2020 Final Notice of Benefit and Payment Parameters

Each year, the Department of Health and Human Services (HHS) is tasked with publishing updated rules and indexes for insurers and health insurance Marketplaces/Exchanges, and typically there a couple of updates in those rules affecting employers. Now that the 2020 rules have been finalized (and summarized in a fact sheet), below are the items we believe are most relevant to employer plans.

Brand Drug Coupons Allowed to Potentially No Longer Count Toward OOP

In the proposed rule, HHS had considered whether to treat brand drugs taken when a generic is available as not meeting the definition of an essential health benefit (EHB) and therefore not counting toward a member’s OOP. While they ultimately abandoned that idea (for now), they did finalize a new rule allowing health plans to treat coupons someone uses toward a brand drug as no longer counting toward OOP when a generic is available (unless the brand is determined medically necessary via the appeals process, or a state law prohibits such accumulator adjustment programs, such as VA and WV).

Please let your IMA Benefits team know if you have any questions; we will continue to monitor regulator guidance and offer meaningful, practical, timely information.