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 next round of reports for data during the “reference year” 2024 must be submitted directly to CMS by Sunday, June 1, 2025.
Who this applies to:
All size employers sponsoring a group medical plan and prescription drug benefit that is not an ICHRA.
Go Deeper:
In order to comply with this requirement, employers must rely heavily on their claims administrators because these service providers possess the required data.
Any gaps in submissions should be addressed by either the employer submitting themselves in the government’s HIOS system or engaging with a third-party vendor to assist with coordinating submissions.
Typically, the claims administrator or carrier will facilitate the full reporting but will ask the employer for key information needed two to three months before the June 1 annual deadline.
- They primarily need to know how much the employer paid vs. how much participants paid (including COBRA participants) for the previous calendar year’s medical/Rx coverage (even if the plan does not operate on a calendar year).
- If self-funded, the premium “equivalent” for this will be actual fixed costs plus actual claims (choose either incurred claims or paid claims for the calendar year, and stick with that choice every year), less stop loss rebates and pharmacy rebates retained by the plan.
Employer plan sponsors, especially self-funded health plan sponsors, should continue to take necessary steps in order to prepare for the June 1 deadline. Helpful information can be found on CMS’s RxDC webpage.
COMMENTS