The deadline for reporting pharmacy and benefit cost data (RxDC) to the Centers for Medicare and Medicaid Services (CMS) is June 1, 2023. While the initial reports on 2020 and 2021 cost data were due December 27, 2022, with an extended deadline of January 31st, we have found there seems to be some confusion surrounding the 2022 reference year submission because some clients weren’t required by their health plan vendors to take any action last year at all. This is because there was good faith relief and the premium information requested on the average monthly premium (D1) report was voluntary.
This year, good faith relief does not apply, and the D1 data file is required. This is true whether your plan is fully-insured or self-funded. While insurers and claims administrators requested information to help clients comply, those questionnaires may have been overlooked causing some clients to have an “uh-oh” moment because they are now being told they must report certain information to CMS directly. If you responded to questionnaires from your vendors, there is no need to take additional action. But, if you find yourself being told by your insurer or claims administrator, that you need to file certain information with CMS directly, keep reading.
RxDC Required Reporting
As a reminder, the following reports are included in each RxDC submission:
P2: Group Health Plan Name and Related Information*
D1: Average Monthly Premium*
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
The majority of this information can be provided by your insurer, claims administrator, and/or pharmacy benefit manager depending on the design of your health benefits plan. However, your vendor requires information from you to complete two (*) of the required reports on your behalf. We have found that the employer is generally required to provide the following information:
- P2: Group Health Plan Name and Related Information*
- Group Health Plan Name
- 5500 Number (if required to file a 5500 otherwise leave blank)
- D1: Average Monthly Premium*
- Average monthly premium paid by members
- Average monthly premium paid by employer
If You Did Not Provide Requested Information to Your Health Plan Vendor(s)
You should take the following actions if you are required to submit information directly to CMS:
- First you should establish an HIOS account. A link to the HIOS system is available here; follow the prompts for “New User Registration”. Detailed instructions for the HIOS system are available here.
- It can take up to two weeks to be approved for a new HIOS account, so acting now is crucial.
- Once you have been approved for an HIOS account, you must submit for the RxDC Submitter Role
NOTE: If you have already established an HIOS account and RxDC submitter role from the previous filing, you may skip steps 1 and 2.
- Complete a D1 and/or P2 for the 2022 reference year found on the CMS website here. The templates can be found under “RxDC templates and data dictionary (ZIP)”. Following are a couple of helpful hints:
- Reporting is on a calendar year basis. If you have a non-calendar year plan year, you may need to file separate reports for the time period January 1 - ? and ? -December 31.
- Reports must be saved and submitted as a CSV file.
- Submit any missing data not submitted by your vendor(s). Follow the instructions in this document to upload for 2022 plans. Submission instructions begin in Section 3.
Summary
Ongoing, RxDC reports will be due June 1st every year. Vendors will continue to send data requests on what information they require from clients to complete submissions on your behalf. As a reminder, best practice is to have a written agreement with your health plan vendor(s) outlining roles and responsibility.
Please contact your HORAN Benefit Consultant with additional questions at 800.544.8306.
The information contained in this document is informational only and is not intended as, nor should it be construed as, legal or accounting advice. Neither HORAN nor its consultants provide legal, tax nor accounting advice of any kind. We make no legal representation, nor do we take legal responsibility of any kind regarding regulatory compliance. Please consult your counsel for a definitive interpretation of current statute and regulation and their impact on you and your organization.
