The Centers for Medicare Medicaid Services (CMS) released final regulations regarding limits on out-of-pocket maximums for 2020 and a prescription drug plan update intended to lower plan costs. CMS also encouraged, but not required, insurers to cover several treatments for opioid addiction.
The allowable maximum out-of-pocket (OOP) will increase to $8,150 (currently $7,900) for individual coverage and $16,300 (currently $15,800) for family coverage. These coverage limits apply regardless of group size or funding type (fully-insured, self-insured, partial, etc.).
Of the three prescription drug pricing-related provisions included in the proposed rule, CMS chose to include only one in the final rule due to concerns brought up during the comment period. The one final rule hopes to encourage members to seek out generic prescriptions by allowing plans, beginning in 2020, to exclude drug manufacturer coupons from counting toward a member’s annual OOP maximum, if a medically appropriate generic drug is available. This means members may no longer be able to use a manufacturer coupon to lower their out-of-pocket costs while their medical plan pays the higher brand price. The permitted change applies to individual, small group, large group and self-funded plans to the extent permitted by state laws and is likely to be adopted by most plans this coming renewal cycle in an attempt to lower plan costs and guide members to lower cost drug options.
Based on public scrutiny over the role medical plans have played in the opioid crisis, the final regulations encourage, but do not require, insurers to cover all four Medication-Assisted Treatment (MAT) drugs for treatment of opioid use disorder and, if the plan excludes MAT for opioid use treatment even though they cover it for other conditions, the insurer must justify the exclusion and explain how the benefit design is not discriminatory. Since this is a recommendation at this point and not a requirement, Aldrich Benefits can discuss and price this option for large group and self-insured plans interested in considering this update for their upcoming renewal.