The launch of the Medicare Prescription Drug Inflation Rebate Program is a vital development for the financial and medical well-being of millions of Americans, specifically designed to ease the financial burden of prescription medications for seniors and individuals with disabilities. By instituting an annual out-of-pocket (OOP) cap on drug costs, the program not only alleviates financial stress but also offers a layer of predictability and security to Medicare beneficiaries.
Key Features of the Program:
- Annual OOP Cap: Sets a definitive cap on out-of-pocket expenses for Medicare prescription drugs, directly benefiting consumers by limiting their annual financial liability.
- Inflation-Based Rebates: Requires drug manufacturers to pay rebates if their price increases exceed inflation, effectively keeping drug prices aligned with economic reality.
- Patient Coinsurance: Coinsurance will be based on 20% of the inflation-adjusted payment amount for the quarter. Patient must be charged with the correct coinsurance amount, which may change quarterly.
- Medicare Portion: This payment will be increased for the difference between the Medicare Part B payment amount and the patient coinsurance, minus any Part B deductible and sequestration.
- April Drug pricing files: The files will reflect patient coinsurance percentages, including adjusted patient coinsurance percentages if the Medicare Part B Drug payment amount is greater than the inflation-adjusted amount.
- Removing of 34B Units: CMS intends to remove unites in claim lines that were identified as being 340B units by being billed with the “JG” or “TB” modifiers.
From an operational perspective, this program introduces complexities for those processing Part B drug claims. The need for manual adjustments due to the change in coinsurance requirements poses a challenge for claims platforms, potentially impacting the accuracy of claims adjudication.
How SymKey Helps:
- Accurately adjudicate Part B Drugs and apply the unique patient coinsurance percentage, including, adjusted coinsurance per code, as outlined on the quarterly drug pricing files.
- Re-adjudicate claims previously processed outside the Part B Rebate Program.
- Remove units on all 2023 Professional and Institutional claims lines billed with modifier “JG” or “TB” submitted by suppliers under the 340B program and process the claims according to Part B Rebate.