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CMS Updates FAQs on MSP Prescription Drug Coverage Reporting


· 5 minute read


· 5 minute read

FAQs: Group Health Plan (GHP) Reporting for Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (Dec. 2019)

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CMS has updated its FAQs on the Medicare Secondary Payer (MSP) reporting requirements for prescription drug coverage, which will become mandatory for responsible reporting entities (RREs) effective January 1, 2020 (see our Checkpoint article). As background, certain insurers, TPAs, plan administrators, and fiduciaries are currently required to report information to CMS about individuals who are entitled to Medicare and are covered under a group health plan. For insured plans, the RRE is generally the insurer, although if a TPA processes group health plan claims for the insurer, the TPA is the RRE. For self-insured plans with TPAs, the TPA is the RRE, but employer sponsors of self-insured, self-administered group health plans without TPAs may also be RREs. Beginning January 1, 2020, RREs will be required to submit information about prescription drug coverage as part of their mandatory MSP reporting.

The updated FAQs include clarifications and two new Q&As:

  • Q/A-1 now clarifies that prescription drug coverage information required to be reported does not include individual prescription drugs prescribed to or used by Medicare beneficiaries.
  • Q/A-2 has been expanded to emphasize that the effective date of primary prescription drug coverage should be reported, even if the effective date was prior to the 2006 implementation of the Medicare Part D program.
  • Q/A-3 now clarifies the circumstances under which an insurer, TPA, or pharmacy benefit manager will be the RRE for a group health plan.
  • New Q/A-11 includes technical directions for adding prescription drug coverage information to previously submitted information on hospital and medical coverage.
  • New Q/A-12 addresses the reporting requirements for HRAs and confirms that coverage information must be reported only for HRAs with balances of $5,000 or greater.

EBIA Comment: Group health plan sponsors should keep in mind the upcoming January 1 effective date of these expanded MSP reporting requirements. Although only a few employers are RREs, employers may be asked to assist their insurers or TPAs in compiling information about plan participants. CMS has emphasized the importance of employer cooperation with their plans’ RREs, noting that employers that do not provide the necessary information to the RREs are putting their insurers and TPAs at risk of noncompliance. For more information, see EBIA’s Group Health Plan Mandates manual at Section XXIV.J (“MSP Mandatory Reporting Requirement”). See also EBIA’s Self-Insured Health Plans manual at Section XXV.C (“Coordination of Benefits With Medicare, TRICARE, and Medicaid”); EBIA’s Consumer-Driven Health Care manual at Section XXV.F (“HRAs and Medicare Secondary Payer (MSP) Requirements (Including Mandatory Reporting)”); and EBIA’s COBRA manual at Section XXX.D (“Medicare Secondary Payer (MSP) Rules”).

Contributing Editors: EBIA Staff.

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