Affordable Care Act FAQ 40 Regarding HHS Notice of Benefit and Payment Parameters for 2020

On August 26, 2019, the U.S. Departments of Health and Human Services, Labor and Treasury issued FAQs about Affordable Care Act Implementation Part 40 that delays the implementation of a rule in the HHS 2020 Notice of Benefit and Payment Parameters. The rule required health plans (including self-insured plans) to credit any amount of financial assistance received from drug manufacturers to the out-of-pocket maximum. The delay is in effect until at least January 1, 2021.

In an earlier regulatory update, HHS finalized a rule to allow private insurance plans to exclude the value of certain manufacturer coupons from a patient’s annual cost-sharing limit. However, the rule also clarified that accumulator programs were prohibited if a generic equivalent is not available or medically appropriate.

WellDyneRx administers the WellAssist Program for certain clients, a program which is designed to identify, manage and reduce the cost of frequently-prescribed specialty medications that offer a direct-to-consumer coupon from the manufacturer. Copay card programs typically fall into one of two categories – copay maximizer or copay accumulator. Our WellAssist program is primarily a copay maximizer that leverages drug manufacturer financial assistance programs to benefit both clients and their members.

WellDyneRx Recommendation:
Although there has been a lot of confusion around the rule, the new ACA FAQ makes it clear that health plans do not need to adopt benefit design changes for 2020. Plans should anticipate a ruling in late 2020, however, that may require them to credit drug manufacturer payments toward a member’s cost-sharing in 2021.

To learn more, please contact your Account Executive.


2019 Quarter Four WellInformed Table Contents