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

Issue Date: April 13, 2016

Program Area: CSR Reconciliation (CSR)

Question: When standard plans have separate deductibles for Medical and Prescription, but the annual Out-of-Pocket (OOP) maximums to Medical and Prescription is combined, how do you develop the separate parameters for Medical and Prescription? What subgroups should we use?

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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