Pharmacy benefits and costs reporting requirements for fully insured and self-funded

Under the Consolidated Appropriations Act (CAA), health insurers offering group or individual health coverage and self-funded (ASO) group health plans are required to report data annually regarding prescription drugs and health care spending to the Departments of Health and Human Services (HHS), Labor (DOL) and Treasury (USDT). This information must be submitted by the delayed enforcement date of Dec. 27, 2022, through a web portal that is being set up by the Centers for Medicare & Medicaid Services (CMS). The Dec. 27, 2022, report must include active and cancelled customer data from Jan. 1, 2020, through Dec. 31, 2021 (including if the client cancelled anytime during that period). 

Beginning in 2023, these reports will be required by June 1 each year. Reports submitted for June 1, 2023, require the 2022 data.

To support the CAA Pharmacy Benefit and Costs reporting, UnitedHealthcare will be submitting the data for all fully insured customers. UnitedHealthcare will also submit this data on behalf of the self-funded UMR customers with integrated Optum Rx, FEHBP and certain self-funded groups. For UnitedHealthcare National Account/Key Account/Public Sector self-funded customers (UNET, USP) and for Empire Plan and Surest™ (BIND) UnitedHealthcare will share responsibility for the filing with the self-funded customer.

  • For fully insured customers: UnitedHealthcare will submit the report and required data for all fully insured. UnitedHealthcare will not accept requests for fully insured customers to submit the data themselves
  • For self-funded customers: There are two standard and one additional approach for submitting data for ASO customers:
    • UnitedHealthcare/UMR submits all data (UMR, All Savers, UnitedHealthcare Level Funded, Railroad
    • UnitedHealthcare and the customer have shared responsibility to submit specific data (National Accounts, Public Sector, Key Accounts, Empire Plan and Surest™ (BIND))
    • Self-funded customers may produce the report and submit the data to CMS themselves. Most customers will fall into one of the first two approaches

Customers using UnitedHealthcare to submit some or all data (standard)

To understand how UnitedHealthcare will support the submission of data, refer to the UHC Approach to CAA Pharmacy Benefits and Costs Reporting Guide. When submitting data, UnitedHealthcare will provide the data as outlined in the CMS documented instructions.

The reporting will be aggregated at the issuer/TPA/state/market level, rather than separately for each plan. The guidance provides uniform standards and definitions, including standards for identifying prescription drugs regardless of the dosage strength, package size or mode of delivery so HHS, DOL and USDT can conduct meaningful data analysis and identify prescription drug trends.

  • Data for fully insured groups will be organized separately by state for individual, small group and large group
  • Data for fully insured groups must be reported for the state where the contract is issued
  • Data organization for self-funded plans are differentiated by self-funded small group and self-funded large group
  • Data for self-funded plans must be reported for the state where the plan sponsor has its principal place of business
  • For multiple employer welfare arrangements (MEWAs), data must be reported for the state where the employer has its principal place of business or where the association is incorporated.

CAA pharmacy benefits and costs reporting for self-funded customers data submission responsibilities? 1

Chart applies if UnitedHealthcare is full-service administrator for medical, Rx, wellness, stop loss.
Refer to UHC Approach to CAA Pharmacy Benefits and Costs Reporting Guide for carve out requirements.

CAA pharmacy benefits and costs reporting for self-funded customers data submission responsibilities? 1
UnitedHealthcare or UMR submits all data UnitedHealthcare & self-funded customer — shared submission
  • UnitedHealthcare/UMR submits P2, D1, D2, D3-D8
  • Applies to:
    • UMR, USP, All Savers, UnitedHealthcare Level Funded, UnitedHealthcare small business, Railroad, Healthscope Benefits
  • Self-funded customer may request P2, D1, D2, D3-D8 data to submit to CMS themselves (action needed)
  • Self-funded customer must submit P2, D1 (required)
  • Applies to:
    • National Accounts, Key Accounts, Public Sector 
    • Empire Plan
    • Surest™ (BIND)
  • UnitedHealthcare submits D2, D3-D8 or
  • Self-funded customer may request D2-D8 to submit to CMS themselves (action needed)

Self-funded customers that plan to submit report data to CMS themselves

The self-funded customer makes request that UnitedHealthcare provide the 2020 and 2021 data required for the report categories so they can submit to CMS by the required date. UnitedHealthcare anticipates customer requests will be limited particularly for this first reporting year. When requested, UnitedHealthcare provides the customer with their own specific data as required in the CMS documented instructions.

Customers who wish to submit their own data must notify their account management team as soon as possible but no later than the Aug. 1, 2022, deadline. Customer may need to sign a non-disclosure agreement and a fee may apply.

  • The customer will receive the data on or about Oct. 1, 2022
  • Data will only be provided to customers who fully committed to filing in its entirety
  • UnitedHealthcare or UMR will not produce individual data files to the customer when UnitedHealthcare or UMR is performing the actual reporting for that group to CMS
  • When a customer performs their own submission of the reporting, those components of data are not included in the aggregate report that UnitedHealthcare/UMR submits
  • For Optum Rx Direct (carve out) business, the customer must obtain the data from Optum Rx directly
  • For mixed funding (fully insured/self-funded) customers where the customer wishes to submit the self-funded data, the fully insured data will still be submitted by UnitedHealthcare/UMR with no exceptions

UnitedHealthcare is prepared to provide support and respond to your questions. Please refer to the UHC Approach to CAA Pharmacy Benefits and Costs Reporting Guide and contact your UnitedHealthcare account management team.

Please contact your broker or UnitedHealthcare representative with questions.

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