Download CY 2018 Tiering of Medical Benefits Request Document

CY 2018 Tiering of Medical Benefits Request Document
MA Organization Contact:
(name/phone/email address)
Date Submitted:
Parent Organization:
Contract and Plan Id(s):
Affected Service Category:
MAO Response:
Define specific PBP benefit description and field(s).
PBP Data Values and Notes:
Specify values to be entered in PBP data field(s) and the PBP
note that describes the proposed tiered cost sharing. The note
must clearly specify the providers, benefits and cost sharing
amounts.
MAO Response:
Availability and Access:
Describe how enrollees will have availability and access to the
specified tiered medical benefits.
MAO Response:
Beneficiary Communications:
Provide the proposed language and marketing materials that will
result in beneficiaries understanding of the benefits that will have
tiered cost sharing.
MAO Response:
Provider Communications:
Explain how plan providers will be educated about plan cost
sharing to enable them to appropriately communicate with and
care for enrolled beneficiaries.
MAO Response:
Reason for tiered benefit
structure:
MAO Response:
Describe reason for providing tiered medical benefits.