CMS Releases Form For Insurers Submitting Contraceptive Claims

The final preventive services regulations issued by the Departments of Health and Human Services (HHS), Labor, and Treasury state that group health plans must provide their enrollees with the full range of FDA-approved contraceptive services without cost sharing. Eligible organizations that object to covering contraceptives for religious reasons, however, are not required to provide, arrange, or make payment for contraceptive services. Rather, they are required to notify either HHS or their third party administrator (TPA) of their objection.

The TPA (including pharmacy benefit managers (PBMs) that administer programs involving contraceptive drugs) must then provide the contraceptive services. To cover the cost of the services, the TPA may enter into an arrangement with a qualified health plan insurer that offers coverage through the Federally Facilitated Marketplaces (FFM). The FFM will then adjust the user fee that the insurer otherwise owes the FFM to offset any funds the insurer paid the TPA for contraceptive claims.

(The plaintiffs in Zubik v. Burwell and related cases recently remanded by the Supreme Court, are exempted from the reporting requirement because they are considered to have already given notice of their objection by virtue of their lawsuits.)

On August 22, 2016, the Centers for Medicare and Medicaid Services (CMS) released at its REGTAP.info website (registration required) a web-based form that TPAs and insurers may use for submitting contraceptive claims that they have paid for 2015. CMS also released at REGTAP.info a set of frequently asked questions describing how the new process will work.

TPAs (including PBMs) are required to submit a Notice of Intent Disclosure Form through the web-based form between August 22, 2016 and September 20, 2016. The TPA must indicate the total value of eligible contraceptive claims that it paid. FFM insurers that claim a user fee offset for money they have paid TPAs must also submit a request for payment for the total amount it paid or has agreed to pay a TPA using the web-based form. TPAs or PBMs that are part of the same entity or parent company as the FFM insurer through which they collect the reimbursement need not submit a separate form from that submitted by the insurer.

FFM insurers that agree to cover claims for TPAs may claim an extra 15 percent administrative fee. No administrative fee is paid to the TPAs, but they may agree with the insurer to split the 15 percent fee. CMS will offset the amount owed to the insurer for contraceptive payments against monthly user fees owed by the insurer beginning in the fall of 2016 and until the total amount is paid. If the amount owed the insurer exceeds the annual user fee, the offset will be carried over to the next year.

Payment will only be made at this time for claims incurred in 2015 (including claims made in 2015 but in fact paid in 2016). CMS states that it will consider reimbursing insurers earlier in 2017 for payments they make to TPAs during 2016.

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