Crosswalk (Before 60-day)

CMS-10824 Collection Instrument Change Crosswalk: High Level Summary of Revisions
for ANOC and EOC
For the 2026 contract year, Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
standardized documents have been revised to reflect policy changes and simplify information for
plan members. Changes to the ANOC and each of the 12 chapters of the EOC are detailed below,
except for routine changes to the documents adjusting applicable dates, minor grammatical
changes, URLs, and other non-substantive word changes. The changes will not result in
additional burden, unless noted in the column titled “effect on burden.”
Annual Notice of Change
Location of
Change
Instructions to
Health Plans
Instructions to
Health Plans
Introduction

Additional
Resources

B1.
Information
about

Description of Change

Reason for Change

Instructions allowing plans to use
the term “Evidence of Coverage”
instead of “Member Handbook”
throughout the documents
Instructions requiring plans to use
the OMB approval information in
the footer of the first page of the
document
Additional language instructing
plans to use alternate language if
the Member Handbook is not
included with the ANOC mailing.

Updated language to
allow states to use the
two terms
interchangeably.
Included required
language

Added language to explain
requirement per new regulatory
language at 42 CFR
422.2267(e)(31)(ii) and
423.2267(e)(33)(ii), requiring plans
to provide a Notice of Availability
of language assistance services and
auxiliary aids and services free of
charge in English and at least the 15
languages most commonly spoken
by individuals in the state in which
the plan operates.
Removed language describing such
a plan as qualifying health coverage
as satisfying the Patient Protection
and Affordable Care Act’s
individual shared responsibility
requirement.

Updated instructions
to provide clear
pathways to
information to
enrollees.
Added language to
account for changes
related to the final
rule, CMS-4205-F.

Effect on
Burden
No effect

No effect

No effect

Consistent
with the final
rule, CMS4205-F, this
requirement
has no effect
on burden.

Under the Tax Cuts
No effect
and Jobs Act, passed
(P.L. 115-97), the
amount of the
individual shared
responsibility payment
is reduced to zero for

B2. Important
things to do

D. Changes to
our network
providers and
pharmacies
D. Changes to
our network
providers and
pharmacies
E1. Changes to
benefits [insert
if applicable:
and costs] for
medical
services
E2. Changes to
drug coverage
E2. Changes to
drug coverage
E2. Changes to
drug coverage

Added language to the second
major bullet point, directing
members to check for any changes
to prior authorization policies for
drug coverage.
Added language to the first
paragraph to account for Part D
copays.

months beginning
after December 31,
2018.
Language added for
additional clarification
for enrollees.

No effect

Language added to
align with current
policy.

No effect.

Added language to the fifth
paragraph to give the option for
plans to remove language if they
included a copy of the provider and
pharmacy directory with the
ANOC.
Deleted Value-Based Insurance
Design (VBID) model benefit
language

Language added for
additional clarification
for enrollees.

No effect

VBID will no longer
be offered after the
conclusion of plan
year 2025.

No effect

Added language to the fifth
paragraph noting that the plan will
update online drug lists at least
monthly.
Added a seventh paragraph which
describes possible changes to the
drug list throughout the plan year.
Added a new paragraph at the end
of the subsection “Changes to our
Drug List” for plans to include
language if they are implementing
the option to immediately substitute
brand name drugs with its new
generic equivalents or authorized
generics.

Language added for
additional clarification
for enrollees.

No effect

Language added for
additional clarification
for enrollees.
Included language is
for plans to include if
they are implementing
the option to
immediately substitute
brand name drugs with
its new generic
equivalents or
authorized generics.
Added language to
account for an option
for plans with one
drug payment stage.
Added language to
clarify for enrollees

No effect.

E2. Changes to
drug coverage

Additional language about changes
to drug cost under the subheader
“Changes to drug costs.”

E2. Changes to
drug coverage

Added language about cost sharing
as it pertains to the Manufacturer

No Effect.

No effect

No effect

Discount Program under the
subheader “Changes to drug costs.”
E3. Stage 1:
“Initial
Coverage
Stage”
E3. Stage 1:
“Initial
Coverage
Stage”
E4. Stage 2:
“Catastrophic
Coverage
Stage”

Added language on cost sharing for
adult Part D vaccines.
Added language to charts on cost
sharing for requirement to show
costs for a one-month drug supply
filled at a network pharmacy.
Additional requirement for plans
that provide preferred cost sharing.
Added language for plans that may
have cost sharing for Part D drugs.

how cost sharing can
interact with the
Manufacturer
Discount Program.
Language added for
additional clarification
for enrollees.

No effect

Language added for
additional clarification
for enrollees.

No effect

VBID will no longer
be offered after the
conclusion of plan
year 202, which
affected Part D cost
sharing.
The Inflation
Reduction Act (P.L.
117-169) requires all
Medicare Part D plans
to offer MPPP.
Special enrollment
periods for specific DSNP enrollees in
CMS-4205-F.
The Inflation
Reduction Act (P.L.
117-169) requires all
Medicare Part D plans
to offer MPPP.

No effect

Description of Change

Reason for Change

Added instructions requiring plans
to use the OMB approval
information in the footer of the first
page of the document
Added instructions requiring
Material ID: H number description
of choice

Included required
language

Effect on
Burden
No effect

F.
Administrative
Changes

Added optional language in the
chart for Part D cost sharing.

G. Changing
plans

Amended language discussing
special enrollment periods

H5. The
Medicare
Prescription
Payment Plan

Added language discussing the
Medicare Prescription Payment
Plan (MPPP).

No effect

No effect

No effect

Chapter 1: Member Handbook
Location of
Change
Introduction,
bullet 11
Introduction,
bullet 12

Included required
language

Member
Handbook
Introduction,
paragraph 7

Disclaimers,
bullet 3

Disclaimers,
bullet 4
Disclaimers,
bullet 5

C. Advantages
of our plan
H. Your
monthly costs,
paragraph 2,
bullet 4
H4. Medicare
Prescription
Payment
Amount

Added language to explain
requirement per new regulatory
language at 42 CFR
422.2267(e)(31)(ii) and
423.2267(e)(33)(ii), requiring plans
to provide a Notice of Availability
of language assistance services and
auxiliary aids and services free of
charge in English and at least the 15
languages most commonly spoken
by individuals in the state in which
the plan operates.
Removed language describing such
a plan as qualifying health coverage
as satisfying the Patient Protection
and Affordable Care Act’s
individual shared responsibility
requirement.
Added language noting that
benefits and/or copayments may
change on January 1, 2027
Added language to note that
covered drugs, pharmacy network,
and/or provider network may
change at any time, and that a
notice will be provided
Added instruction to note that plans
can include additional examples of
the care coordinator role
Added bullet point to note potential
enrollee cost for Medicare
Prescription Payment Plan Amount

Added language to
account for changes
related to the final
rule, CMS-4205-F.

No effect

The Inflation
Reduction Act (P.L.
117-169) requires all
Medicare Part D plans
to offer MPPP.

No effect

Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.

No effect

Comments received
based on previous
PRA comment period
Language added for
additional clarification
for enrollees.

No effect

Added language describing the
Medicare prescription payment
amount.

The Inflation
Reduction Act (P.L.
117-169) requires all
Medicare Part D plans
to offer MPPP.
Language added for
additional clarification
for enrollees.

No effect

Language added for
additional clarification
for enrollees.

No effect

J1. Paragraph 3 Added language describing how
enrollees may be asked to show
Medicare cards for hospital
services, hospice services, or
clinical research studies.
J2. Paragraph 2 Added language on timeline for
requesting hard copies for Provider
and Pharmacy Directories

No effect

No effect

No effect

J3. List of
Covered Drugs
J3. List of
Covered Drugs

Added language explaining that
formulary drugs are either required
by Medicare or selected with the
help of doctors and pharmacists.
Added language noting that drugs
with negotiated prices will be
included on the Drug List unless
they have been removed or replaced
per Chapter 5.

Language added for
additional clarification
for enrollees.

No effect.

The Inflation
Reduction Act (P.L.
117-169) established
the Medicare Drug
Price Negotiation
Program

No effect

Description of Change

Reason for Change

Amended explanation of State
Insurance Assistance Program
(SHIP).

Language added for
additional clarification
for enrollees.

Effect on
Burden
No effect

Added bullet point about reasons to
contact the SHIP to include
answering questions about
switching plans.
Amended explanation of QIO.

Language added for
additional clarification
for enrollees.

No effect

Language added for
additional clarification
for enrollees.

No effect

Amended bullet point about reasons Language added for
to contact the QIO regarding having additional clarification
a problem with the quality of care.
for enrollees.

No effect

Added language to explain
relationship between the agency
and Medicare.
Added and amended rows to
provide information on how to
contact Medicare, what information
can be provided, and how to submit
a complaint.
Updated language discussing extra
help.

Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.

No effect

Language added for
additional clarification
for enrollees.

No effect

Chapter 2: Important phone numbers and resources
Location of
Change
C. Statespecific SHIP
Name,
paragraphs 1
and 2
C. Statespecific SHIP
Name,
paragraph 3
D. Quality
Improvement
Organization
(QIO),
paragraph 1
D. Quality
Improvement
Organization
(QIO),
paragraph 2
E. Medicare,
paragraph 2
E. Medicare,
table under
paragraph 2
I1. Extra Help
from
Medicare,
paragraph 2

No effect

I4. The
Medicare
Prescription
Payment Plan

Added language for plans that will
have cost sharing for Medicare Part
D starting in 2026

J. Social
Security

Amended language regarding how
Social Security determines
eligibility for Medicare.

The Inflation
Reduction Act (P.L.
117-169) requires all
Medicare Part D plans
to offer MPPP.
Technical clarification

No effect

No effect

Chapter 3: Using our plan’s coverage for your health care and other covered services
Location of
Change
B. Rules for
getting
services our
plan covers.
Bullet 4
B. Rules for
getting
services our
plan covers.
Bullet 4, sub
bullet 2
B. Rules for
getting
services our
plan covers.
Bullet 4, sub
bullet 3
D1. Services
you can get
without
approval from
your PCP
D. When a
provider leaves
our plan,
paragraph 2
D. When a
provider leaves
our plan,
paragraph 3
D. When a
provider leaves

Description of Change

Reason for Change

Added language describing edits
available to plans with POS option.

Language added to
clarify option for plans

Added language describing where
more information is on getting
approval to use an out-of-network
provider.

Language added for
additional clarification
for enrollees.

No effect

Removed language regarding where Language added for
to receive dialysis services and
additional clarification
added language on maintenance
for enrollees.
dialysis.

No effect

Consolidated bullet points
regarding urgently needed services

Language added to
clarify option for
enrollees

No effect

Added sub bullets describing what
plan notifications when a provider
leaves the plan.

Language added for
additional clarification
for enrollees.

No effect

Added additional language to
Language added for
clarify that the plan will help select additional clarification
a new qualified in-network provider for enrollees.

No effect

Added bullet providing information
on available enrollment periods and
options to change plans

No effect

Language added for
additional clarification
for enrollees.

Effect on
Burden
No effect

our plan,
paragraph 5
D. When a
provider leaves
our plan,
paragraph 6
D. When a
provider leaves
our plan,
paragraph 7
I1. Care in a
medical
emergency
I1. Covered
services in a
medical
emergency
I2. Urgently
needed care
I2. Urgently
needed care
outside our
plan’s service
area
J. What if
you’re billed
directly for
covered
services
K1. Definition
of a clinical
research study
M1. DME as a
member of our
plan
M2. DME
ownership if
you switch to
Original
Medicare

Added language on plan
arrangement for out-of-network
specialist when in-network
specialist is unavailable.
Added bullet from existing
language on provider arrangement
of new provider when chosen
provider is leaving the plan.
Amended language on care in a
medical emergency
Updated language on covering
medical emergencies
Amended example language
Added language on routine
provider visits not being considered
urgently needed.

Language added for
additional clarification
for enrollees.

No effect

Language added for
additional clarification
for enrollees.

No effect

Language amended for No effect
additional clarification
for enrollees.
Language amended for No effect
additional clarification
for enrollees.
Language amended for No effect
additional clarification
Language added for
No effect.
additional clarification
for enrollees.

Rearranged language on billing
requirements.

Language amended for No effect
additional clarification
for enrollees.

Rearranged and amended language
on remaining enrolled in plan and
enrolling in a clinical research
study.
Amended language on how to
access DME

Language added for
additional clarification
for enrollees.

No effect

Language added for
additional clarification
for enrollees.
Removed language to
improve the flow of
the section and focus
on DME. The
information is located
in Chapter 12.

No effect

Removed language on where to
find definitions of Original
Medicare and MA Plans.

Chapter 4: Benefits chart

No effect

Location of
Change
A1. During
public health
emergencies
C. About our
plan’s Benefits
Chart, bullet 3
C. About our
plan’s Benefits
Chart, bullet 8
C. About our
plan’s Benefits
Chart,
language on
VBID

Description of Change

Reason for Change

Removed language on required
coverage and permissible
flexibilities to members subject to a
public health emergency
declaration
Added language noting that new
enrollees may not be required to get
approval for an active course of
treatment in the first 90 days of
enrollment
Added language for plans to
include, if applicable, valid
approval for PA for as long as
medically reasonable.
Removal of language on VBID.

There is information
in Ch 3, section I3
regarding care during
a disaster or
emergency.
Added language
aligning with current
regulation

D. Our plan’s
Benefits Chart

Added language on Acupuncture on
provider requirements

D. Our plan’s
Benefits Chart

Amended title to cardiovascular
(heart) disease screening tests

D. Our plan’s
Benefits Chart

Added section on chronic pain
management and treatment services

D. Our plan’s
Benefits Chart

Colorectal cancer screening

D. Our plan’s
Benefits Chart

Dental services

D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart

Diabetes screening

D. Our plan’s
Benefits Chart

Hospice care

Emergency care

Effect on
Burden
No effect

No effect

Language added for
additional clarification
for enrollees.

No effect

VBID will no longer
be offered after the
conclusion of plan
year 2025, which
affects Part D cost
sharing.
Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.
Language updates to
reflect the current
requirements
Language updates to
reflect the current
requirements
Language updates to
reflect the current
requirements
Technical
clarifications
Language updated for
additional clarification
for enrollees.
Language updated for
additional clarification
for enrollees.

No effect

No effect
No effect
No effect
No effect
No effect
No effect
No effect
No effect

D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
D. Our plan’s
Benefits Chart
G1. Benefits
covered
outside of our
plan, Hospice
care

Lung cancer screening with low
dose computed tomography
(LDCT)
Medicare Diabetes Prevention
Program (MDPP)
Medicare Part B drugs

Technical
clarifications

No effect

Technical
clarifications
Technical
clarifications
Technical
clarifications
Technical
clarifications
Technical
clarifications
Technical
clarifications
Technical clarification

No effect

Language added for
additional clarification
for enrollees.
Partial hospitalization services and Technical
intensive outpatient services
clarifications
Physician/provider services, deleted Language updates to
non-routine dental care
reflect the current
requirements
Pre-exposure prophylaxis (PrEP)
Language updates to
for HIV prevention
reflect the current
requirements
Prosthetic and orthotic devices and Technical
related supplies
clarifications
Screening for Hepatitis C Virus
Language updates to
infection
reflect the current
requirements
Skilled nursing facility (SNF) care
Language added for
additional clarification
for enrollees.
Urgently needed care
Language added for
additional clarification
for enrollees.
Removed language on hospice care Language was
consolidated and
moved to covered
benefits section

No effect

Opioid treatment program (OTP)
services
Outpatient diagnostic tests and
therapeutic services and supplies
Outpatient hospital observation
Outpatient mental health care
Outpatient substance use disorder
services
Outpatient surgery

Chapter 5: Getting your outpatient drugs

No effect
No effect
No effect
No effect
No effect
No effect

No effect
No effect
No effect
No effect
No effect
No effect
No effect
No effect

Location of
Change
Rules for our
plan’s
outpatient drug
coverage,
paragraph 4
Rules for our
plan’s
outpatient drug
coverage,
paragraph 7
A1. Filling
your
prescription at
a network
pharmacy
A2. Using your
Member ID
Card when you
fill a
prescription,
paragraph 2
A9. Paying
you back for a
prescription,
paragraph 1
B. Our plan’s
Drug List
B1. Drugs on
our Drug List,
Paragraph 2
B1. Drugs on
our Drug List,
Paragraph 3-4
B1. Drugs on
our Drug List,
Paragraph 5
B2. How to
find a drug on
our Drug List,

Description of Change

Reason for Change

Added language to insert if
applicable to refer enrollees to fill
prescriptions through mail order
service.

Language added for
additional clarification
for enrollees.

Effect on
Burden
No effect

Added language to note that drugs
Language added for
may require approval from the plan. additional clarification
for enrollees.

No effect

Added language on cross reference
for information on prescriptions at
out-of-network pharmacies

Language added for
additional clarification
for enrollees.

No effect

Added language alerting enrollees
that they can ask the pharmacy to
look up plan enrollment
information.

Language added for
additional clarification
for enrollees.

No effect

Added language to insert if
applicable to note that the enrollee
may be required to pay the
difference in cost at an out-ofnetwork pharmacy.
Removed optional language for
plans to add if they have indication
based formulary design.
Added optional language for plans
to add if they have indication based
formulary design.
Amended language on biological
products.

Language added for
additional clarification
for enrollees.

No effect

Removed from this
section, added to the
next section.
Removed from the
previous section,
added to this question.
Language amended for
additional clarification
for enrollees.
Language amended for
additional clarification
for enrollees.

No effect.

Language added for
additional clarification
for enrollees.

No effect

Added language on cross reference
for information on the definition on
different types of drugs that may be
on the drug list
Added language on “Real Time
Benefit Tool.”

No effect
No effect
No effect

paragraph 1,
bullet 4
B3. Drugs not
on our Drug
List
C. Limits on
some drugs,
paragraph 2
C1. Limiting
use of a brand
name drug
C2. Getting
plan approval
in advance
C3. Trying a
different drug
C4. Quantity
limits
D. Reasons
your drug
might not be
covered, bullet
point 3
D1. Getting a
temporary
supply
D3. Asking for
an exception,
bullet 3
E. Coverage
changes for
your drugs,
paragraph 1
E. Coverage
changes for
your drugs,
paragraph 2
E. What
happens if
coverage
changes for a
drug you’re
taking?

Added bullets to describe drugs that Language added for
are not on the plan’s drug list.
additional clarification
for enrollees.
Added language to describe why
Language added for
drugs may appear more than once
additional clarification
on the drug list.
for enrollees.
Modified optional language to
Technical clarification.
include interchangeable biosimilar
when discussing generic drugs
Added language describing prior
Language added for
authorization and where to get more additional clarification
information.
for enrollees.
Language added to describe where
Language added for
more information could be found.
additional clarification
for enrollees.
Language added to describe an
Language added for
example of quantity limits.
additional clarification
for enrollees.
Added bullet point to direct plans to Language added for
delete the section if there is no Part additional clarification
D cost sharing or if the formulary
for enrollees.
structure doesn’t allow for tiering
exceptions.
Removed and moved to another
Moved further down
section language describing
in the section for flow.
descriptions of getting temporary
supplies of prescription drugs.
Added bullet point on approving
Language added for
exception requests.
additional clarification
for enrollees.
Added optional language discussing Language added for
whether the plan may replace an
clarity of information
original biological product with a
provided by plan.
biosimilar.
Added language stating that the
Language added for
plan must follow Medicare
additional clarification
requirements before we change the for enrollees.
Drug List.
Added language discussing that
Technical clarification.
plans may or may not make certain
generic and biosimilar
substitutions.

No effect
No effect
No effect
No effect
No effect
No effect
No effect

No effect

No effect
No effect

No effect

No effect

E. Changes we
may make to
the Drug List
that affect you
during the
current plan
year
E. Changes to
the Drug List
that don’t
affect you
during this
plan year
G. Programs
on drug safety
and managing
drugs,
paragraph 1
G3. Drug
management
program for
safe use of
opioid
medications
G3. Drug
management
program for
safe use of
opioid
medications,
paragraph 3

Amended language on when an
enrollee would hear if they were
affected by changes to the drug list.

Language added for
additional clarification
for enrollees.

No effect

Added language to describe how
changes to the drug list would
affect drugs that enrollees are
taking.

Language added for
additional clarification
for enrollees.

No effect

Added bullet point to note that
plans look for possible problems
when enrollees fill a prescription.

Language added for
additional clarification
for enrollees.

No effect

Amended language discussing the
drug management program.

Language added for
additional clarification
for enrollees.

No effect

Added language describing the
letter that the plan will send an
enrollee if the plan limits coverage
of drugs.

Language added for
additional clarification
for enrollees.

No effect

Chapter 6: What you pay for your Medicare and Medicaid program [name] drugs
Location of
Change
Introduction
A. The
Explanation of
Benefits
(EOB)
A. The
Explanation of

Description of Change

Reason for Change

Added language discuss the plan’s
Real Time Benefit Tool

Language added for
additional clarification
for enrollees.
Added language discussing how the Language added for
plan tracks enrollee drug costs and
additional clarification
payment.
for enrollees.
Removed “TRICARE” from list of
entities that could pay for
prescriptions on behalf of enrollees.

Technical
clarifications

Effect on
Burden
No effect
No effect

No effect

Benefits
(EOB)
B. How to
keep track of
your drug costs
B. How to
keep track of
your drug costs
C. Drug
Payment

D. Your
pharmacy
choices
D. End of the
Initial
Coverage
Stage
E. Stage 2: The
Catastrophic
Coverage
Stage
G. What you
pay for Part D
vaccines
G. Prescription
cost-sharing
assistance for
persons with
HIV/AIDS

Added information on State
Pharmaceutical Assistance Program

Language added for
additional clarification
for enrollees.
Removed redundant
information.

No effect

VBID will no longer
be offered after the
conclusion of plan
year 2025, which
affects Part D cost
sharing.
Added optional language describing Language added for
preferred cost sharing and mail
additional clarification
order pharmacies.
for enrollees.
Added optional language describing Language added for
coverage of drugs that aren’t
additional clarification
normally covered.
for enrollees.

No effect

Added optional language for plans
that cover Medicaid drugs or
excluded drugs under an enhanced
benefit.
Added section for plans to revise as
necessary.

Language added for
additional clarification
for enrollees.

No effect

Technical update

No effect

Removed section on cost sharing
assistance for persons with
HIV/AIDS

This information is
currently located in
Chapter 2

No effect.

Removed information on where to
find more information.
Removed language discussing
VBID.

No effect

No effect
No effect

Chapter 7: Asking us to pay [plans with cost sharing, insert: our share of] a bill you got for
covered services or drugs
Location of
Change
A. Asking us
to pay for your
services or
drugs; When
you use an outof-network
pharmacy to

Description of Change

Reason for Change

Added bullet to describe that the
plan may not pay back the
difference between in-network and
out-of-network costs.

Language added for
additional clarification
for enrollees.

Effect on
Burden
No effect

fill a
prescription
A. Asking us
to pay for your
services or
drugs; When
you pay the
full
prescription
cost
B. Sending us
a request for
payment
C. Coverage
decisions,
bullet 2

Added bullet and other language to Language added for
describe that the plan may not pay
additional clarification
back the difference in the cash price for enrollees.
and the negotiated price.

No effect

Removed optional language
describing required timeframe for
submitting claims.

This section has
variable language
where this information
can be included.
Language added for
additional clarification
for enrollees.

No effect

Description of Change

Reason for Change

Added language to give examples
of areas in which services could be
delivered in culturally competent
and accessible manners.

Language added for
additional clarification
for enrollees.

Effect on
Burden
No effect

Added language on uses of PHI

Language added for
additional clarification
for enrollees.

No effect

Added language to discuss advance Language added for
directives.
additional clarification
for enrollees.

No effect

Amended the bullet to include that
the plan may not reimburse the
enrollee if they paid the full cost of
the drug.

No effect

Chapter 8: Your rights and responsibilities
Location of
Change
A. Your right
to get services
and
information in
a way that
meets your
needs,
paragraph 1
C. Our
responsibility
to protect your
personal health
information
(PHI)
G2. Your right
to say what
you want to
happen if you
can’t make
health care
decisions for
yourself

I. Your
responsibilities
as a plan
member

Added bullet noting that enrollees
should alert Social Security (or
RRB) if they move.

Language added for
additional clarification
for enrollees.

No effect

Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
Location of
Change
E. Coverage
decisions and
appeals
E1. Coverage
decisions
E2. Appeals,
paragraph 4

Description of Change

Reason for Change

Added language regarding the
scope of coverage decisions and
appeals.
Added example language to explain
coverage decisions.

Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.
Repetitive of prior
sentence.

Removed language discussing the
content of the letter for Level 2
appeals.
F. Medical
Amended language and removed
care, paragraph complexity.
2
F2. Asking for Amended language describing
a coverage
coverage decision timeframes.
decision;
standard
coverage
decision
F2. Asking for Amended language describing
a coverage
coverage decision timeframes.
decision; fast
coverage
decision
F4. Making a
Amended language to allow states
Level 2
to fill in their own requirements for
Appeal, when
state fair hearings
your problem
is about a
service or item
Medicaid
usually covers
F5. Payment
Amended language on timeframe
problems,
for payment.
bullet 1

Effect on
Burden
No effect
No effect
No effect

Language amended for No effect
additional clarification
for enrollees.
Language amended to No effect
more clearly align
with regulations and
standard practices.
Language amended to
more clearly align
with regulations and
standard practices.

No effect

Language amended to
more clearly align
with state practices.

No effect

Language amended to
more clearly align
with regulations and
standard practices.

No effect

F5. Payment
problems,
bullet 4

Removed bullet discussing policy
on fast appeals for payment

G2. Medicare
Part D
exceptions,
paragraph 4
G2. Medicare
Part D
exceptions,
item 1
H2. Making a
Level 1
Appeal, bullet
3

Added language on tiering
exceptions.

H4. Making a
Level 1
Alternate
Appeal

Removed language on making an
appeal to the QIO.

H5. Making a
Level 2
Alternate
Appeal

Removed the language on making
an appeal to the QIO.

I2. Making a
Level 1
Appeal, Your
deadline for
contacting this
organization,
bullet 2

Removed language on deadline for
contacting the QIO.

I2. Making a
Level 1
Appeal, Your
deadline for
contacting this

Removed timeframe for contacting
1-800-MEDICARE

Amended language applicable to
plans that have cost sharing.
Removed language on missing
deadlines for contacting the QIO.

We removed the bullet
because enrollees can
ask for a fast appeal
for payment cases.
Moved from later in
section G2.

No effect

Language amended to
more clearly align
with regulations and
standard practices.

No effect

CY 2025 final rule
changed the process so
that enrollees will appeal
to the QIO even if they
are late. Removing
language as it is no
longer applicable in
2025.
CY 2025 final rule
changed the process so
that enrollees will appeal
to the QIO even if they
are late. Removing
language as it is no
longer applicable in
2025.
CY 2025 final rule
changed the process so
that enrollees will appeal
to the QIO even if they
are late. Removing
language as it is no
longer applicable in
2025.
CY 2025 final rule
changed the process so
that enrollees will appeal
to the QIO even if they
are late. Removing
language as it is no
longer applicable in
2025.

Removed to mirror
current practices.

No effect

No effect

No effect

No effect

No effect

No effect

organization,
text box
I3. Making a
Level 2
Appeal, bullet
6

Removed language on letters from
the QIO.

CY 2025 final rule
changed the process so
that enrollees will appeal
to the QIO even if they
are late. Removing
language as it is no
longer applicable in
2025.
CY 2025 final rule
changed the process so
that enrollees will appeal
to the QIO even if they
are late. Removing
language as it is no
longer applicable in
2025.
CY 2025 final rule
changed the process so
that enrollees will appeal
to the QIO even if they
are late. Removing
language as it is no
longer applicable in
2025.

No effect

Language added for
additional clarification
for enrollees.

No effect

Description of Change

Reason for Change

Amended language on special
enrollment periods.

Language amended to
align with current
regulations.

Effect on
Burden
No effect

Amended language on MA Open
Enrollment Period.

Language added for
additional clarification
for enrollees.

I4. Making a
Level 1
Alternate
Appeal

Removed language on making an
appeal to the QIO.

I5. Making a
Level 2
Alternate
Appeal

Removed language on making an
appeal to the QIO.

J3. Appeal
Levels 3, 4 and
5 for Medicare
Part D Drug
Requests, level
4 appeal

Added language on if the council
denies the review the request.

No effect

No effect

Chapter 10: Ending your membership in our plan
Location of
Change
A. When you
can end your
membership in
our plan,
paragraph 1
A. When you
can end your
membership in
our plan,
paragraph 2,
bullet 2

No effect

A. When you
can end your
membership in
our plan,
paragraph 6
C1. Your
Medicare
services,
paragraph 1
C1. Your
Medicare
services, item
1 in text box
C1. Your
Medicare
services, item
4 in text box
E. Other
situations
when your
membership in
our plan ends

Added language to note that
language on drug management
program is optional for plans to
include.

Language added to
align with current
practice.

No effect

Amended language on special
election periods and open
enrollment periods.

Language amended to
align with current
regulations.

No effect

Amended language describing
options for changing plans.

Language added for
additional clarification
for enrollees.

No effect

Added language on current special
enrollment period.

Language amended to
align with current
regulations.

No effect

Added language on deemed
eligibility.

Language added for
additional clarification
for enrollees.

No effect

Reason for Change

Effect on
Burden
No effect.

Chapter 11: Legal notices
Location of
Description of Change
Change
B. Notice about
Removed language on gender and
nondiscrimination sexual orientation.
C. Notice about
Medicare as a
second payer and
<[ Medicaid
program name>]
as a payer of last
resort.

Language added to note that plans
can include other legal notices
regarding Medicare as secondary
payer.

Language amended to
reflect current
administrative
priorities.
Language added to
clarify for plans what
can be included.

No effect.

Chapter 12: Definitions of important words
Location of
Change
Introduction

Description of Change

Reason for Change

Added term “Biological Product”

Language added for
additional clarification
for enrollees.

Effect on
Burden
No effect

Introduction

Added term “Biosimilar”

Introduction

Amended term “Brand name drug”

Introduction

Amended term “Catastrophic
coverage stage”

Introduction

Added term “Integrated D-SNP”

Introduction

Added term “Interchangeable
Biosimilar”

Introduction

Updated term “Long-term services
and supports” to provide additional
details to the description
Amended the term “Medication
Therapy Management”

Introduction
Introduction

Added term “Original Biological
Product”

Introduction

Added term “Preventive Services”

Introduction

Added term “Real Time Benefit
Tool”

Introduction

Amended term “Urgently needed
care”

Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.
Language added for
additional clarification
for enrollees.
Language amended to
align with current
regulations.
Language added for
additional clarification
for enrollees.

No effect
No effect
No effect
No effect
No effect
No effect
No effect
No effect
No effect
No effect
No effect