Text of Joint Agencies Interim Final Rule with Request for Comments: Prescription Drug and Health Care Spending
135 pages. "These interim final rules implement provisions of the Code, ERISA, and PHS Act that increase transparency by requiring group health plans and health insurance issuers in the group and individual markets to submit certain information about prescription drugs and
health care spending to [HHS, DOL] and the Department of the Treasury (collectively, the Departments). The Departments are issuing these interim final rules with largely parallel provisions that apply to group health plans and health insurance issuers offering group or individual health insurance coverage....
"The term 'group health plan' includes both insured and self-funded group health plans, and includes private employment-based group health plans subject to ERISA, non-federal governmental plans (such as plans sponsored by states and local governments) subject to the PHS Act, and church plans subject to the Code.... These interim final rules do not apply to health reimbursement arrangements
(HRAs), or other account-based group health plans[.]...
"[T]hese interim final rules provide that the report for the 2020 reference year must be submitted to the Secretaries of the Treasury, Labor, and HHS ... by December 27, 2021, and that beginning with the 2021
reference year, the report for each reference year is due by June 1 of the year following the reference year.... [T]he Departments will not initiate enforcement action against a plan or issuer that does not report the required information by the first statutory deadline for reporting on December 27, 2021 or the second statutory deadline for reporting on June 1, 2022, and that instead submits the section 204 data
submissions for the 2020 and 2021 reference years by December 27, 2022....
"For fully-insured group health plans, these interim final rules ... provide that, to the extent coverage under a group health plan consists of group health insurance coverage, the plan
may satisfy the section 204 data submission requirements if the plan requires the health insurance issuer offering the coverage to report the required information in compliance with these interim final rules, pursuant to a written agreement. Under this provision, if the issuer fails to report the required information, then the issuer, not the plan, violates the reporting requirements....
"These interim final rules require plans and issuers to separately report total annual spending on health care services by the plan or coverage, and total annual spending on health care services by participants, beneficiaries, and enrollees, as applicable.... These interim final rules require plans and issuers to submit
the actual average monthly premium amounts separately with respect to payments by employers on behalf of participants, beneficiaries, and enrollees, and payments by participants, beneficiaries, and enrollees.... [T]hese interim final rules further require reporting of total prescription drug rebates, fees, and other remuneration with respect to amounts passed through to the plan or issuer, amounts passed through to participants,
beneficiaries, or enrollees, as applicable, and amounts retained by the PBM." MORE >>
U.S. Department of Health and Human Services [HHS]; Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL]; U.S. Department of the Treasury, and U.S. Office of Personnel Management [OPM]
CMS Fact Sheet: Prescription Drug and Health Care Spending Interim Final Rule with Request for Comments
"[The Interim Final Rule with Request for Comments (IFC)] requires plans and issuers in the group and individual markets to submit certain information on prescription drug and other health care spending to the Departments annually, including:
- General information
regarding the plan or coverage;
- Enrollment and premium information, including average monthly premiums paid by employees versus employers;
- Total health care spending, broken down by type of cost (hospital care; primary care; specialty care; prescription drugs; and other medical costs, including wellness services), including prescription drug spending by enrollees versus employers and issuers;
- The 50 most frequently
dispensed brand prescription drugs;
- The 50 costliest prescription drugs by total annual spending;
- The 50 prescription drugs with the greatest increase in plan or coverage expenditures from the previous year;
- Prescription drug rebates, fees, and other remuneration paid by drug manufacturers to the plan or issuer in each therapeutic class of drugs, as well as for each of the 25 drugs that yielded the highest amount
of rebates; and
- The impact of prescription drug rebates, fees, and other remuneration on premiums and out-of-pocket costs.
"The IFC provides that plan sponsors, issuers, and FEHB carriers generally will be required to submit this information aggregated at the
state/market level, rather than separately for each plan.... [T]he IFC further provides uniform standards and definitions, including for identifying prescription drugs regardless of the dosage strength, package size, or mode of delivery." MORE >>
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]
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BenefitsLink Retirement Plans Newsletter, ISSN no. 1536-9587.
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