CMS Pub. 100-04, ch. 17, § 10.1

Coinsurance Policy

(Rev. 12511; Issued:02-15-24; Effective: 01-01-24; Implementation: 03-18-24)

For calendar quarters starting April 1, 2023, if the payment amount for a rebatable drug specified in

section 1847A(i)(3)(A)(ii)(I) of the Act exceeds the inflation-adjusted payment amount, two payment

adjustments are necessary. First, beneficiary coinsurance for a Part B rebatable drug is to be 20 percent

of the inflation-adjusted payment amount if the Medicare payment amount for a calendar quarter

exceeds the inflation-adjusted payment amount. A/B MACs should find the applicable coinsurance

amount for a rebatable drug in the ASP pricing file where the coinsurance is expressed as a percent of

the Medicare payment amount. If adjusted beneficiary coinsurance does not apply, the percentage is 20

percent.

Second, Medicare Part B pays, subject to the deductible and sequestration, the difference between the

allowed payment amount determined under section 1847A of the Act and 20 percent of the inflation-adjusted amount. In other words, the Part B payment for a rebatable drug with an inflation-adjusted

coinsurance will be greater than 80 percent of the payment amount.