NPLB: CMS Rule to Lower Maximum Out-of-Pocket Costs by $400 Will Help Patients, More Reductions Needed

APRIL 30, 2021 - WASHINGTON, DC

No Patient Left Behind, a non-profit organization dedicated to eliminating patients’ out-of-pocket costs and ensuring that drugs go generic without undue delay, welcomed key provisions in the CMS Notice of Benefit and Payment Parameters for 2022 Final Rule – particularly the lowering of maximum patient out-of-pocket costs by $400.

“The Final Rule is evidence that the new Administration understands the importance of lowering out-of-pocket costs for patients,” Said NPLB Executive Director Peter Rubin. Cost sharing is an additional payment beyond the premiums consumers pay for health coverage. High insurance deductibles, coinsurance, and copayments can be insurmountable barriers for accessing care prescribed by a doctor and authorized by an insurance company. “A $400 reduction in the annual cost-sharing limits will help patients who struggle to afford healthcare – especially given the challenges confronting many Americans during the ongoing COVID pandemic,” Rubin said.

He added that “The final annual cost-sharing limitation of $8,700 for an individual and $17,400 for a household remains way too high. Additional insurance reforms are needed to meaningfully lower out-of-pocket costs for all Americans, regardless whether they are insured through health exchanges, Medicare, employer-sponsored plans, or other coverage.”

Rubin applauded other provisions in the Final Rule that would ease the special enrollment period (SEP) to make it easier for Americans to purchase health coverage and require greater transparency from pharmacy benefit managers (PBMs). PBMs often receive large discounts from pharmaceutical manufacturers but do not always pass those savings on to consumers who need medication.