Single Deductible Rules for Regional and Local PPOs

50.4 – Single Deductible Rules for Regional and Local PPOs (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) A single deductible is a specified dollar amount to be paid annually by the enrollee for health care services or for covered Part D drugs before the plan begins to pay its share of the cost for those benefits. The single deductible amount may apply to all plan services or to specific categories of plan services with the exception of emergency or urgently needed services. Plans may not charge enrollees the plan-level deductible prior to receiving Emergency Care/Urgently Needed Services and the cost sharing for those services must always contribute to satisfying the MOOP. Plans may count Emergency Care/Urgently Needed Services cost sharing towards the plan-level deductible or plans may choose to not have enrollee cost sharing count towards the plan-level deductible. However, plans must apply this policy uniformly across the entire plan and marketing materials provided to enrollees must be transparent regarding whether or not cost sharing applies toward the plan-level deductible. In addition to the applicable cost-sharing requirements listed in section 50.1 above, both local and regional PPOs that choose to charge a deductible must establish a single deductible that applies to services furnished in-network and out-of-network (OON). The local or regional PPO may: • Not apply the deductible to in-network $0 cost-share preventive services, but may exempt any or all other in-network Medicare Part A and Part B services from the deductible; that is, the regional or local PPO may choose to cover specific in-network items or services at plan cost-sharing levels whether or not the single deductible has been met; • Charge different dollar amounts that count toward the single deductible for specified Medicare Part A and Part B services furnished in-network; • Exempt the OON $0 cost-share preventive services from the plan deductible. However, plans may not exempt from the single deductible any other OON Medicare Part A and Part B services; and • Choose whether to require that the single deductible applies to non-Medicare covered services (optional and mandatory supplemental benefits) furnished either IN or OON. Example: A local or regional PPO charges a single deductible of $1,000. The plan limits the application and amount of the deductible to IN inpatient hospital services ($500) and IN physician services ($100). Additionally, the MA plan exempts Medicare covered OON $0 preventive services from the deductible. Analysis: The local or regional PPO in this example, complies with the PPO deductible guidance because it: • Charges a single plan deductible; • Has elected to differentiate the applicability of this single deductible for two in- network Medicare Part A and Part B services (Inpatient hospital and physician services); and • Does not exempt from the single deductible any Medicare Part A or B benefits furnished out-of-network.