America's Benefit Specialist March 2023

BENEFIT REPORTING

Subject

Plan Lists

Data Files

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 The data files collect premium and spending information at an aggregate level.

File Name

P stands for Plan: • P1 Individual and student market plan list • P2 Group health plan list • P3 FEHB plan list

Purpose

The plan lists identify the plans in a submission. The plan lists also collect plan-level informa tion 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. • P1 is required for plans in the individual or student market • P2 is required for employer-based health plans (not FEHB plans) • P3 is required for FEHB plans

Requirement

All eight data files are required.

File Format

Comma Separated Values (CSV)

Comma Separated Values (CSV)

File Format—Narrative MS Word or PDF

MS Word or PDF

“It’s not a problem if multiple reporting entities upload different narrative responses on behalf of the same plan, issuer or carrier. The narrative response is going to be a word or PDF document that you are going to file along with the P and D files, that provides some clarifying or explanatory information,” Monahan explained. “It’s also used as a kind of a catch-all, so if there is an area in your reporting where you have to explain a methodology, then you add the explanation for this in the narrative response.“ When filing, the narrative must include, at a minimum, the following: employer size for self-funded plans, net payments from federal or state reinsurance or cost-sharing reduction programs, drugs missing from the CMS crosswalk, medical benefit drugs, prescription drug rebate descriptions, alloca tion methods for prescription-drug rebates and impact of prescription-drug rebates. The narrative response is also used to describe certain methodologies chosen. THE PHARMACY BENEFIT REPORTING WRITTEN AGREEMENT Just like the TiC MRF requirements, the CAA pharmacy benefit reporting requirements have a requirement for a written agreement.

“That written agreement mandate, that same structure that applies to the MRFs, also applies to the prescription drug reporting requirement,” said Monahan. “Whether you’re fully insured or self-funded, you can outsource this to your insurance company, your TPA, your ASO or your PBM, but you have to have a written agreement in place.” To summarize the action items and provide a conclusion, the most important thing for an employer to do is get a writ ten agreement in place with vendors as soon as possible, to identify who is doing what, and to get vendors to commit to complying by the due dates. If the plan is fully insured, the plan satisfies the reporting mandate if the plan requires the health insurance issuer offering the coverage to provide the information pursuant to a written agreement. “With regard to fully insured plans, much of the filing has to be done by the insurance company, but you still have to have a written agreement with an insurance company,” added Monahan. “If you have that written agreement and the insurance company fails to perform, it will be the insur ance company, not the employer, who will be deemed to be out of compliance.” If the plan is self-funded, the plan may satisfy the man date if it enters into a written agreement under which

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