With the start of each year, the Centers for Medicare and Medicaid Services (CMS) implement changes to their regulations and guidelines. The updates for 2016 incorporate a number of modifications that directly affect our customer facilities and the residents they serve.
CMS awards a “Benchmark Status” to Part D plans that meet specific criteria. Beginning January 1, 2016, a number of plans have lost their Benchmark status and therefore Medicaid will no longer pay 100 percent of the premium of the listed plans:
- AARP Medicare Saver Plus
- Express Scripts Value
- Cigna-Healthcare Rx Secure
In order to modify their situation, Medicaid recipients can enroll in a new Part D plan anytime. Additionally, for Medicaid recipients who were paying $2.65 copays for generics and $6.60 for brands, copays have increased for 2016. These residents will now have to pay $2.95 for generic and $7.40 for brands.
Other CMS mandated modifications include an increase of the maximum deductible from $320 to $360 and a reduction of out-of-pocket expenses during the “donut-hole” period (the time between satisfaction of deductables and reaching maximum out-of-pocket costs) to 65 percent of insurance adjusted cost for generics and 45 percent of insurance adjusted cost for brands. Over the next four years, “donut-hole” out-of-pocket costs are scheduled to decrease even more.
Billing experts at Southern Pharmacy Services are available to answer your questions or clarify any issues related to CMS standards and your prescription related costs. Please call us at 1-866-768-8479 and select the billing option for any questions.