RxDC FAQ

For the legal plan name, use the name included on formal legal documents, such as the XYZ Inc. Medical Plan or the XYZ Inc. Health and Welfare Benefits Plan.

The levels have to do with whether you purchase an insurance policy directly from an insurance company or take on part of the risk related to your medical plan in your role as the employer. In most cases where an employer doesn’t know, they are fully insured. This is something that your benefits broker can confirm for you.

Please use the group’s current legal name.

If you have a non-calendar year plan and you change carriers’ mid-year, list the carrier that you have at the beginning of the calendar year first, then put a semicolon in and put the second carrier.

The D1 reporting requirements are the same regardless of whether prescription drug coverage is carved out under your health plan. If it is carved out, in many circumstances, both your PBM and third-party administrator (TPA) will be involved in getting your D2-D8 filings completed. Relative to your D1, CXC will need to list both your TPA and your PBM on your D1 filing. Your total plan spend, as well as your pharmacy rebates and any stop loss reimbursements, will also be included by CXC on your D1 filing.

If you do not file a Form 5500 because your plan is exempt from that filing requirement, you do not need to fill out the Form 5500 number here. If you have not filed a Form 5500 and you are not exempt from the filing requirement, please contact info@cxcnetwork.com or your CXC sales representative for more information.

One of the requirements of the RxDC reporting is to identify which market segment each plan belongs to. One methodology for doing so is to rely on the ACA rules. To do this, we ask if you are an ALE under the ACA.

The enrollment number requirements for purposes of RxDC reporting look at all covered lives under the plan. This includes spouses and dependents, so the end of month counts should include spouses and dependents for this purpose.

One of the questions asked about each plan for RxDC reporting purposes is where the plan is available. Essentially, CMS is asking whether or not an individual will be able to get coverage in a given state. They are trying to understand if the plan is an HMO or not.

CMS specifically says, “Would the individual be eligible to obtain coverage under the plan in a given location?” They are asking if someone was hurt or needed a benefit in a given state, would they be able to get that benefit. We believe that most plans that aren’t HMOs will be considered national for this purpose.

If your plan doesn’t provide coverage in all fifty states, answer “no” to this question. If not, the answer should be “yes.”

Self-insured plan sponsors should report the total cost of their plan for 2023 in the total plan cost section. For this purpose, include all claims-related costs, administrative costs, stop loss premiums, network access fees, and other related fees necessary to maintain the plan.

While previous guidance notes that fees and costs considered for purposes of determining COBRA premiums could be included for these purposes, this is not the same as your COBRA rates and COBRA rates should not be used to determine total cost.

When determining total plan cost for your self-insured plan, both medical and prescription drug claims should be included in your calculation.

One of the more complex components of RxDC reporting is going to be for level-funded plans. CMS has asked that level-funded plans be treated like self-insured plans for purposes of RxDC reporting. This makes sense because level-funded plans are technically self-insured. However, in many cases, CXC understands that level-funded plan sponsors won’t have access to the same degree of information about their plans that self-insured plans have access to.

For example, as a level-funded plan sponsor, you may not know in detail what portion of the money that you provide to your level-funded partners goes towards ASO and TPA fees and what amount goes towards stop loss fees. This specific question is being asked by CMS.

If that’s the case, let CXC know that you don’t know by answering “N/A” to our questions and we will report to CMS that the plan is level-funded and explain to them how level-funded arrangements work in more detail along with comments requesting additional guidance and relief for level-funded plan sponsors because level-funded plans don’t work exactly the same way that self-insured plans work. Additional information and partnership with the government is needed in this regard.