Markets: All Commercial Groups and CFA, except Group Medicare Advantage
CareFirst/CareFirst Administrators is changing the submission process for the upcoming Prescription Drug Data Collection (RxDC), and clients will be responsible for filing certain data.
The RxDC reporting provision of the Consolidated Appropriations Act (CAA) requires reporting on drug utilization and spending trends to be submitted to the U.S. Department of Health and Human Services. This reporting also includes reporting on premium and other information that CareFirst does not maintain.
For the initial filing of 2020/2021 data, CareFirst submitted the aggregated data by market segment on behalf of their groups, for the benefits they administer and maintain. For this initial reporting year, this submission included aggregated D1 Premium and Life Years report.
Important Filing Change
For the June 1, 2023, submission of 2022 data, ALL FULLY INSURED AND SELF-FUNDED groups will be responsible for the filing of the D1 Premium and Life Years report. This will also require the submission of a corresponding P2 Group Health Plan List.
CareFirst will continue to complete the following reporting on behalf of all groups:
- P2 – Group Health Plan List (required for any entity submitting any data in D1–D8 on behalf of a group)
- D2 – Spending by Category Reporting (included in aggregate submission for the business we administer and maintain)
- Narrative Response applicable to the CareFirst/CFA business
For clients that have integrated pharmacy benefits under our CVS Caremark PBM contract, CareFirst will also submit the aggregated data in the D3 – D8 Pharmacy specific reports. The updated charts in this Excel file provide additional details.
Why is CareFirst making this change?
There are several factors leading to this change. To obtain all of the required information to file one consolidated D1 report, CareFirst/CFA would have to collect, store, and report data from groups and third-party vendors. This raises concerns because this reporting includes financial and competitively sensitive data.
The Interim Final Rule continues to evolve. While the Centers for Medicare & Medicaid Services (CMS) provided flexibility for multiple entities to submit separate D1 files on a group’s behalf for the 2020 and 2021 reference years, that flexibility does not extend to the upcoming submission under the current reporting instructions. Given the complex challenges and multitude of questions that were brought to their attention across all stakeholders involved in the initial submission efforts, CMS has publicly stated that they will be releasing revised reporting instructions and guidance prior to the June 1 due date, but have no clear indication on what changes are being made or when they will be effective. Unfortunately, CMS confirmed on 2/22/2023 that they still do not have an anticipated publication date for that revised guidance as it is still going through the approval process.
In many cases, CareFirst self-funded groups use one or more third-parties or carve-out vendors to support their business, including, but not limited to, PBMs, Behavioral Health vendors, and Stop Loss carriers.
In addition, the D1 reporting includes other data elements, such as the employer and employee premium contribution, which, unlike some other carriers, CareFirst does not currently collect and maintain for any of their group business. The safe harbor that allowed for member and employer contributions to not be included on the D1 report expired after the initial reporting submission under the current reporting instructions.
Groups have access to all of the data required to submit a complete D1 report, as they are ultimately the source for their data. With the recent CMS guidance alluding to only one D1 report for each group, it makes the most sense for them to take ownership of the filing for the D1 report.
CareFirst understand some of their competitors in the local region are collecting this data to report on behalf of fully insured groups under the current instructions—specifically, some of the national for profit health carriers. However, since CareFirst does not already collect several of the required data elements from our 30,000+ groups and the timeline between the completion of the initial submission and the due date for this next submission is extremely short, CareFirst made the difficult decision to not submit the D1 on behalf of their group business.
Important things to note:
- CareFirst is committed to assisting their groups and brokers and will be developing detailed instruction guides to support groups and/or their broker representatives in creating and uploading the D1 and P2 files. A guide for fully insured groups and a guide for self-funded groups will be distributed in the near future.
- CMS confirmed that they have improved the HIOS registration process specifically applicable to RxDC Reporting, so that only one person needs to register and be approved to be able to submit the files in HIOS. This will greatly streamline the process, particularly for smaller groups.
- CareFirst is anxiously awaiting the release of the revised RxDC reporting instructions so they can respond quickly and communicate any important updates.
CareFirst is diligently working to develop the detailed instructional guides that will assist their clients in preparing and submitting plan level P2 and D1 files for the upcoming submission of 2022 reference year data. In the interim, they would like to share a list of FAQs with additional details to help answer some common questions they have received.
Please make sure that your clients are aware of this change as soon as possible. More information about the RxDC reporting requirements can be found on the CMS website here: Prescription Drug Data Collection (RxDC) | CMS