Feds allow reference-based pricing

The feds say they’re still deciding how to handle reference-based pricing but will let plans use it, for now.

Officials also said employers can use last year’s templates to create new Summary of Benefits and Coverage notices, and that large-group and self-insured plans can often leave part of the cost of expensive brand-name drugs out of annual out-of-pocket spending calculations.

The officials – at the Centers for Medicare & Medicaid Services, the Employee Benefits Security Administration, and the Internal Revenue Service – have discussed those topics and others in a new set of answers of frequently asked questions about PPACA. 

The section on reference-based pricing refers to a strategy that requires plan enrollees to find and use providers who accept a fixed amount for certain procedures.

Federal officials fear some plans could use reference-based pricing to limit patients to using a tiny number of doctors and hospitals that charge rock-bottom prices, officials say.

Officials are asking for comments about how to allow reference-based pricing while ensuring individuals have “meaningful access to medically appropriate, quality care.”

But, until the agencies develop guidance on the topic, a plan can use reference-based pricing, as long as the plan uses a reasonable method to ensure it provides adequate access to quality providers, officials say.