Frequently Asked Questions PBP Data Entry/Cost Sharing 1. Q. How should we answer the following new question in the 2016 PBP Sections B-1 and 2: What is your inpatient hospital benefit period? The answer choices include: Original Medicare, Annual, or Other/ describe. If our cost-sharing is applied on a per stay basis, should we select Other? A. A benefit period begins the day an enrollee is admitted as an inpatient. The benefit period ends when the enrollee hasn t received any inpatient care for a number of days in a row (e.g., 60 days in Original Medicare). If the enrollee is admitted for an inpatient stay after one benefit period has ended, a new benefit period begins. The enrollee may be responsible to pay the inpatient deductible and other cost sharing for each benefit period. The PBP requires the plan to choose one of the following benefit periods: Original Medicare, Annual, or Other. Plans choosing the Original Medicare benefit period are following Original Medicare and plans choosing the Annual benefit period are applying the inpatient deductible annually (only once in the contract year). Plans choosing the Other benefit period have established their own benefit period approach (e.g., per stay) and are required to describe the benefit period in the notes section, including how cost sharing applies for readmissions and transfer admissions are applied. Q. How should we address inpatient mental health benefits in the PBP? The benefit descriptions for PBP Section B-1a includes coverage for mental health care and B-1b describes both psychiatric care received in a psychiatric unit of a general acute hospital, as well as acute care received in a free standing psych hospital. A. Cost sharing for acute mental health care delivered on a psychiatric unit of a general inpatient acute hospital should be reflected in 1a, as the benefit description for inpatient acute care received in a general hospital also includes mental health care. Acute mental health care delivered in a freestanding Medicare certified psychiatric facility should be reflected in 1b. 2. Q. For PBP Sections B-8a, 8b, 14b, 14e, and 17a; the option to indicate whether a separate cost share applies: was removed. Does this mean that we cannot continue to charge a separate cost share nor does this only mean that this no longer needs to be defined in the PBP? A. Plans can still charge separate office visit cost sharing, but it no longer needs to be defined in the PBP at the various service categories. Once the data is entered in the PCP and specialist service categories, there is no need for additional information. 1
3. Q. Can a plan limit the Inpatient Substance Abuse benefit to an Inpatient Psychiatric Hospital? A. No, a MA plan cannot limit access to a Medicare Part A benefit. Please review the Medicare Managed Care Manual, Chapter 4 section 10.5 Federal Requirements Related to Uniform Benefits and Non-Discrimination, 10.5.2 Anti-Discrimination and 10.5.3 Review for Discrimination and Steering, which states that a plan cannot inhibit access to services. 5. Q. Is PBP Section B-9a Outpatient Hospital Services the correct service category to enter cost sharing that would be applicable to a claim for a 'clinic/facility fee'? A. No. Clinic/facility fees are not benefits or services. Therefore, there should not be separate cost sharing for clinic/facility fees. If there is a difference in cost sharing based on place of service, those fees are to be combined (bundled) into the cost sharing amount for that particular place of service. 6. Q. Can MA plans define supplemental benefit allowances for greater than one year (e.g., eye glasses or hearing aids)? A. CMS encourages plans to design benefit packages based on one contract year to minimize potential beneficiary confusion. However, plan enrollees may be offered multi year supplemental benefits in accordance with the Medicare Managed Care Manual, Chapter 4, Section 30.1. For example, plans may offer a yearly allowance or an allowance over two years. 7. Q. Can a MAO remove the glaucoma screening from the vision benefit since it is a preventive service? A. Glaucoma screening is a preventive service and the cost sharing for this service must be placed in the PBP Section B-17a Vision. Glaucoma screening is not one of the Medicare $0 cost share preventive services that are placed in PBP Section B-14a. 8. Q. Where should out-of-network cost sharing be entered in the PBP? A. All Out of Network cost sharing must be entered in the PBP Section C. 9. Q. What does the term Maximum plan benefit coverage amount mean and how is it applied? A. Maximum plan benefit coverage amount is the maximum dollar amount per period that a plan will cover towards a supplemental benefit service(s). A maximum coverage limit is applicable only for supplemental benefits offered by the plan, because Medicare does not allow a Maximum Plan Benefit Coverage expenditure limit for Medicare Parts A and B services. Therefore, the maximum plan benefit coverage is the plan contribution; it does not include any member cost sharing. Dental 1. Q. Where are Medicare-covered dental services placed in the PBP? A. PBP Section 16b is Comprehensive Dental and includes both Medicare-covered and supplemental benefits. Cost sharing for Medicare-covered comprehensive dental should be placed in 16b and not included in any other PBP categories to avoid duplication. 2
2. Q. How should dental services be reflected in the PBP Section 16 if they are not specifically identified with data entry fields? For example, office visits and cleanings have data entry fields, but space maintainers and mouth guards do not. A. Individual services included in your benefit that do not have specific PBP data entry fields in 16b can be accommodated within the range of cost sharing for services that do have data entry fields. This can be accomplished by entering minimum and maximum cost sharing amounts and briefly describing the benefit in the notes field without listing dental codes. 3. Q. How should optional supplemental benefits for dental be entered into the PBP? A. PBP Section B16 must be completed as the data entry fields allow the plan to offer either mandatory or optional supplemental benefit. PBP Section D also has an optional supplemental screen that must be completed. 4. Q. Where in the PBP would a limited benefit for dentures be placed? A. Dentures offered as a supplemental benefit may be placed in the PBP Section B-16b. Supplemental Benefits 1. Q. If a plan is offering an Annual Physical Exam as a supplemental benefit, can CMS explain what they expect to see in the Plan Benefit Package (PBP) notes field? A. An Annual Physical Exam will qualify as a supplemental benefit if it is provided by a qualified physician or qualified non-physician practitioner, hereafter referred to as a practitioner. At a minimum, the exam must include a detailed medical/family history and the performance of a detailed head to toe assessment with hands-on examination of all the body systems. For example, the practitioner must use visual inspection, palpation, auscultation and manual examination in his/her full examination of the enrollee to assess overall general health and detect abnormalities or signs that could indicate a disease process that should be addressed. CMS wants to clarify, however, that these components are the minimum elements and not meant to be an exhaustive list. Other aspects of the Annual Physical Exam may include, as appropriate, follow-up orders for referral to other practitioners, lab tests, clinical screenings, EKG, etc. The Annual Physical Exam also should emphasize prevention, i.e., the recommendations for preventive screenings, vaccination(s), and counseling about healthy behaviors. We emphasize that providers have the ability to exercise clinical judgment when determining the additional components necessary for an Annual Physical Exam to meet the individual needs of the enrollee. Please note that, SNPs are expected to provide higher levels of enrollee assessment than non-snp MA plans and therefore, may not offer Annual Physical Exams as supplemental benefits (CY 2016 Final Call Letter, April 6, 2015). 3
2. Q. How should data be entered into the PBP to have a single plan maximum for multiple supplemental benefits included in PBP section B-14c? A. The plan should enter the same plan maximum at each benefit and must explain the cost sharing in the notes at each benefit. 3. Q. Can meal replacement drinks such as Ensure, Nepro, Protenix, Novasource Renal, and Body Fortress be included in an OTC supplemental benefit? A. Meal replacement drinks are not an allowable item under the OTC benefit. Please refer to the Medicare Managed Care Manual, Chapter 4, Section 40.4 Items and Their OTC Status. Table V displays a chart of ineligible OTC items and meal replacement drinks are in the category of food product or supplements and are listed as not eligible. Meal replacements drinks may be offered under the Meal Benefit, but only as an addition to the service; they cannot replace the meal itself. 4. Q. Chapter 4 of the Medicare Managed Care Manual allows MAOs to offer medically necessary transportation as a supplemental benefit. Can CMS confirm if this definition includes transportation beyond physician offices, hospitals and other traditional medical facilities? For example, are plans permitted to provide transportation to providers of covered benefits, such as pharmacies, fitness facilities, vision, dental, hearing and other supplemental benefits? A. MAOs are permitted 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). 5. Q. Can plans cover services for ESRD members that are not part of the plan's benefit package such as transportation? A. Medically necessary transportation can be included as part of an Enhanced Disease Management program. In this situation, the benefit is only accessible to members in the Enhanced Disease Management program (Medicare Managed Care Manual, Chapter 4, section 30.3, Enhanced Disease Management). 6. Q. What supplemental benefits do not require an out-of-network benefit for PPOs? For example, some supplemental benefits such as remote access technologies, telemonitoring services, safety devices such as shower safety bars, and health education would not be possible to operationally administer on an out-of-network basis. 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. 4
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. In general, a nursing hotline or telemonitoring services could be made available through use of a tollfree number or reimbursement could be provided for use of an out-of-network fitness facility if the enrollee has an in-network fitness facility 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-ofnetwork benefit. 7. 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 may offer a bundled home infusion mandatory supplemental drug benefit. 8. 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. 9. Q. Can a MA plan offer attorney services to enrollees that would assist with advance directives and other related matters in our Medicare Advantage plan? A. No. The proposed benefit, to provide enrollees access to a plan-employed attorney who would assist enrollees with drafting advance directives etc., does not satisfy our criteria for being an eligible supplemental benefit as defined in the Medicare Managed Care Manual, Chapter 4, section 30). General 1. Q. If a plan is separated into two or more segments, is each segment evaluated independently for purposes of TBC? A. Each bid is evaluated independently and each plan segment submits a separate bid. 2. Q. Some states offer dental coverage to only small portions of the Medicaid population. In states where only a portion of the population is served and D-SNPs are required to enter a full capitation arrangement to assume Medicaid coordination and liability, is a D-SNP prohibited from offering dental coverage as a mandatory supplemental benefit thus providing dental to all Medicaid beneficiaries? A. It is also important to consider Federal Requirements Related to Uniform Benefits and Non- Discrimination (Medicare Managed Care Manual, Chapter 4, section 10.5). Potential solutions to the situation described in the question may include giving consideration to offering separate plans with different benefits or offering a supplemental dental benefit in the MA plan that does not inappropriately duplicate an existing service that some or all dually eligible enrollees are permitted to receive from the state. 5
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? A. The CMS meaningful difference evaluation is performed at the contract level unless there is a unique situation. Please refer to the Final Call Letter for detailed information regarding meaningful difference requirements. 4. Q. How are plans to manage the frequency of preventive services for members that change plans and the new plan has no knowledge of when the member received preventive services previously? 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 available resources 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. 5. Q. Can PPO plans have an exceptions process for their benefits by using prior authorization? A. PPO plans are not permitted to require prior authorization or notification for out-of-network services. 6. Q. Is the plan-specific premium or Part B premium included in the MOOP calculation? A. No. The MOOP calculation includes cost sharing (e.g., copayments, coinsurance and deductibles), but does not include either the Part B premium or a plan-specific premium. 6