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Feds allow reference-based pricing

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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.

In another answer, officials say insurers and employers can use the templates the agencies posted in April 2013 to develop new SBCs and “uniform glossaries” of health insurance terms.

All of the agency decisions that protected carriers, employers and others against SBC-related enforcement conditions will continue to protect them, officials say.

Officials also answered several questions about the PPACA limits on the amount enrollees in PPACA-compliant plans can be expected to pay out of pocket.

If an enrollee uses a brand-name drug when a medically appropriate drug was available, the plan can keep the extra cost of the brand-name drug out of out-of-pocket spending calculations, officials say.

But officials say that, in a situation like that, a plan should have a reasonable approach to including the cost of brand-name drugs in the calculations when patients need brand-name drugs.

Plans do not have to let patients include any of the cost of care from out-of-network care providers in out-of-pocket spending calculations, but plans can use any reasonable method to let patients include part or all of the cost of out-of-network care in out-of-pocket spending totals, officials say. 

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