Who decides if non-Medicare prescription drug coverage is “creditable”?
Creditable drug coverage is that which is at least as good as basic standard Part D coverage. In general, the actuarial equivalence test measures whether the expected amount of paid claims under the entity's prescription drug coverage is at least as much as the expected amount of paid claims under the standard Part D benefit. A non-Part D plan sponsor must submit an actuarial attestation to CMS that provides information demonstrating that the coverage is at least equal to the actuarial value of a standard Part D plan.
Source: Section 423.56(a)-(b) of the MMA Regulations addresses the topic of creditable coverage. See also CMS’s Simplified Creditable Coverage Determination.
§ 423.56 Procedures to determine and document creditable status of prescription drug coverage. (a) Definition. Creditable prescription drug coverage means any of the following types of coverage listed in paragraph (b) of this section only if the actuarial value of the coverage equals or exceeds the actuarial value of defined standard prescription drug coverage as demonstrated through the use of generally accepted actuarial principles and in accordance with CMS actuarial guidelines.
(b) Types of coverage. The following coverage is considered creditable if it meets the definition provided in paragraph (a) of this section: (1) Prescription drug coverage under a PDP or MA-PD plan. (2) Medicaid coverage under title XIX of the Act or under a waiver under section 1115 of the Act. (3) Coverage under a group health plan, including the Federal employees health benefits program, and qualified retiree prescription drug plans as defined in section 1860D–22(a)(2) of the Act. (4) Coverage under State Pharmaceutical Assistance Programs (SPAP) as defined at § 423.454. (5) Coverage of prescription drugs for veterans, survivors and dependents under chapter 17 of title 38, U.S.C. (6) Coverage under a Medicare supplemental policy (Medigap policy) as defined at § 423.205. (7) Military coverage under chapter 55 of title 10, U.S.C., including TRICARE. (8) Individual health insurance coverage (as defined in section 2791(b)(5) of the Public Health Service Act) that includes coverage for outpatient prescription drugs and that does not meet the definition of an excepted benefit (as defined in section 2791(c) of the Public Health Service Act). (9) Coverage provided by the medical care program of the Indian Health Service, Tribe or Tribal organization, or Urban Indian organization (I/T/U). (10) Coverage provided by a PACE organization. (11) Coverage provided by a cost-based HMO or CMP under part 417 of this chapter. (12) Coverage provided through a State High-Risk Pool as defined under 42 CFR 146.113(a)(1)(vii). (13) Other coverage as the Secretary may determine appropriate.
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