学海无涯Exhibit B: Washington EHBs on the 2020 Plans & Benefits Template PurposeThese instructions explain how to correctly populate the Essential Health Benefit (EHB) information of your Plans and Benefits template (PBT) for Washington State. Note that the changes included in these instructions are in addition to the changes made by the Washington State EHB add-In file provided by the Center for Consumer Information and Insurance Oversight (CCIIO). Please go to the CCIIO Qualified Health Plan Application Instructions, Templates and Materials page https:/www.qhpcertification.cms.gov/s/Application%20Materials) for 2020 Qualified Health Plan templates and Add-In files.Summary of Changes Plan Year 2020There are no changes from the 2019 to the 2020 Add-in file for Washington State. These instructions are essentially the same as Plan Year 2019.Background InformationThe Plans & Benefits template (PBT) is an Excel workbook made up of at least two sheets (or “tabs”). One is labeled “Benefits Package Number”, and the other is labeled “Cost Share Variances Number”. The Benefits Package tab is separated into three sections. The first section is the identification of the issuer and market to which the binder applies (labeled “Binder Identification” in the screen shot below). The next section is where the issuer identifies the plans and their attributes (labeled “Plan Identification and Attributes” in the screen shot below). These sections are followed by the third section that begins with the heading “Benefit Information” across columns A through C. (Labeled “EHB Information” in the screen shot below.) This third section includes the information about coverage of the Essential Health Benefits (“EHBs”) required in the applicable state.EHB InformationPlan Identification and AttributesBinder Identification CCIIO provides an add-in file that helps users complete the EHB Information section of the PBT. The add-in file will populate the EHB Information automatically once the “Issuer State” (WA) and applicable “Market Coverage” or “Dental Only Plan” fields are selected in the “Binder Identification” portion of the template (red circle). Although most of this information is correct, some changes are required. These instructions explain how to make changes necessary to correct the information that is automatically populated, and to customize it based upon your plan design.How to use these instructionsThere are two sections to these instructions: these narrative instructions and a visual map of corrections (referred to in the General Filing Instructions as Exhibit C, Visual Map of PBT with Washington EHBs). The two sections are designed to be used in combination.Visual map The visual map is an Excel workbook with 3 sheets. The sheet labeled “Individual Medical” shows the changes to be made in medical individual market PBTs. The sheet labeled “Small Group Medical” shows the changes to be made in medical small group market PBTs. The sheet labeled “SAPDental” shows the changes to be made in stand-alone pediatric dental PBTs for both the individual and small group markets. Each sheet contains two views: how the EHB information is populated by the PBT add-in file, and how the final EHB information must look in each Benefits Package tab of the PBT when submitted to the OIC. Note that the visual map includes some changes that will be made depending on the benefits covered in the specific plan shown on the PBT. See the legend below. The visual map for medical plans is designed so that sheets 1 and 2 can be printed double-sided, making a one-page (Legal Paper Size) reference for your use. Sheet 3 can be printed as a separate sheet for use with SAPD plans.LegendRed: Required ChangesGold: Optional Changes (whether a change is necessary depends on whether and how the benefit is covered)Medical Plans InstructionsColumns: You will be working in the following columns in the PBT: Column LetterColumn HeadingDIs this Benefit Covered?EQuantitative Limit on ServiceFLimit QuantityGLimit UnitIBenefit ExplanationJEHB Variance Reason All Generic and Brand Drugs (whether preferred or non-preferred):The Washington State EHB add-in file includes the following in the Benefit Explanation column (Column I): “Coverage is limited to a 30-day supply retail or 90-day supply mail order.” If your product contains the same quantitative limits on prescription fills and refills as the base benchmark plan (30 day supply when purchased at a participating pharmacy or a 90-day supply when purchased via mail order), you must:o Add the words “per fill or refill” to the end of the benefit explanation in Column I for Generic and Preferred Brand Drugs, and add the entire explanation “Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.”) to Column I for Non-Preferred Brand Drug