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

Issue Date: January 30, 2019

Program Area: CSR Reconciliation (CSR)

Question: How do Issuers develop separate parameters for plans that have separate deductibles for medical care and prescriptions, but apply out-of-pocket maximum to both medical care and prescriptions combined?

Answer: For plans with separate medical and pharmaceutical deductibles but a combined annual limitation on cost sharing, issuers should develop separate effective cost sharing parameters for the medical and pharmaceutical claims. However, the total amount of cost sharing estimated under the standard plan for any policy must be limited to the combined annual limitation on cost sharing.

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