CMS Issues 2016 Medicare Part D Benefit Parameters

CMS Issues 2016 Medicare Part D Benefit Parameters

from EBIA

Announcement of Calendar Year (CY) 2016 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter (Apr. 6, 2015)

Under Medicare Part D regulations, most group health plan sponsors offering prescription drug coverage to Part D eligible individuals (including active or disabled employees, retirees, COBRA participants, and beneficiaries) must disclose to Part D eligible individuals and to CMS whether the plan coverage is creditable or non-creditable. For coverage to be creditable, its actuarial value must equal or exceed the actuarial value of defined standard Medicare Part D coverage under CMS guidelines. In simple terms, the actuarial equivalence determination measures whether the employer’s coverage is, on average, at least as good as standard Medicare prescription drug coverage; if it is, the employer’s coverage is creditable.

CMS has released the following 2016 parameters for the defined standard Medicare Part D prescription drug benefit:

  • CMS-logoDeductible: $360 (a $40 increase from 2015);
  • Initial coverage limit: $3,310 (a $350 increase from 2015);
  • Out-of-pocket threshold: $4,850 (a $150 increase from 2015);
  • Total covered Part D spending at the out-of-pocket expense threshold for beneficiaries who are not eligible for the coverage gap discount program: $7,062.50 (a $382.50 increase from 2015);
  • Estimated total covered Part D spending at the out-of-pocket expense threshold for beneficiaries who are eligible for the coverage gap discount program: $7,515.22 (a $453.46 increase from 2015); and
  • Minimum cost-sharing under the catastrophic coverage portion of the benefit: $2.95 for generic/preferred multi-source drugs (a $.30 increase from 2015), and $7.40 for all other drugs (a $.80 increase from 2015).

EBIA Comment: These parameters will be used by group health plan sponsors to determine whether their plans’ prescription drug coverage is creditable for 2016. The information is needed for required disclosures to Part D eligible individuals and to CMS. In addition to the annual participant disclosure notice requirement, which may be satisfied by providing a single notice at the same time each year, disclosure notices may also be required at other times (for example, prior to an individual’s Medicare Part D initial enrollment period or upon request from a Medicare Part D eligible individual).

Contributing Editors: EBIA Staff.