Bloomberg Government

By Sara Hansard | August 18, 2016 6:58PM ET

  • Patients eligible for Medicare/Medicaid may be steered to individual plans by health-care providers
  • CMS considering potential regulations and civil fines to limit premium payments

Aug. 18 (BNA) -- The CMS wants information on the improper steering of Medicare and Medicaid patients by health care providers to Affordable Care Act plans to get higher reimbursements.

The Aug. 18 request for information (CMS-6074-NC, RIN:0938-ZB31) and letters to all Medicare dialysis facilities “focus on situations where patients may be steered away from Medicare or Medicaid benefits, which can among other concerns result in beneficiaries experiencing a disruption in the continuity and coordination of their care as a result of changes to their network of providers,” as well as cost more to the individual insurance market, the agency said in a release. Information was requested on “instances of problematic steering of consumers to individual market plans,” it said.

The issue involves third-party organizations that pay premiums and cost sharing for qualified individual health plans in the ACA marketplaces. Health insurers have fought against allowing the payments, arguing that they can pose a conflict of interest for the providers who stand to receive coverage payments, while the provider groups argue that allowing them to make the premium and cost-sharing payments provides needed care for patients.

Possible CMS Action

The Centers for Medicare & Medicaid Services said it is considering “potential regulatory and operational options to prohibit or limit premium payments and routine waiver of cost sharing for qualified health plans by health care providers, revisions to Medicare and Medicaid provider enrollment rules, the imposition of civil monetary penalties for individuals that fail to provide correct information about consumers enrolling in a plan, and potential changes that would allow issuers to limit their payment to health care providers to Medicare-based amounts for particular services and items of care.”

In particular the CMS said it is looking at imposing civil monetary penalties on health-care providers when their actions result in late enrollment penalties for Medicare-eligible individuals who are steered to an individual market plan and as a result are delayed in enrolling in Medicare. The request for information will be published in the Aug. 23 Federal Register with comments due 30 days after publication, Sept. 22.

“We are concerned about reports that some organizations may be engaging in enrollment activities that put their profit margins ahead of their patients' needs,” acting CMS Administrator Andy Slavitt said in the release. “These actions can limit benefits for those who need them, potentially result in greater costs to patients, and ultimately increase the cost of Marketplace coverage for everyone.”

The CMS said it was taking the steps as “part of the Administration's ongoing work to strengthen and expand the Health Insurance Marketplace.” Aetna Inc. recently announced it is withdrawing from most ACA marketplaces due to plan losses, and UnitedHealthcare and Humana have taken similar actions.

Third-Party Payments Currently Discouraged

Currently third parties affiliated with health-care providers are discouraged from paying premiums and cost sharing for ACA qualified health plans in the individual market. The ultimate decision about accepting those payments is left to health insurance companies, the CMS said in the release.

The guidance doesn't apply to some federal, state or local government programs, Ryan White HIV/AIDS programs or Indian tribes, which are expressly permitted to pay insurance premiums for consumers under CMS regulations, the release said.

At an April meeting of the National Association of Insurance Commissioners, the American Kidney Fund and the Dialysis Patient Citizens gave a presentation on “insurance companies that refuse third-party payments from charitable organizations or refuse to cover individuals who receive charitable assistance.”

To contact the reporter on this story: Sara Hansard in Washington at
To contact the editor responsible for this story: Kendra Casey Plank at

For More Information

The CMS request for information (CMS-6074-NC, RIN 0938-ZB31) is at The letters to dialysis facilities are at
The NAIC presentation is on page 9 of

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