Code of Massachusetts Regulations
957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS
Title 957 CMR 2.00 - Payer Data Reporting
Section 2.07 - Reporting Prescription Drug Rebates
Universal Citation: 957 MA Code of Regs 957.2
Current through Register 1531, September 27, 2024
(1) Prescription Drug Rebate Reporting.
(a)
Reporting Requirements.
1. Payers must report rebate data
for all Massachusetts residents for whom the payer has complete
pharmacy claim and rebate data.
a.
If Payers are not able to report data solely for Massachusetts
residents, they must notify the Center in writing and propose a
different Member population definition for Center approval.
b. Any Members for which a Payer
has no pharmacy expenditure or prescription drug rebate data, or
partial pharmacy expenditure or prescription drug rebate data, should
be excluded from this data reporting.
2. Payers must report rebate data
separately by Medicare, Medicaid, and commercial plans (fully-insured
and self-insured), and any other insurance categories as defined by
the Data Specification Manual.
If rebate data is only available to a Payer at an aggregated level and cannot be separated to provide unique information for each insurance category, the Payer shall report data at the most granular level available. In such instances, the Payer shall report a separate observation with all required data elements for each insurance category using a Combined Rebate Identifier, as specified in the Data Specification Manual.
3. Payers shall report all data in
the prescription drug rebate data submission at the aggregate level
for all Massachusetts residents, or in the aggregate for any
alternative Member population approved by the Center.
4. Payers shall report prescription
drug rebate and pharmacy expenditure data using IBNR estimates
resulting in approximated completed claim and rebate amounts for
periods that are not yet considered complete.
(b)
Required Data
Elements. The Center will delineate required data
elements in the Data Specification Manual.
(2) Pharmacy Benefit Manager (PBM) Reporting.
(a)
Reporting
Requirements.
1. Payers
must report PBM data separately by Medicare, Medicaid, and commercial
plans (fully-insured and self-insured), and any other insurance
categories as defined by the Data Specification
Manual.
2.
Payers must identify the level of services performed by each PBM
vendor for each insurance category. Payers shall identify the level
of services in the following categories:
a. Claims Processing;
b. Drug Formulary
Management;
c.
Manufacturer Drug Rebate Contracting; or
d. any other category defined in
the Data Specification Manual. Payers shall identify
whether a PBM performed a given service for "all", "some", or "none"
of its Members in a given insurance category. Payers may report
multiple PBMs in an insurance category.
(b)
Required
Data Elements. The Center will delineate required data
elements in the Data Specification Manual.
(3) Due Dates: Annual Reports. Each year, Payers must submit:
(a) preliminary data for the prior
Calendar Year; and
(b)
final data for the Calendar Year for which the payer submitted
preliminary data during the last reporting cycle. Payers shall allow
for a claims run-out period of at least 90 days after December
31st of the previous Calendar Year. Final
data should reflect at least 15 months of claims run-out. Specific
deadlines will be established in the Data Specification
Manual.
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