The Centers for Medicare & Medicaid Services (CMS) has proposed updates to its standards for health plan issuers offering plans through federally-facilitated and state-based Exchanges for 2021. The proposed rule would, among other things: revise the risk adjustment methodology; update issuer user fees and cost-sharing limits; amend medical loss ratio regulations (including with regard to treatment of prescription drug rebates received and retained by an entity that provides pharmacy benefit management services to the issuer); modify special enrollment period rules; encourage value-based insurance plan designs; and make changes to the quality rating information display requirements for Exchanges.
With regard to drug manufacturer coupons, CMS proposes to give plans and issuers "flexibility to determine whether to include or exclude coupon amounts from the annual limitation on cost sharing, regardless of whether a generic equivalent is available." Under the proposed rule, to the extent consistent with applicable state law, amounts paid toward reducing enrollee cost sharing using any form of direct support offered by drug manufacturers to enrollees for specific prescription drugs are permitted, but not required, to be counted toward the annual cost sharing limitation.
Comments on the proposed rule will be accepted until March 2, 2020. CMS is accepting comments on its related Draft 2021 Letter to Issuers in the Federally-facilitated Exchanges until February 24, 2019. Finally, CMS issued a bulletin extending for an additional year its current non-enforcement policy that permits states to allow issuers to offer certain non-grandfathered health insurance coverage in the individual and small group market that does not meet all Affordable Care Act coverage standards.
This article is presented for informational purposes only and is not intended to constitute legal advice.