The Consolidated Appropriations Act (CAA) requires self-funded group health plans and fully insured health plans to report specific data about prescription drug pricing (including prescription drug rebates) and healthcare spending to the federal government starting on December 27, 2022.
The federal government is seeking to collect and track information about:
- Premiums and Life Years – Premiums include all money paid for plan coverage, whether by employees, dependents, or the employer. This amount includes fees or any other contributions associated with the coverage.
- Spending by Category – This reporting requirement primarily relates to medical benefits, not prescription drugs offered under the prescription drug portion of the plan.
- Top 50 Most Frequent Brand Drugs – This requires mandated reporting about the brand name drugs most frequently dispensed during the reporting year.
- Top 50 Most Costly Drugs – These should be tracked and measured for the reporting year.
- Top 50 Drugs by Spending Increase – This reporting category highlights apples-to-apples RX spending compared to the prior year.
- Rx Totals – These are comprehensive gross payments under the plan or policy for the year.
- Rx Rebates by Therapeutic Class
- Rx Rebates for the Top 25 Drugs – This reporting element spotlights the 25 drugs with the highest rebate amounts.
Fully insured and self-funded group health plans, including governmental plans and church plans, must complete the RxDC filings. Filings are not required for account-based plans (such as health reimbursement arrangements) or excepted benefit plans (like stand-alone dental/vision plans or short-term limited duration insurance).
The insurance carriers are legally responsible for the filings for their fully insured plans.
Fully-insured employers may contract with their insurance carriers to provide prescription drug reporting on their behalf. Contracting should be straightforward and likely does not present a special challenge apart from the need to explicitly contract with the carrier. For self-funded plans, plan sponsors must ensure the filings are completed by the appropriate plan vendors.
Organizations that sponsor self-funded health insurance plans can submit the necessary data themselves or work with their plan third party administrator (TPA) or another third party such as a Pharmacy Benefit Manager (PBM) to report the required data. If an organization decides to work with the TPA, PBM or another third party, there should be a written agreement with the TPA, third party or PBM that should detail the information being reported. For example, a self-funded organization may work with both a TPA and a PBM, both of which have some of the required data, but not all. It will be important to know who is reporting what information to make certain all the required data is submitted.
Additionally, self-funded organizations may have data that the entities reporting on their behalf do not have access to. These organizations will need to ensure they are providing the reporting entity with any required information. Organizations that work with more than one third party to administer their health insurance should ensure that all the required data is being reported.
Unlike fully insured entities, organizations that sponsor self-funded health insurance are liable for any failures to report data, even if a third party was supposed to report the data on their behalf.
The deadline to submit 2020 and 2021 data is December 27, 2022. Thereafter, the data must be submitted annually every June 1. The data will be formatted on a “reference year” or calendar year basis. For example, June 1, 2023 is the deadline for submitting 2022 data while June 1, 2024 is the deadline for submitting 2023 data.
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