CY2013_RESPONSE_CMS-R-262_60-day comments_LAR

D epartment of Health & Human Services

7500 Security Boulevard

Baltimore, Maryland 21244-1850

C enters for Medicare & Medicaid Services

TO: Office of Management and Budget

FROM: Lori Robinson, Director

Division of Plan Data

Medicare Drug Benefit and C & D Data Group

Center for Medicare

DATE: December 15, 2011

SUBJECT: Response to CMS-R-262 60-Day PRA comments

CMS appreciates the comments provided on the Paperwork Reduction Act (PRA) package CMS-R-262, Plan Benefit Package (PBP) and Formulary Submission for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDP). Our responses to the comments submitted are below.

Plan Benefit Package (PBP) Comments

1. PBP – Section B – 1a and 1b (Inpatient Hospital Acute and Inpatient Hospital Psychiatric).

Issue: Incorrect Summary of Benefits (SB) sentences and Plan Finder sentences generated. Our Cost plans are structured with a flat dollar cost-sharing per benefit period for Inpatient benefits. For CY2012 we entered the maximum enrollee out of pocket cost and indicated per benefit period. We also indicated “no” when asked if a copay or coinsurance applies. Even though we checked “no” a sentence still generates in the SBs and Medicare Plan Finder that states “$0 copay”. Also “per benefit period” language does not generate.

CMS RESPONSE: CMS recommends that the user enter a copayment amount for each Medicare-covered stay in the PBP software instead of entering the cost-sharing as a maximum enrollee out of pocket cost. Using this approach, the SB sentences will generate with the cost-sharing that was entered for the inpatient stay.

If additional modifications are necessary to accurately reflect the benefits offered, the organization should submit a Summary of Benefits (SB) Hard Copy Change Request to CMS. CMS reviews these requests, and as appropriate, will approve SB changes to ensure the benefit is accurately portrayed to beneficiaries.

2. PBP – Section B-4 (Emergency Care)

For worldwide emergency care, the SB does not display cost sharing. The PBP does not allow entry regarding the cost-sharing for worldwide coverage.

CMS RESPONSE: Organizations offering this supplemental benefit do have the ability to enter a coinsurance and/or copayment amount for worldwide coverage in the PBP software.

The SB represents a high-level summary of benefits offered by Medicare Advantage and Part D organizations. As a result, not every benefit will generate an SB cost-sharing sentence. Organizations are permitted to use SB Section III to describe additional benefits that are not generated in Section I or Section II of the SB. Also, the Evidence of Coverage (EOC) is the comprehensive document that should communicate all benefits offered to beneficiaries.

CMS cannot accommodate this new SB sentence for CY 2013. CMS will consider this suggestion for a future release of the PBP/SB software.

3. PBP – Section B – 4b (Urgently Needed Care)

PBP does not accommodate a plan structure with worldwide urgent care coverage.

CMS RESPONSE: Organizations enter worldwide coverage in the PBP software under Section B4a, not B4b. Please see the response to question number two above for more information.

4. PBP – Section B-16B (Comprehensive Dental)

PBP does not accommodate a plan that offers both mandatory preventive dental coverage and optional preventive dental coverage.

CMS RESPONSE: Organizations do have the ability to enter both a mandatory preventive dental coverage benefit and an optional preventive dental coverage benefit under the same plan in the PBP software.

The mandatory preventive dental benefit should be entered in Section B-16B. The optional preventive dental benefit should be entered in Section D of the PBP software in the Optional Supplemental Data entry screens.

If you have any questions regarding our responses, please contact Sara Silver at Sara.Silver@cms.hhs.gov or 410-786-3330.

Thank you.

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