Preparing for June 1 RxDC Reporting Deadline
Background
Under the Consolidated Appropriations Act, 2021 (CAA), insurance companies and employer-based health plans must submit a RxDC report, containing information about prescription drugs and health care spending. The Rx stands for prescription drug, and the DC stands for data collection. This includes both fully insured and self-insured health plans, grandfathered and non-grandfathered plans, as well as those subject to ERISA and those not subject to ERISA, including nonfederal governmental entities and church plans.
Initially, the first RxDC report was required to have been filed by December 27, 2021, and then June 1 of each year thereafter. However, enforcement was deferred for one year, such that the first reporting requirement would be due on December 27, 2022, for the 2020 and 2021 reference years. This deadline was subsequently extended to January 31, 2023. Going forward, the next reporting will be due on June 1, 2023, for the 2022 reference year, and then annually thereafter.
Note: A reference year refers to the calendar year of the data that is in the RxDC report. Thus, a plan with a non-calendar year plan year will contain information for two plan years to the extent it happened in a year being reported on. For example, the 2022 RxDC report for a plan with a July 1 – June 30 plan year will contain information pertaining to January 1 – June 30 of the 2021 plan year and July 1 – December 31 of the 2022 plan year.
The reporting is done through the Health Insurance Oversight System (HIOS) (which is through the CMS Enterprise Portal). The responsibility for the reporting officially lies with the plan sponsor. For fully insured plans, the good news is that the insurer can be directly responsible for the reporting obligation as long as the plan sponsor and insurer execute a written agreement that requires the insurer to be responsible for the reporting. Plan sponsors of self-insured or level-funded plans may have a third-party, such as a third-party administrator (TPA), or pharmacy benefit manager (PBM) submit some or all of the data on their behalf. In nearly all instances, this should be the case because the third-party will have access to HIOS. Otherwise, the plan sponsor must set up its own HIOS account with CMS.
Action Items
- Reach out to carriers, TPAs, and /or PBMs (collectively, reporting entities). Plan sponsors should reach out to the applicable reporting entities to learn their specific RxDC reporting process, and any instructions the plan sponsor is required to follow. Depending upon the reporting entity, this information may be requested regardless of whether the plan is fully insured or self-insured. A chart depicting the required information is reflected in the “Required Reporting Data” section below. Specifically, plan list P2 and data file D1 information may be needed, which are explained in more detail in the next section of this Alert.
- Comply with deadlines to provide any requested information. Several reporting entities have already contacted plan sponsors with requests for specific information necessary in order to file on the plan sponsor’s behalf. These requests have strict deadlines with which plan sponsors must comply to ensure the reporting entity files on its behalf in a timely manner (some are as soon as March 1, 2023).
- Establish HIOS account if necessary. Should you, as plan sponsor, be required to report on a portion of the RxDC information, you will need to set up an HIOS account with CMS online. CMS has published an updated user manual, available here, that explains how to use the RxDC module within the HIOS.
- Execute written agreements. If you have not done so already, we continue to recommend that employers sponsoring health plans contact their respective reporting entities and execute a written agreement that requires the reporting entity to be responsible for the reporting.
Required Reporting Data
Plans and carriers must submit one or more plan lists (P1-P3) and eight data files (D1-D8) in accordance with specific file layout requirements, as well as a narrative response that includes a description of the impact of Rx drug rebates on premiums and cost sharing. Specific instructions are available here.
| SUBJECT | PLAN LISTS | DATA FILES |
| File Names | P stands for Plan:
· P1 Individual and student market plan list · P2 Group health plan list* · P3 FEHB plan list
*For employer group health plans, P2 is the required plan list that must be completed |
D stands for Data:
· D1 Premium and Life-Years · D2 Spending by Category · D3 Top 50 Most Frequent Brand Drugs · D4 Top 50 Most Costly Drugs · D5 Top 50 Drugs by Spending Increase · D6 Rx Totals · D7 Rx Rebates by Therapeutic Class · D8 Rx Rebates for the Top 25 Drugs |
| Purpose | The plan lists identify the plans in a submission. The plan lists also collect plan level information required by statute, such as the beginning and end dates of the plan year, the number of members, and the states in which the plan or coverage is offered | The data files collect premium and spending information at an aggregate level
All 8 data files are required. Much of this information except for the D1 File should already be in the possession of the reporting entity; D1 File data is typically needed from the plan sponsor |
The D1 Data File
Included in the D1 Data File requirement are the following data elements with respect to the reference year:
- Each row must have a unique combination of employer identification number (EIN), state and market segment
- Average monthly premium amounts paid by members
- Average monthly premium amounts paid by employers
- Life years (the average number of members throughout the year (e.g., enrollees, dependents, participants, and beneficiaries are all considered members)
- Earned premium (fully insured plans)
- Premium equivalents (self-insured plans)
- ASO/TPA fees paid (self-insured plans)
- Stop loss premium paid (self-insured plans)
The information required will be used to assist the Departments of Labor, Health and Human Services, and the Treasury (Departments) in understanding prescription drug and health care spending costs, which prescription drugs account for the most spending, which drugs are prescribed most frequently, Rx rebates received from drug manufacturers, and premiums and cost-sharing information. CMS and the Departments plan to issue a report that will be made public regarding this information.
ADDITIONAL INFORMATION
Additional information, including specific reporting instructions, FAQs and training webinars, is available here. Outside vendor assistance is also available to assist clients.
For questions regarding this Legislative Update or any other related compliance issues, please contact your Burnham Benefits Consultant or Burnham Benefits at 949‐833‐2983 or inquiries@burnhambenefits.com.
This Legislative Update was prepared by the Baldwin Regulatory Compliance Collaborative (the “BRCC”), a partnership of compliance professionals offering client support and compliance solutions for the benefit of the Baldwin Risk Partners organization, which includes: Jason Sheffield, BRP National Director of Compliance; Richard Asensio, Burnham Benefits Insurance Services; Nicole L. Fender, the Capital Group; Bill Freeman, AHT Insurance; Stephanie Hall, RBA/TBA; Caitlin Hillenbrand, AHT Insurance; Paul Van Brunt, Baldwin Krystyn Sherman Partners (BKS); and Natashia Wright, Insgroup.
Burnham Benefits and the BRCC do not engage in the practice of law and this publication should not be construed as the providing of legal advice or a legal opinion of any kind. The consulting advice we provide is intended solely to assist in assessing its compliance with applicable federal and state law requirements, and is based on our interpretation of federal guidance in effect as of the date of this publication. To the best of our knowledge, the information provided herein, and assumptions relied on, are reasonable and accurate as of the date of this publication. Furthermore, to ensure compliance with IRS Circular 230, any tax advice contained in this publication is not intended to be used, and cannot be used, for purposes of (i) avoiding penalties imposed under the United States Internal Revenue Code or (ii) promoting, marketing or recommending to another person any tax-related matter.