On May 7, 2020, the Centers for Medicare & Medicaid Services (CMS) issued final regulations and related guidance on a number of Affordable Care Act (ACA) provisions and related health care topics including out-of-pocket (OOP) maximums, prescription drug coupons and cost-sharing, Medical Loss Ratio (MLR) calculations, and Exchange updates and reforms. These regulations are generally effective for plan years beginning on and after Jan. 1, 2021.
2021 OOP maximums
The 2021 OOP maximums will increase to $8,550 for individual coverage and $17,100 for family coverage. These coverage limits apply to all non-grandfathered plans, regardless of size or funding type.
Prescription drug coupons
Beginning in 2021, plans are permitted, but not required, to include coupon amounts and other drug manufacturer direct assistance for prescription drugs as amounts paid toward a covered person’s annual OOP maximum, regardless of whether a generic equivalent is available. This applies to individual, small group, large group, and self-funded plans, to the extent permitted by state laws.
Medical Loss Ratio
Beginning with the 2022 MLR reporting year (i.e., MLR reports filed in 2023), issuers must report expenses of functions outsourced to, or services provided by, other entities consistently with issuers’ non-outsourced expenses. It also requires issuers to deduct prescription drug rebates and price concessions from MLR incurred claims. These rebates and price concessions must be deducted not only when received by the issuer, but also when received and retained by an entity that provides pharmacy benefit management services to the issuer.
Exchange regulations
The final rule includes a number of provisions that impact the Health Insurance Exchanges, including:
- Maintain user fees from the 2020 plan year for Federally-facilitated Exchanges and State-based Exchanges on the Federal platform, 3.0% and 2.5% of total monthly premiums, respectively;
- Finalize how Qualified Health Plan (QHP) issuers could voluntarily incorporate value-based insurance design principles into their QHPs;
- Exchange eligibility enrollment and termination requirements;
- Establish quality-rating information-display standards for Exchanges; and
- Finalize changes to the risk adjustment program for insurers with high-cost enrollees.
The final rule also makes improvements, some beginning in January 2022, to Special Enrollment Period (SEP) rules.
Review the information at these links for additional details: