CMS clarifies user fee adjustment mechanism for contraception accommodation

Third-party administrators (TPAs) must submit the Notice of Intent Disclosure Form to CMS stating their intention to seek a user fee adjustment even though the original deadline has passed. CMS has issued answers to frequently asked questions for TPAs, pharmacy benefit managers (PBMs), and federally-facilitated marketplace (FFM) issuers who are seeking reimbursement for contraceptive services. The information that these parties must submit will allow CMS to determine the discount to be applied to the user fee paid for participation on the FFM (CMS FAQ, November 9, 2015).

User fee discount

The government has provided an accommodation for self-insured nonprofit religious organizations that object to the contraceptive coverage mandate found in sections 1001 and 1004 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). Under the accommodation, the nonprofit or their TPA notifies HHS of the objection. The TPA will cover the contraceptive services and will contract with an FFM issuer. The FFM reduces the issuer’s marketplace user fee to account for the payment made to the TPA to cover the services. In order to receive this discount, FFM issuers and TPAs must submit certain information to CMS.

FAQs

TPAs and PBMs must submit the notice of intent form by November 13, 2015, via email. FFM issuers seeking the 2014 benefit year adjustment should submit their spreadsheets by December 11, 2015. CMS will provide webinar training on completing the forms. The document contains instructions regarding recipient email address, subject lines, and attachments.

CMS clarifies that PBMs can enter in the same arrangements as TPAs to provide contraceptive services. PBMs must follow the requirements imposed on TPAs. However, if the TPA or PBM and the FFM issuer are part of the same entity or parent company, only the FFM should submit its spreadsheet. If the entities are separate, the TPA must submit its form indicating the total value of eligible paid claims.

The user fee discount is limited to the dollar amount of contraceptive claims. CMS intends to deduct the appropriate amount from the issuer’s monthly obligation at the end of the 2015 calendar year. The FFM issuer is also eligible for an additional 15 percent payment for administrative costs. Although CMS has not established reimbursement for TPA or PBM administrative costs, these groups may require that the FFM share part of its administrative payment.