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  1. FHIR Specification Feedback
  2. FHIR-30924

Adjusting Cost-Sharing Options to support Medicaid

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    • Change Request
    • Status: Published (View Workflow)
    • Medium
    • Resolution: Persuasive with Modification
    • US Da Vinci Drug Formulary (FHIR)
    • 1.0.1
    • Pharmacy
    • Qualifier for coinsurance rate
    • Artifacts Summary
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      Add “Not applicable” to http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS.  Zero-deductible cost sharing to be represented by a co-pay value of “Not applicable” and co-insurance value of “No charge”.

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      Add “Not applicable” to http://hl7.org/fhir/us/davinci-drug-formulary/CodeSystem/usdf-CopayOptionCS .  Zero-deductible cost sharing to be represented by a co-pay value of “Not applicable” and co-insurance value of “No charge”.
    • Dave Saul/Melva Peters: 9-0-0
    • Enhancement
    • Compatible, substantive

    Description

      Reference:  https://chat.fhir.org/#narrow/stream/197730-Da-Vinci.20PDex.20Drug.20Formulary/topic/CostSharing.20.20Extension

      The available selections for CopayOption and CoinsuranceOption don't seem to fit if the Medicaid Plan has a deductible of $0. All of these would mislead the member if there is no deductible:
      after-deductible
      before-deductible
      no-charge
      no-charge-after-deductible

      Is there something we're missing? We can use "after-deductible" for now but recommend adding another selection that is specific to this situation for the next build.

      The structure/definition of the cost sharing extensions were (rightly or wrongly) based on the QHP Formulary – see https://github.com/CMSgov/QHP-provider-formulary-APIs#cost-sharing-sub-type.

      The QHP Formulary definition is a bit thin on how to actually use the fields.
      Looking at the 2021 instructions for registering a QHP formulary (see https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/QHP_Slides_040220_5CR_040220_8.pdf, starting at slide 21) there is a bit more detail.

      1) There is an additional value of "Not Applicable" for both the CopayOption and the CoInsuranceOption.
      2) There is a plan-level text field for any explanation of features that don't fit well into the structure.
      3) Zero-Cost Drugs, two options are presented:
       - CoPaymentOption: N/A, CoInsuranceOption: No Charge, or

      • CoPaymentOptiion: No Charge, CoInsuranceOption: N/A
        4) Business rule says you can't specify N/A for both CoPaymentOption and CoInsuranceOption

      Seems like we are missing the N/A values for both CopaymentOption and CoinsuranceOption, and some guidance on how to handle some of the expected corner cases.

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            Unassigned Unassigned
            saul_kravitz Saul Kravitz
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              Created:
              Updated:
              Resolved: