Recent CMS FAQs simplify RxDC reporting 

Regulators recently posted a number of FAQs that should ease the prescription drug data collection (RxDC) reporting burden for employers sponsoring complex group health plans. Under Centers for Medicare and Medicaid Services (CMS) June 29, 2022 instructions, many plan sponsors with multiple third party administrators (TPAs), multiple pharmacy benefit managers (PBMs), or point solutions (like a behavioral health carve out) likely would have had to combine their vendors’ plan-level data and submit unique data files to CMS themselves by the Dec. 27, 2022 deadline. However, six CMS FAQs posted on Sept. 23 allow more plans to rely on their vendors’ aggregate filings, vastly simplifying reporting for many employers.

Regulators confirmed that they will accept multiple data files of the same type from the same group health plan (e.g., two or more D2 files reporting the plan’s total annual healthcare spending), if there are “extenuating circumstances” preventing vendors from working together. CMS wants to use the plan-specific (P2: group health plan list) files to connect a particular group health plan with the multiple data files submitted by its vendors, and provides sample P2 files for a variety of situations. The FAQ also “instructs reporting entities to contact the CMS help desk at CMS_FEBS@cms.hhs.gov if there are ‘extenuating circumstances’ that prevent vendors from working together to submit a unique file for each data file type.”

What steps should a plan with multiple TPAs, multiple PBMs or point solutions take now?

• Review the recent FAQs and continue to watch for additional guidance and clarifications from the regulators about the reporting process.
• Watch for any additional vendor materials issued in response to the Sept. 23 FAQs. These materials may request additional information about the employer’s plan, including the name and EIN of all other vendors.
• Confirm whether all vendors – including TPAs, PBMs, and point solutions with reportable data – will submit timely aggregate data files to CMS, including the plan’s data. (There may be rare circumstances where plan level data is submitted.)
• Ensure that each of the plan’s insurers, TPAs, or point solutions will submit a P2 (the group health plan list file) that uses a unique plan name and number for each separate benefit package option offered by a plan.
• If the vendors do not use unique plan names and numbers for each benefit package option, ensure that all P2 files (certainly at least one P2 file) submitted identify all of the group health plan’s vendors. The plan sponsor may be able to provide the information to vendors to submit with their P2 files, or the plan sponsor could submit its own P2 identifying all of the plan’s insurers and TPAs (which would require a HIOS account).
• Document the extenuating circumstances preventing the submission of a single data file for the plan.
• Confirm with legal counsel whether additional steps are required to rely on the vendors’ aggregate filings. This might include submitting a P2 file, contacting CMS’ help desk, or submitting an optional supplemental document describing the “extenuating circumstances.”

What should fully insured plans with one carrier or self-funded plans with only one TPA do now?

Plans with less complicated designs should be able to rely on their vendors for most (if not all) of the reporting, though they should get confirmation (in writing if possible).

When does a plan need a HIOS account?

Only plans that are submitting any plan file (e.g., the P2 file) need a HIOS account. The reason could be that the plan sponsor needs to submit a clarifying P2 (as described above), one or more data files, a separate narrative response and/or an optional supplemental document. See this CMS Quick Guide.