in-network Part A or B service (s) from the deductible. While it is true that an MA PPO plan with a $500 deductible may elect to exempt all in-network Part A and B services from its deductible. The effect of this approach is that the deductible would only apply to out-of-network Part A and B services. The important point to note here is that the MAO that elects to have a PPO with a deductible has greater flexibility regarding the application of the deductible to in-network Part A and B services. Supplemental Benefits 1. Q. Can a Medicare Advantage plan cover driving evaluations done by an occupational therapist? Does Original Medicare pay for this service? Is there CMS guidance that describes coverage for this service? A. Occupational Therapy (OT) driving evaluations, fall within the 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 vision, dental, hearing and other supplemental benefits? 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 8

9 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. Please clarify if MAOs are permitted to offer telemonitoring services as a supplemental benefit to enrollees with specific health conditions 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, the plan 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. 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 of-network 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. 1) HMO enrollees have a 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 9

10 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 requirements on an enrollee s right to obtain medically necessary care from a non contracted 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 out-of 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. 6. 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? 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. 7. Q. Our plan has a readmission prevention program that provides similar services to those outlined previously by CMS. There are a few differences, such as our program has a duration that is 90-days post-hospital discharge. While most of the intervention takes place within 30 days of discharge, when the risk of readmission is highest, the transitional care nurses continue to touch base with the member and trouble shoot issues as needed until 90-days post hospital discharge. CMS guidance says the intervention cannot exceed 4 weeks. With this difference in the program s duration, can this transitional care program still be considered a supplemental benefit, per the guidance? A. The benefit you describe seems like it may be consistent with the Readmission Prevention benefit. The 90 day duration of your benefit could be appropriate and consistent with our described benefit so long as you are not including in your program benefit 90 days of meal delivery. We would not expect to approve meal delivery over such a long period. 10

11 In the PBP notes describing your program benefit, please be sure to clarify which services are provided in the first weeks after discharge and which may be provided over a longer period to support the enrollee s ability to stay in the community and prevent readmission. 8. Q. It appears from previous guidance that CMS is expecting plans that offer a telemedicine benefit to share information about the encounter with the member s PCP or other selected physician. What happens if the member will not provide PCP information? Members that are in a PPO, are not required to select a PCP, therefore refusing to treat a member who calls this service after hours because they do not want the information released or do not have a PCP could result in member dissatisfaction. A. We do not anticipate a risk that a plan would refuse to treat an enrollee because s/he does not identify a plan physician but would note that the web-and telephone-based technology will not be an appropriate treatment modality for many health problems and therefore, there will be circumstances in which an enrollee will not receive treatment through this supplemental benefit because such treatment is not possible or because providing a treatment without examining the enrollee is not consistent with accepted clinical guidelines. Furthermore, depending on the protocol implemented by the plan, misuse of the benefit may result in an enrolled beneficiary being referred to a plan provider rather than treatment through the web-and telephone-based technology. 9. Q. What supplemental benefits don t need an out of network benefit? Some supplemental benefits (such as Nursing Hotline, Telemonitoring services, Safety Devices such as shower safety bars, and Health Education) simply don t make sense in terms of how CMS would operationally administer the benefit. There are no out of network providers who just administer these benefits. Can CMS provide guidance so a MAO will know exactly which supplemental benefits need to have OON benefits? A. As codified at 42 CFR 422.4(a)(1)(v)(B), PPOs are required to provide reimbursement for all covered services both in-network and out-of-network. An enrollee may receive out-of-network services either because s/he chooses to receive them from an out-of-network provider or because s/he is traveling outside of the service area and has either the need or desire for a covered service. Although the plan may charge different cost sharing for services received out-of-network, all appropriate services must be available to the plan s enrollees. The plan must make reasonable accommodations for enrollees to obtain such services. Given the flexibility afforded to MA organizations in defining supplemental benefits, it is difficult to definitively state exceptions and/or accommodations for each type of benefit or service. As a result, we are willing to respond to specific plan questions or proposals through the mailbox. In general, a nursing hotline or telemonitoring services could be made available through use of a toll-free number or reimbursement could be provided for use of an out-of-network gym if the enrollee has an in-network gym membership benefit. There is no expectation, however, that shower safety bars that a plan may offer for the enrollee s home would also be available as an out-of-network benefit. 11

12 11. Q. Regarding Telemonitoring services, does the plan have to use Telemonitoring services as the name in the PBP or can they be more specific and enter the name Telemonitoring Services for Hypertension? A. CMS would allow the plan to enter a more specific title, such as Telemonitoring Services for Hypertension, as long as that is the only specific health condition they are monitoring under the proposed benefit. 12. Q. An MAO is looking to offer acupuncture and naturopathic medicine services; however they would like a combined benefit such as 12 visits per calendar year. Are they allowed to offer a combined limit on a benefit? And how would this be entered into the PBP? A. The MAO should use the acupuncture service category (B-13a) to enter this benefit. The PBP category description for B-13a includes other alternative therapies. Use the notes field to clarify the benefit by noting that naturopathic therapies also are covered and explain the benefit and coverage limits. Put as much information as possible into the data entry fields and then use the notes to explain, for instance, whether the benefit would cover 12 acupuncture visits or 12 naturopathic visits or whether the benefit must be a combination of the two therapies. A plan may limit supplemental benefits to a number of visits or to an amount. 13. Q. Can CMS clarify what services can be provided in a Physical Exam. Is the critical difference between the existing Annual Wellness Visit and proposed Routine Physical Exam centers on the review of physiological systems and physical examination? Due to the preventive nature of the Wellness Visit, its review of systems and physical examination is focused on prevention and targeted to results of the health risk assessment and screenings. In contrast, the Routine Physical Exam includes a comprehensive review of systems and physical examination, which allows flexibility for the physician to manage chronic conditions in addition to evaluation and/or treatment of new or prior existing problems. The availability of the Routine Physical Exam allows members to seek a separate visit with their physician to discuss general health questions or issues without presentation of a specific chief complaint. This flexibility serves to further support the bond between patient and primary care physician while enabling the physician with an additional opportunity to detect undiagnosed conditions and deliver care in a timely manner. In summary, the Wellness Visit is preventive in nature and focused on wellness while the Routine Physical Exam has the flexibility to be disease focused. This physical exam could include all or some of the following components as applicable: a. History b. Vital Signs c. General Appearance d. Heart Exam e. Lung Exam f. Head and Neck Exam g. Abdominal Exam h. Neurological Exam i. Dermatological Exam j. Extremities Exam 12

13 A. The inquiry reflects an excellent understanding of the difference between a routine physical exam and the Medicare-required Annual Wellness Visits. The routine physical exams that you describe are consistent with what CMS would expect to approve in CY 2013 bids. 14. Q. An MAO would like to offer an annual physical exam, if the following description is entered in the note section would this meet CMS approval? a. Skin observation of appearance and notation of lesions. b. Hair, scalp, skull, and face are examined. c. Eyes are observed using an ophthalmoscope. d. Ears are inspected using an otoscope. e. Nose and sinuses using a penlight and a nasal speculum. f. Mouth and pharynx including lips, gums, teeth, roof of the mouth, tongue, and pharynx are inspected. g. The lymph nodes on both sides of the neck and the thyroid gland are palpated. h. The spine and muscles of the back are palpated and checked for tenderness. The upper back, where the lungs are located, is palpated on the right and left sides and a stethoscope is used to listen for breath sounds. i. Breasts and armpits, the lymph nodes in the armpits are felt with the examiner s hands. Including the movement of the joints in the hands, arms, shoulders, neck, and jaw. j. Chest and lungs. The area is inspected with the fingers, using a stethoscope to listen to internal breath sounds. k. A stethoscope is used to listen to the heart s rate and rhythm. The blood vessels in the neck are observed and palpated. l. Abdomen. Light and deep palpation is used on the abdomen to feel the outlines of internal organs including the liver, spleen, kidneys, and aorta, a large blood vessel. m. Rectum and anus. An internal digital examination and in men, the prostate gland is also palpated. n. Reproductive organs. The external sex organs are inspected and the area is examined for hernias. o. The legs are inspected for swelling, and pulses in the knee, thigh, and foot area are found. The groin area is palpated for the presence of lymph nodes. The joints and muscles are observed. p. Musculoskeletal system is examined for straightness of the spine and the alignment of the legs and feet is noted. q. The presence of any abnormally enlarged veins (varicose), usually in the legs, is noted. r. Neurologic screen. The patient s ability to take a few steps, hop, and do deep knee bends is observed. The strength of the hand grip is felt. With the patient sitting down, the reflexes in the knees and feet can be tested with a small hammer. The sense of touch in the hands and feet can be evaluated by testing reaction to pain and vibration. A. Although we cannot approve the described benefit until it is submitted in the PBP, the physical exam that is described is consistent with a physical exam that CMS would expect to approve because it is a comprehensive screening examination of the enrolled beneficiary and does not include services that are covered by Original Medicare. 13

14 15. Q. Can MA-only plans (no Part D coverage) cover home infusion drugs under the Part B benefit with a coinsurance? A. No, only MA-PD and cost plans may offer a bundled home infusion mandatory supplemental drug benefit. 16. Q. Is palliative care an allowable MA benefit? A. Palliative care (pain management) is already a Medicare covered benefit and cannot be offered as a supplemental benefit 17. Q. We are hoping to offer attorney services to enrollees that would assist with advance directives and other related matters in our Medicare Advantage D-SNP plan. Would this type of benefit be allowable? A. The proposed supplemental benefit, to provide enrollees access to a plan-employed attorney who would assist them with drafting advance directives etc., does not satisfy our criteria for being an eligible supplemental benefit. Although you state that the benefit is primarily health-related and that the plan would incur non-zero medical cost in order to provide the benefit, the description of the proposed supplemental benefit does not demonstrate how the benefit is directly health-related or that the plan would incur non-zero medical cost in order to provide the benefit. Validation Tests 1. Q. If an MA plan fails to satisfy a CMS requirement (e.g., meaningful difference evaluation, Total Beneficiary Cost (TBC)) in its initial bid submission, will they have another opportunity to modify their plan bid? A. CMS expects plans to satisfy our bid review criteria in their initial bid submissions because MAOs have access to the CMS requirements and the necessary tools to develop a compliant bid. 2. Q. Does CMS consider different plan types (e.g., HMO, PPO, LPPO) as being meaningfully different? A. Yes, as in previous years, difference in plan type is considered to be a meaningful difference. Please refer to Chapter 4 of the Medicare Managed Care Manual for detailed information regarding meaningful difference requirements. 3. Q. Will the test for meaningfully different MA plan offerings in a service area be performed at the contract level or at the parent organization level? Other A. We review plans at the contract level unless there is a unique situation. Please refer to Chapter 4 of the Medicare Managed Care Manual or the Final Call Letter for detailed information regarding meaningful difference requirements. 1. Q. Does the Maximum Out-of-Pocket (MOOP) requirement apply to all MA plan types? A. Yes, MOOP requirements apply to all MA plan types, including employer and non-employer 14

15 plans. Please refer to Chapter 4 of the Medicare Managed Care Manual or Final Call Letter for detailed information regarding MOOP requirements. 2. Q. Which services are required to be included in the MOOP? Does the cost sharing for supplemental benefits count towards the MOOP? A. MA plans must establish an annual MOOP limit, based on the total enrollee cost sharing liability for all required Medicare Parts A and B services, but may choose whether to include enrollee cost sharing for supplemental benefits in the MOOP amount. Please refer to Chapter 4 of the Medicare Managed Care Manual for detailed information regarding MOOP requirements. 3. Q. This question is in regards to the $0 cost-sharing preventive services which must adhere to the Original Medicare schedule. For members that change plans where the plan has no knowledge of when the member received preventive services how are the plans to manage the frequency of these services or does the preventive schedule start over when a member changes plans. A. In order to furnish services to new plan members on a schedule that is consistent with the Original Medicare requirements, the plan must use whatever resources are available to determine what services the enrollee is eligible to receive. CMS expects plans to make reasonable efforts to obtain information about a plan member s eligibility for Medicare-covered preventive screening services. The member s previous providers and the Medicare Administrative Contractor may be able to provide some information. However, we are aware that obtaining that information may not always be possible and therefore, do not require that the plan verify the member s eligibility in order to provide the services to him/her. 4. Q. For PPO plans offering a travel benefit, can there be an exception process to their travel benefit using prior authorization? A. It is difficult to fully respond to your question, since CMS would need more detailed information on what the plan wants to offer. However, PPO plans are not allowed to require prior notification for out-of-network services. 5. Can MA plans choose to offer a MOOP amount that's lower than the defined Mandatory or Voluntary MOOP amounts? A. Yes. Please refer to Final Call Letter for a list of the acceptable MOOP amounts. 6. Is the plan-specific premium or Part B premium included in the MOOP calculation? A. No, the MOOP calculation includes copayments, coinsurance and deductibles but does not include either the Part B premium or a plan-specific premium. Please refer to the Medicare Managed Care Manual, Chapter 4; the Final Call Letter for additional details regarding MOOP requirements. 15