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Updating Plan and Drug Data

← JSON - Programmatic Requirements

Question:

It is our understanding that if an issuer wants to make any kind of changes to data in QHP plans, networks, and formularies after CMS’s final determination on August 25th of the year prior to a plan year start then the issuer must supply documentation, and request approval from CMS and the State regulating the plan. If approval is granted, which is quite rare, then there is a process to update the data for the change.
- Assuming this is the current process, we will NOT have monthly updates to the plans.json and drugs.json. 
-  Assuming this is the current process, we WILL have monthly updates to providers.json. 

How do we harmonize the frequency of updates given the QHP requirement of 8/25 and the machine readable update frequency requirement of “no less than monthly”?

Answer:

Formularies and providers can change throughout the year based upon provider contracts and drug changes in the market (a generic version of a drug enters the market mid-year, or a drug is pulled by the FDA, for example). Issuers are required to provide up-to-date provider and formulary information in a machine-readable format updated not less than monthly.

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