America's Benefit Specialist March 2023

BENEFIT REPORTING

employee contributions to the plan); the average monthly premium amount paid by participants and beneficiaries; and the total annual premium amount and the total number of life-years. Life-years are the total number of members covered on a given day of each month of the reference year, divided by 12. Be advised that for premium data, enforcement relief was offered for 2020 and 2021 reference years. Again, the information that outside parties may not have but will need from employers includes all or part of what is needed for the P1 and D1 information, whether they are fully insured or self-funded. AGGREGATED DATA THAT NEEDS TO BE REPORTED The aggregated data is provided by carriers for all of their block of business, or by the TPA or ASO for their block of busi ness, aggregated into one or more files that will be reported. The chart on the following page summarizes the contents of each data file that contains aggregated data. THE PROCESS Again, the data is submitted to CMS through its Health Insur ance and Oversight System. Plans must submit one or more plan lists (P1-P3), eight data files (D1-D8) and a narra tive response. One or more third parties or vendors (“reporting entity”) may submit on behalf of the employer’s plan. Each submits a P file (so CMS can identify by plan), along with the 8 data files. Many resources were provided by CMS. It has issued “Prescription Drug Data Collection (RxDC) Reporting Instruc tions,” templates for each data file, “RxDC Data Dictionary for the 2020 and 2021 Reference Years,” “HIOS Prescription Drug Data Collection (RxDC) User Manual” and FAQs. In addition, CMS provides webinars, resources, FAQs and other educa tional tools through the Registration and Technical Assis tance Portal (REGTAP—registration required), and there is a phone number and email address to submit questions. See www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insur ance-Protections/Prescription-Drug-Data-Collection. We have created the chart on page 22 for the process, plan lists and data files: THE NARRATIVE In addition to the plan and data files (P and D), a narrative response is required. In it, parties submitting data must describe the impact of prescription-drug rebates on premi um and cost-sharing, and address other topics that may be described in places throughout the Instructions. The narra tive response file format must be Portable Document Format (.pdf) or Microsoft Word (.doc or .docx). You can, but do not have to, submit additional information about your submission using PDF or Word documents.

to 1) have a written agreement with the carrier that specifies that it will perform the duties related to the pharmacy-re porting requirements and 2) watch for updates from emails, letters, notes on billings, etc. from the carrier, as one of these may have information related to these requirements, and the employer may receive a notice of a contract change or other, stating that they will do these things on their behalf. To be safe, we are sending written agreements on our fully insured clients’ behalf to all of our clients’ carriers, so that we can have documented correspondence with them. Some may not accept these agreements (as they have thousands of plan sponsors and may not want to have individual agreements), but if/when they respond, we can capture their responses for our clients’ files. Again, carriers may simply just send plan sponsors a contract change by email or mail. It is the plan sponsor’s responsibility to keep that in their contract file. WHAT DATA IS REPORTED? In summary, for fully insured employers, group health plan data will typically be reported by the issuer (as the “reporting entity”)—but the issuer will typically need certain “plan-level” data from the employer. For self-funded employers, group health plan data will typically be reported by one or more third-party vendors (such as a TPA, PBM, ASO)—but these “reporting entities” will need certain “plan-level” data from the employer. When the data is filed by the issuer or TPA, plan-lev el data for each plan is included (P2), along with “aggregated” data for the issuer or TPA’s book of business (but broken down by market segment and state) (D1-D8). Note that data is re ported on a calendar year, or ”reference year” basis. For both fully insured and self-funded plans, the em ployer must have a contract/written agreement with the reporting entity or entities. The employer plan sponsor may be in possession of some items that the carrier or issuer, or if self-funded, the TPA or ASO provider simply won’t have. This is called “Plan-Level Data.” The specific plan file that you may hear of is the P2 Data File, which may or may not be known by other parties and includes: identifying information such as plan name; plan number(s); plan sponsor; plan sponsor EIN; and issuer, TPA and PBM names and EINs; beginning and end dates of the plan year that ended on/before the last day of the reference year; the number of participants and beneficiaries (“mem bers”) covered on the last day of reference year; and each state in which the plan or coverage is offered. There are also items needed from the employer health plan that needs to be submitted with the aggregated data—the D-1 file in particular. The D-1 file includes premium amounts, including: the average monthly premium amount paid by employers and other plan sponsors on behalf of participants and beneficiaries (i.e., the carrier may have the total premium collected, but it may not have the split between what is paid by the employer and what is paid by the plan participants in

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