Purpose of Part D Regulatory Reporting
In 2008, CMS required for all Part D sponsors to have an effective procedure to develop, compile, evaluate, and report to CMS, to its enrollees, and to the general public, at the times and in the manner that CMS requires, statistics indicating the following:
- The cost of its operations.
- The patterns of utilization of its services.
- The availability, accessibility, and acceptability of its services.
- Information demonstrating that the Part D plan sponsor has a fiscally sound operation
- Pharmacy performance measures
- Other matters that CMS may require.
Plans that are contracted to offer Part D benefits are required to report data to CMS on a variety of measures. The data is used for inquiries from Congress, oversight agencies, and the public about a Part D sponsors performance. Part D sponsors can expect to report out their quarterly data for Enrollment and Disenrollment, Coverage Determinations and Redeterminations, Grievances, Medication Therapy Management (MTM), Improving Drug Utilization Review Controls (IDURC). Additionally, EGWP Sponsors will submit an Employer/Union Group report. Most of these reports are provided by the Plan’s PBM if they are contracted to provide these services, otherwise, it is up to the Plan to develop these reports that are required for CMS submission. The purpose is to ensure that Part D sponsors are reporting health and drug plan data that are reliable, valid, complete, comparable, and timely. The required reporting uses indicators to monitor a Part D plan on their operations, costs, availability of services, provider network adequacy and grievance. CMS develops on a yearly basis, the standards, and specifications with respect to the Part D reporting requirements. These standards and specifications provide a review process for Part D sponsors to use to conduct validation on their reported Part D data. The CMS required reporting submission is done annually and occurs in the year subsequent to the measurement year (for example, the data validation for CY 2022 will be conducted in CY 2023). CMS annually posts the technical specifications and Part D reporting requirements that Part D sponsors must adhere to when validating their data.
Part D Annual Submissions and Reporting Content
The following reports are provided to Plan sponsors as part of the CMS required reporting. These are due on an annual basis and are provided by their PBM if the PBM is contracted to perform these services otherwise the Plan is responsible for the reporting. Compliance with these reporting requirements is a contractual obligation of all Part D sponsors. Compliance requires that the data not only be submitted in a timely manner but that they also are accurate. Sponsors must report all data based on the most current technical specifications as of the reporting deadline.
- The Coverage Determinations and Redeterminations report is a review of coverage determination or adverse coverage determinations made by the Part D sponsor on the benefits the member believe he or she is entitled to receive.
Why Reporting Accuracy Matters
The data collected in these reports allows CMS to have an inside look at Part D Sponsors cost of their operation, patterns of utilization of their services, availability, accessibility and acceptability of their services, pharmacy performance, and other matters that CMS requires.
Part D sponsors can take advantage of the required reporting process to effectively assess their own performance and make improvements to their internal data, systems, and reporting processes. This data may also be used for Star Ratings and other plan performance measures. Medicare Star Ratings are an important factor to help consumers compare health plans and providers based on quality and performance and to reward top-performing health plans. The Star rating system measures how well plans perform in several categories ranging from quality of care to customer service. The Star Ratings system rewards higher-performing plans, plans with three or more stars can receive an annual payment from CMS.
Validating the reported data is crucial to Part D plans since CMS reviews plan performance yearly and releases new star ratings each fall. Regulatory reporting data reflects a Part D sponsors quality of care to their beneficiaries along with viable plan data to CMS, which in return results in potential rewards to the health plan. In order to verify data accuracy, Part D sponsors must hire an independent Data Validation Contractor to audit source and submitted data. Annual Data Validation occurs annually between April 1st to June 30th and satisfies CMS’ oversight responsibilities of Part D regulatory data submissions by ensuring health and drug plan data is accurate and reliable.