Build Back Better Act passed by House of Representatives
Includes V-BID Elements
On November 19, 2021 the U.S. House of Representatives passed the Build Back Better Act (H.R.5376), which allocates funds to combat climate change, bolster the U.S. social safety net, and expand healthcare. The bill promotes elements of value-based insurance design (V-BID), including pre-deductible coverage and cost sharing cap of $35 month on selected insulin products (Sec. 27001), a $2,000/year cap and even monthly distribution of out-of-pocket costs for Medicare beneficiaries (Sec. 139201 and 139202), and the removal of co-pays for vaccines under Medicare Part D as recommended by ACIP (Sec. 139402). Excerpts from the bill are included below.
SEC. 27001. SEC. 726. REQUIREMENTS WITH RESPECT TO COST-SHARING FOR CERTAIN INSULIN PRODUCTS
“(a) IN GENERAL.– for plan years beginning on or after January 1, 2023, a group health plan or health insurance issuer offering group health insurance coverage shall provide coverage of selected insulin products, and with respect to such products, shall not–
“(1) apply any deductible; or
“(2) impose any cost-sharing in excess of the lesser of, per 30-day supply–
“(A) $35; or
“(B) the amount equal to 25 percent of the negotiated price of the selected insulin product net of all price concessions received by or on behalf of the plan or coverage, including price concessions received by or on behalf of third-party entities providing services to the plan or coverage, such as pharmacy benefit management services.
SEC. 139201. MEDICARE PART D BENEFIT REDESIGN.
“(a) Benefit Structure Redesign.– Section 1860D-2(b) of the Social Security Act (42 U.S.C. 1395w-102(b)) is amended–
“(3)(B)(III) by adding at the end the following new subclauses:
“(VII) for 2024, is equal to $2,000; or
“(VIII) for a subsequent year, is equal to the amount specified in this subparagraph for the previous year, increased by the annual percentage increase described in paragraph (6) for the year involved.”
SEC. 139202. MAXIMUM MONTHLY CAP ON COST SHARING PAYMENTS UNDER PRESCRIPTION DRUG PLANS AND MA–PD PLANS
“(a) Benefit Structure Redesign.– Section 1860D-2(b) of the Social Security Act (42 U.S.C. 1395w-102(b)) is amended–
“(1)(E)(iii) Beneficiary Monthly Payments.–With respect to an enrollee who has made an election pursuant to clause (i), for each month described in clause (ii), the PDP sponsor or MA organization shall bill such enrollee an amount (not to exceed the maximum monthly cap) for the out-of-pocket costs of such enrollee in such month.
“(iv) Maximum Monthly Cap Defined.–In this subparagraph, the term ‘maximum monthly cap’ means, with respect to an enrollee–
“(I) for the first month for which an enrollee has made an election pursuant to clause (i), an amount determined by calculating–
“(aa) the annual out-of-pocket threshold specified in paragraph (4)(B) minus the incurred costs of the enrollee as described in paragraph (4)(C); divided by
“(bb) the number of months remaining in the plan year; and
“(II) for a subsequent month, an amount determined by calculating–
“(aa) the sum of any remaining out-of-pocket costs owed by the enrollee from a previous month that have not yet been billed to the enrollee and any additional out-of-pocket costs incurred by the enrollee; divided by
“(bb) the number of months remaining in the plan year.”
SEC. 139402. COVERAGE OF ADULT VACCINES RECOMMENDED BY THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES UNDER MEDICARE PART D
“(a) (9)(A) In General.– For plan years beginning on or after January 1, 2024, the following shall apply with respect to an adult vaccine recommended by the Advisory Committee on Immunization Practices (as defined in subparagraph (B)):
“(i) No Application of Deductible.–The deductible under paragraph (1) shall not apply with respect to such vaccine.
“(ii) No Application of Coinsurance or Any Other Cost-Sharing.–There shall be no coinsurance or other cost-sharing under this part with respect to such vaccine, regardless of whether for costs below, at, or above the initial coverage limit under paragraph (3) or the out-of-pocket threshold under paragraph (4).”
Implementation of V-BID programs reduce consumer cost-sharing for high-value services and providers. Moreover, the alignment of consumer engagement initiatives with ongoing provider-facing, value-based payment initiatives is a critical step to improve quality of care, enhance patient experience, and contain cost growth.
The V-BID Center Director, Dr. Mark Fendrick, is available for questions and comments at vbidcenter@umich.edu.
