As previously reported, plan sponsors of group health plans must submit information annually about prescription drugs and health care spending to the Centers for Medicare and Medicaid Services ("CMS"). The first deadline is December 27, 2022, for reporting on calendar years 2020 and 2021. The next deadline is June 1, 2023, for reporting on calendar year 2022. Most commonly:
- The carrier will submit on behalf of an insured medical plan.
- The TPA will file on behalf of a self-funded plan (includes a level funded plan) with an integrated medical/drug plan and stop loss insurance.
- The TPA and PBM will partially file on behalf of a self-funded plan with a carved-out drug program and/or carved-out stop loss, but the employer may have responsibility for the other parts of the filing.
However, the exact process will depend on the carrier/TPA/PBM and their processes may not yet be announced or may have changed since the last communication. It is important to know how your carriers, TPAs and PBMs will assist in this process.
Recently, some TPAs of self-funded plans have changed direction and indicated that if the plan has any carve-out arrangements (e.g., pharmacy and/or stop loss) the employer may be responsible for filing a P2 and partial D1 to reflect stop loss premium and/or pharmacy information that is not captured in the TPA’s system. The TPA may not collect this information to include in the D1 that it files with CMS.
If an employer must submit some of the files on behalf of the group health plan, the employer must register with HIOS and receive account information before filing which can take up to two weeks. These employers will need to appoint two individuals, with at least one of those individuals designated as the "RxDC Submitter," and should start the process now.
CMS has resources available to assist in this process: