Sarah Borders, CEBS December 27, 2022 6 min read

Departments Release Delayed Enforcement Policy for RxDC Submissions

On December 23, 2022, the Departments issued joint FAQ guidance on the delayed enforcement policy for the CAA’s prescription drug and health care spending reporting requirements for 2020 and 2021 data. The FAQ provides a welcomed delay for good faith submission efforts, and additional flexibilities to assist in complying with the first round of submissions.

Section 204 of the Consolidated Appropriations Act (CAA) requires group health plans and issuers to report detailed prescription drug data, but also requires information related to healthcare spending. The already once-delayed reports for data during the “reference years” 2020 and 2021 must be submitted directly to CMS by December 27, 2022 (now delayed) and then annually by June 1st thereafter.

FAQ #1 confirms that the Departments will provide a submission grace period through January 31, 2023, and will not consider a health plan or issuer to be out of compliance as long as a good faith submission of the 2020 and 2021 data is made on or before Tuesday, January 31, 2023.

In addition, to ease the complex submission process, several flexibilities and clarifications have been provided. Here is a summary of the clarifications that pertain most to self-funded plan sponsors involved in whole or in part in their plan’s RxDC submission:

  • Multiple submissions by the same reporting entity are allowed. When a reporting entity submits on behalf of more than one plan, the reporting entity may make more than one submission for the reference year, instead of including data from all clients on a single set of plan lists (P1-P3) and data files (D1-D8). 
  • Submissions by multiple entities are permitted for the same plan or issuer. More than one reporting entity (i.e., multiple TPAs or PBMs) can submit the same data file on behalf of the same plan, instead of consolidating all of the plan’s data into one single data file for each type of data.
  • Submission of Premium and Life-Years Data to CMS via email is allowed for certain group plans. If a group health plan or an entity reporting on behalf of a plan is only submitting a P2, premium and life-years data on the D1, a narrative response, and no other data, it may be submitted by email to CMS instead of through HIOS. 

Additional clarifications are given that relate more to TPAs, PBMs, and other third-party reporting entities. 

The flexibility only applies to 2020 and 2021 submissions. Any future reference year submission requirements will be based on future guidance issued by the Departments. 

In order to comply with this requirement, even with the delayed enforcement and good faith effort policies, employers must still rely heavily on vendors, TPAs, and PBMs because these service providers possess the required data. Any gaps in submissions should be addressed by either the employer submitting themselves in HIOS or engaging with a third-party vendor to assist with coordinating submissions. Employer plan sponsors, especially self-funded health plan sponsors, should continue to take necessary steps in order to prepare for the January 31st deadline. Helpful information can be found on CMS’s RxDC webpage.


Sarah Borders, CEBS

Principal, Benefits Compliance Solutions. Sarah has spent the last 15 years in the employee benefits industry, has numerous designations and serves on NAHU’s Employer Working Group Subcommittee and is an active board member of Austin AHU. She recently stepped down as Vice President of Benefits Compliance at one of the nation's largest brokerage firms to start her own compliance consulting practice. Her designations include an active license with the Texas Department of Insurance, CEBS (Certified Employee Benefits Specialist), Certified Health Care Reform Professional, HIPAA certification and Health Care Service Associate. She holds an MBA from Texas A&M Corpus Christi and a BA from University of Incarnate Word. Her consulting firm, Benefits Compliance Solutions, partners with employers to identify unknown risks and avoid hundreds of thousands of dollars in fines and lawsuits from failure to comply with their healthplan obligations.