The Medicare Advantage and Prescription Drug Program: Part C Explanation of Benefits and Supporting Regulations (CMS-10453) - IRA

Section 11201 of the IRA makes significant changes to the Part D benefit design which require CMS to make corresponding revisions to the Part D EOB model. Beginning in 2024, the IRA revises section 1860D-2(b)(4)(A)(i)(II) of the Act to eliminate enrollee cost sharing after the enrollee has incurred costs equal to the annual out-of-pocket threshold specified in section 1860D-2(b)(4)(B)(i) of the Act. Beginning in 2025, the IRA eliminates the coverage gap benefit phase, sunsets the Coverage Gap Discount Program, and introduces new manufacturer discounts in the initial and catastrophic coverage phases. Medicare Advantage organizations (MAOs) and Medicare Prescription Drug Program (Part D) plan sponsors are required to provide their enrollees with a written explanation of benefits (EOB) when benefits are provided under the plan. Section 1860D-4(a)(4) of the Social Security Act, requires that Part D sponsors distribute to enrollees a notice of benefits used in relation to the Part D initial coverage limit and annual out-of-pocket threshold. CMS codified Part D EOB requirements at 42 CFR § 423.128(e). Section 1852(k)(2)(C)(i) of the Act requires MAOs that offer a private fee-for-service (PFFS) plan to provide enrollees with a written EOB, including a clear statement about the enrollee’s liability, when payment is sought under the plan. CMS regulations specifying that all MAOs provide an EOB when Part C benefits are used are codified at 42 CFR § 422.111(k). Information in this collection is needed to ensure that MA and Part D enrollees receive consistent and timely information about costs associated with their medical claims. Part C and Part D EOBs allow enrollees to track their out-of-pocket expenses and benefit utilization in relation to their plan’s deductible and out-of-pocket threshold.

The latest form for The Medicare Advantage and Prescription Drug Program: Part C Explanation of Benefits and Supporting Regulations (CMS-10453) - IRA expires 2027-03-31 and can be found here.