The CAA, 2021 requires fully insured and self-insured group health plans to annually report certain information regarding prescription drug and healthcare spending to CMS. Reporting for the 2025 calendar year (termed the “reference year”) is due by June 1, 2026.
As in prior years, the data must be submitted to the Health Insurance Oversight System (HIOS) in files and formats specified by CMS. Detailed information regarding the reporting requirements, including the RxDC reporting instructions, FAQs, and a HIOS portal user guide, is available on the CMS RxDC website.
Employers should work closely with their carriers, TPAs, PBMs, and other vendors, as applicable, to ensure the required information is provided in a timely and accurate manner. In some cases, an employer that sponsors a self-insured plan may need to submit data directly to HIOS. In other situations, the carrier, TPA, or other service provider may agree to submit information on behalf of the plan.
However, the employer will still need to provide certain data (e.g., the average monthly premium paid by employers and employees) and should respond promptly to their service providers’ requests for information. Failure to timely respond to a request may result in the employer being required to submit the RxDC data on their own. Employers should also request written confirmation from their carrier, TPA, or service provider of the timely RxDC reporting submission.
For further information on RxDC reporting, please download a copy of the PPI publication Prescription Drug Data Collection Reporting: A Guide for Employers.