The Inflation Reduction Act is keeping drug plan sponsors, pharmacies, Medicare educators and anyone who works with Medicare drug plans very busy.
So far, the IRA has:
- Dropped any cost-sharing for Part D vaccines
- Capped insulin costs at $35, and
- Eliminated the 5% Catastrophic Coverage coinsurance.
Many more changes are coming. The biggest one may be the $2,000 cap on Part D drug costs that takes effect in 2025, which has spawned a new program: the Medicare Payment Prescription Plan or MPPP.
This may seem simple in concept but it’s really quite complicated. On the website for this new program, the Centers for Medicare and Medicaid Service has nine documents, including fact sheets, cost calculations, timelines, and final guidance, totaling 316 pages.
Trying to figure out what those who have Part D drug coverage, referred to as enrollees, need to know and do about the MPPP is rather mind boggling. So, here are 15 essential points you need to know.
1. Initially labeled the OOP (out-of-pocket) Smoothing Program, this is similar to an installment payment plan.
Those who reach the $2,000 Part D cap likely will face a big bill at the pharmacy. The MPPP will allow a drug plan enrollee to pay that bill in monthly installments, spread out over the year, instead of all at once.
2. Anyone who has Part D drug coverage is eligible for this program.
This can include a standalone Part D drug plan or a Medicare health plan with prescription drug coverage, such as a Medicare Advantage plan.
3. CMS has spelled out the many requirements to help plans identify and notify eligible individuals.
These include:
- How to identify those who will qualify for the plan as of January 1, 2025
- What to do if someone qualifies during the year
- Procedures, including calculating and handling payments, dealing with pharmacies and grievances, and
- Model materials for communicating with enrollees about all aspects of the program.
4. Plans must notify enrollees likely to benefit from the MPPP before and during the plan year.
A drug plan must send the “Medicare Prescription Payment Plan Likely to Benefit Notice” to those who:
- Will incur $2,000 in out-of-pocket drug costs by the end of September and
- Have a new high-cost prescription during the year that would trigger a point-of-sale notification. (The trigger amount mentioned in CMS documents is $600.)
Enrollees may also receive a notification from the pharmacy when getting a prescription. The requirement to give a notice does not obligate the pharmacy to provide counseling or education about the MPPP. That is the plan’s responsibility.
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This article originally appeared here and was republished with permission.
