Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: January 30, 2019

Program Area: CSR Reconciliation (CSR)

Question: When standard plans have separate deductibles for Medical and Rx, but the annual out-of-pocket (OOP) maximums to Medical and RX is combined, how do you develop the separate parameters for Medical and Rx?

Answer: When developing parameters for medical and pharmaceutical claims with separate OOPs but a combined deductible, issuers should develop effective parameters for the following subgroups: medical claims toward deductibles/combined medical & pharmaceutical Maximum Out-of-pocket (MOOP) and pharmaceutical claims toward deductible/combined medical & pharmaceutical MOOP.

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