Jan 25 -- The Centers for Medicare & Medicaid Services, Health and Human Services (HHS), invites comments to OMB by February 26, 2024 regarding the CMS Plan Benefit Package (PBP) and Formulary CY 2025 data collection.
Under the Medicare Modernization Act (MMA), Medicare Advantage (MA) and Prescription Drug Plan (PDP) organizations are required to submit plan benefit packages for all Medicare beneficiaries residing in their service area. The plan benefit package submission consists of the Plan Benefit Package (PBP) software, formulary file, and supporting documentation, as necessary. MA and PDP organizations use the PBP software to describe their organization's plan benefit packages, including information on premiums, cost sharing, authorization rules, and supplemental benefits. They also generate a formulary to describe their list of drugs, including information on prior authorization, step therapy, tiering, and quantity limits.
CMS requires that MA and PDP organizations submit a completed PBP and formulary as part of the annual bidding process. During this process, organizations prepare their proposed plan benefit packages for the upcoming contract year and submit them to CMS for review and approval. CMS uses this data to review and approve the benefit packages that the plans will offer to Medicare beneficiaries. This allows CMS to review the benefit packages in a consistent way across all submitted bids during with incredibly tight timeframes. This data is also used to populate data on Medicare Plan Finder, which allows beneficiaries to access and compare Medicare Advantage and Prescription Drug plans.
CMS has incorporated the following changes to address the Inflation Reduction Act (IRA). This includes new attestations and data entry fields to reflect Part D policy changes (i.e., new insulin and vaccine benefits and $0 cost sharing in the catastrophic phase) that are required by the IRA, specifically Sections 11101, 11201, 11401, and 11406. CMS is also modernizing the PBP software by migrating from its current client/server based platform to a new web-based module within HPMS. This initiative is critical, as the current platform technically antiquated. The new PBP module will enhance system security, improve the user interface, streamline the bid submission process, increase system performance, and provide greater flexibility to accommodate unique benefit designs.
The PBP is broken into six specific sections:
1) The General Set-up Section defines certain plan-specific data characteristics in the Plan Benefit Package (PBP). This Section consists of plan level information, which allows organizations to indicate if they are offering a bid that mirrors fee-for-service cost sharing, the Medicare and Supplemental benefits offered for the plan, prior authorization and referral requirements, visitor/travel and plan level cost-sharing. The plan level cost sharing consists of:
-- Plan Deductible
-- Maximum Enrollee Out-of-Pocket Costs
-- Maximum Coverage for Supplemental Benefits
-- Balance Billing (PFFS only)
-- Medical Savings Account Information (for MSA plans only)
-- Medicaid Covered vs. Plan Covered Cost sharing (for MMPs only)
Note: This functionality has been modified as part of the PBP modernization effort. One question removed, and a select all option being added for a question.
2) The Benefit Details Section collects in-network benefit information for MA plans. This includes cost sharing for any Medicare and Supplemental benefits offered. The benefit details are broken into the following sections:
-- Inpatient Hospital Services
-- Skilled Nursing Facility (SNF)
-- Cardiac and Pulmonary Rehabilitation Services
-- Emergency Care/Urgently Needed Services
-- Partial Hospitalization
-- Home Health Services
-- Health Care Professional Services
-- Outpatient Procedures, Tests, Labs & Radiology Services
-- Outpatient Services
-- Ambulance/Transportation Services
-- DME, Prosthetics and Medical & Diabetic Supplies
-- Dialysis Services
-- Other Supplemental Services
-- Preventive and Other Defined Supplemental Services
-- Medicare Part B Prescription (Rx) Drugs
-- Dental
-- Eye Exams/Eyewear
-- Hearing Exams/Hearing Aids
-- Prescription Drugs (ONLY for Cost Plans not offering Part D
Note: This functionality has been redesigned as part of the PBP modernization effort. New Yes/No questions being added, minor wording changes to clarify questions.
3) The Cost Share Groups Section collects detailed cost-sharing information for benefits data that have multiple groups/offerings of benefits. Each cost share group has a management screen to manage the groups created as part of the section. The following sections are available (only MA plans complete this section):
-- Out-of-Network
-- Point-of-Service (POS)
-- Combined Supplemental Benefits
-- Reduction in Cost Sharing (RICS)
-- Optional Supplemental benefit packages
Note: This functionality has been redesigned as part of the PBP modernization effort.
4) Section Rx contains all Part D information. All plans that offer Part D must complete this section. This includes:
-- Medicare Rx Screens
-- Pre-Initial Coverage Limit (ICL) Screens
-- ICL Screens
-- Gap Coverage Screens
-- Out-of-Pocket Threshold Screens
-- Locations and location supply Screens
-- Rx attestations
-- Medicare Rx Notes
Note: This functionality has been redesigned as part of the PBP modernization effort. Questions have been removed from this section.
5) Section Rx VBID (only for plans offering the Part D VBID) includes:
-- Part D Rewards & Incentives packages
-- Part D reduced cost sharing (for Defined Standard Plan Types)
-- Part D reduced cost sharing packages (for all other Part D plan types, and collects data at the tier level)
Note: This functionality has been redesigned as part of the PBP modernization effort. Gap related screens have been eliminated.
6) Section VBID/Uniformity Flexibility (UF)/Supplemental Benefits for the Chronically Ill (SSBCI) packages includes:
-- Identification of which benefits the plan is offering (either 1, 2, or 3 of the benefits in this section)
-- VBID Wellness and Health Care Planning (only if VBID is offered)
-- VBID Hospice (only if VBID is offered)
-- VBID Rewards and Incentives (only if VBID is offered)
-- Reduction in Cost Sharing Packages
-- Additional Benefits Packages
Note: This functionality has been redesigned as part of the PBP modernization effort. Multiple questions were removed, or clarified in this section.
The formulary submission contains the following files:
-- Formulary Submission File (required for all Part D plans offering a formulary. This file lists all Part D covered drugs offered by the plan)
-- Formulary Over-the-Counter (OTC) Drugs File (required for any plans offering OTC drugs as part of their Part D plan)
-- Formulary Prior Authorization (PA) File (required for any Part D plans requiring PA for any drugs on their formulary)
-- Formulary Partial Gap Coverage File (required if there is partial tier gap coverage for the Part D plan)
-- Formulary Free First Fill File (required if any drugs are offered for free for their first fill)
-- Formulary Excluded Drug File (required if the Part D plan offers excluded drugs)
-- Formulary Additional Demonstration Drug File (only required for MMP plans)
MA and Part D Benefits Data:
https://www.cms.gov/data-research/statistics-trends-and-reports/medicare-advantagepart-d-contract-and-enrollment-data/benefits-data
Monthly PDP Formulary & Pharmacy Network Information:
https://data.cms.gov/provider-summary-by-type-of-service/medicare-part-d-prescribers/monthly-prescription-drug-plan-formulary-and-pharmacy-network-information
CMS submission to OMB:
https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=202401-0938-014 Click IC List for information collection instrument, View Supporting Statement for technical documentation. Submit comments through this webpage.
FRN:
https://www.federalregister.gov/d/2024-01383
For AEA members wishing to submit comments, "A Primer on How to Respond to Calls for Comment on Federal Data Collections" is available at
https://www.aeaweb.org/content/file?id=5806