Finalization of the Affordable Care Act Federal Upper Limit

This notification is to update states and stakeholders on the finalization of the Affordable Care Act Federal upper limits (FUL) for multiple source drugs. The Centers for Medicare & Medicaid Services (CMS) plans to publish draft Affordable Care Act FULs calculated in accordance with the Medicaid Covered Outpatient Drug final rule with comment (CMS-2345-FC) for two months beginning in January 2016 before finalizing the FULs. The final Affordable Care Act FULs will be published in late March 2016 and will be effective on April 1, 2016 to coincide with the effective date of the final rule with comment. States will have up to 30 days from the April 1, 2016 effective date to implement the FULs. Thereafter, the FULs will be updated monthly on the Medicaid.gov website, and will be effective on the first date of the month following the publication of the update. States will, likewise, have up to 30 days after the effective date to implement the FULs. CMS also plans to publish an updated Methodology and Data Elements Guide used to calculate these draft FULs.    

CMS will issue a monthly Listserv notification when the updated draft FULs are available on the Medicaid.gov website, and when the FULs are finalized. Further, CMS will continue to issue these monthly Listserv notifications to stakeholders when the updated monthly FULs are available on the Medicaid.gov website for the first six months after the finalization of the FULs.

Although CMS will no longer be publishing the draft Affordable Care Act FULs based on the methodology proposed in the Notice of Proposed Rulemaking (CMS-2345-P) (77 FR 5345) published in February 2012, those draft files and the draft Methodology and Data Elements Guides used to calculate those FULs will be available on the Medicaid.gov website at the address provided below.

Once we publish the final Affordable Care Act FULs, the prior FULs calculated using the methodology at 42 CFR 447.332 (FUL Changes Made To Transmittal No.37 and Transmittal No.37 – FUL November 20, 2001), as in effect on December 31, 2006, under the authority of the Medicare Improvements for Patients and Providers Act of 2008 will no longer be in effect.

We look forward to continuing to work with you as you apply the provisions of the Affordable Care Act.

For more information on the Affordable Care Act FULs, please visit http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Prescription-Drugs/Federal-Upper-Limits.html.