CMS details process for new insulin cap
By HME News Staff
Updated 10:09 AM CST, Mon February 20, 2023
WASHINGTON – Part B co-insurance for a month’s supply of insulin used in an insulin pump covered under the DME benefit can’t exceed $35 starting on July 1, 2023, according to an MLN facet sheet. CMS will adjust payments to suppliers and pharmacies to account for the balance of the reduced co-insurance. Suppliers will continue to get the Medicare payment amount for the insulin (average sales price plus 6%), minus any applicable co-insurance, which, again, is now capped at $35. “Don’t bill for supplies of insulin for July or subsequent months before July 2023,” the fact sheet states. “We’ll complete the system updates to make sure patients aren’t charged more than the $35 maximum allowed for the month of July. Your DME Medicare Administrative Contractor will also educate you about billing during the May – June transition period.” Two new modifiers have been added to the April 2023 HCPCS quarterly file: JK, drug one-month supply or less; and JL, drug three-month supply. Before July 2023: For “from date of service” in May or June 2023, suppliers shouldn’t bill a three-month supply on insulin; instead, they should bill a 1-month supply with the JK modifier. Starting July 2023: For “from date of service” in July and later, they should bill a three-month supply of insulin with the JL modifier or a one-month supply with the JK modifier.
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