Medicare Pharmacy Benefits Final Rule Addresses Cost Sharing Limits, Special Enrollment Periods, Data Collection from PBMs for 2022

April 30, 2021

On April 30, 2021, the Centers for Medicare & Medicaid Services (CMS) released part two of the Notice of Benefit and Payment Parameters for 2022 and Pharmacy Benefit Standards final rule (NBPP). The rule finalizes some of the standards in the proposed rule for states, exchanges, non-federal governmental plans, issuers in the individual and small-group markets (including those that participate in the federally facilitated exchange direct enrollment program), and web brokers. Select highlights are summarized below.

Cost Sharing Annual Maximum Limits

The final maximum annual limitation on cost sharing for 2022 is $8,700 for self-only coverage and $17,400 for other-than-self-only coverage.

For eligible enrollees, the annual limitation on cost sharing by income is:

  • Between 100% and 200% of the federal poverty level (FPL):  $2,900 for self-only coverage and $5,800 for other-than-self-only coverage
  • Above 200% and through 250% FPL: $6,950 for self-only coverage and $13,900 for other-than-self-only coverage

The rule finalizes a maximum annual limitation on cost sharing that is $400 below what CMS proposed in November 2020.

Special Enrollment Periods (SEPs)

CMS finalized several policies related to SEPs:

  • Exchange enrollees who qualify for a SEP because they lose advance payment of premium tax credit (APTC) eligibility may change to a new plan at any level
  • An individual who did not receive timely notice of a SEP triggering event and was otherwise reasonably unaware that a triggering event occurred, will be allowed to select a new qualified health plan (QHP) within 60 days of the date that he or she knew, or reasonably should have known, of the occurrence of the triggering event
  • Individuals with Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage may qualify for a SEP to enroll in individual health insurance coverage on- or off-exchange based on the cessation of employer contributions or government subsidies (such as those provided for under the American Rescue Plan Act of 2021) to COBRA continuation coverage

CMS also finalized a minor clarifying amendment related to the market-wide application of the SEP that is triggered upon an error by an exchange.

Pharmacy Benefit Management (PBM) Transparency

CMS finalized a rule to provide for collecting prescription drug data directly from PBMs; currently, data is often collected through the QHPs instead of directly from PBMs. CMS states that the data will be used to enhance the agency’s understanding of the true cost of prescription drugs provided in exchange plans and shed light on the role that PBMs play in their cost. The data collected is required to be kept confidential and may only be disclosed for limited purposes outlined in statute.

Co-Pay Accumulators

Part two of this final rule is silent on co-pay accumulators. The Association for Clinical Oncology (ASCO) objected to CMS’ proposal to allow co-pay accumulators in the 2021 NBPP proposed rule and continues to object to their use on the basis that the programs impede patient access to necessary cancer therapies.

Co-pay accumulator programs have been rapidly adopted by Marketplace plans since CMS finalized its policy to allow their use, as shown by a study examining the use of co-pay accumulators in 2021 Marketplace plans. This study found that, in 14 states, every Marketplace plan includes a copay accumulator; in 32 states, at least two-thirds of plans include a copay accumulator adjustment policy; and there are only three states where fewer than half of plans include a copay accumulator adjustment policy. The report also found that information on these policies is very difficult for consumers to identify.

ASCO will continue to urge CMS to reverse its position on the use of copay accumulators and to advocate for policies ensuring equitable access to high-quality cancer care.

Rulemaking to Continue this Spring

Part one of this final rule was released on January 19, 2021. In compliance with an earlier executive order, and as a result of a Department of Health and Human Services’ (HHS) review of the proposed and final 2022 Payment Notices, HHS intends to issue additional rulemaking this spring to further address policies established by both parts of the final 2022 Payment Notice.

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