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HIV Groups Protest Insurers' Rejection Of Third-Party Payments For Premiums
  Posted: February 14, 2014
CMS says its November guidance discouraging providers and other stakeholders from making payments to help qualified health plan enrollees pay their premiums does not apply to payments made by the Ryan White HIV/AIDS Program, yet three insurers participating in Louisiana's exchange have moved to deny such payments, according to sources and documents obtained by Inside Health Policy. Advocates for patients with HIV/AIDS plan to send a letter later this month to HHS Secretary Kathleen Sebelius asking that QHPs be required to accept third-party premium payments from government-supported programs and that the essential health benefits rule be amended to prohibit specialty drugs' coinsurance from exceeding 25 percent when no generic alternative exists.
HHS made a splash and spurred significant confusion when the secretary sent a letter last October saying qualified health plans were not "federal health care programs" for anti-kickback purposes - clearing the way for industry to make premium payments and offer discounts on drugs for QHP enrollees -- but then days later CMS issued guidance that discouraged hospitals and other commercial entities from paying premiums on behalf of exchange plan enrollees. In that Nov. 4 Frequently Asked Questions document, CMS' Center for Consumer Information and Insurance Oversight urged QHP issuers to reject such third-party payments, something hospitals said was inappropriate.
But for payments for premiums and cost-sharing made on behalf of QHP enrollees by Indian tribes, tribal organizations, urban Indian organizations and programs such as the Ryan White program, CMS writes in a Feb. 7 FAQ that QHP issuers and exchanges are encouraged to accept such payments. In the guidance, CMS also clarifies that the Nov. 4 FAQ does not apply to QHP premium and cost-sharing payments on behalf of enrollees from private, non-profit foundations. Hospitals had sought guidance on whether payments could be made in such a fashion, in addition to making direct payments on behalf of QHP enrollees.
The Health Resources and Services Administration in September also said that Ryan White program funds "may be used to cover the cost of private health insurance premiums, deductibles, and co-payments to assist eligible low-income clients in maintaining health insurance or receiving medical benefits under a health insurance or benefits program, including high-risk pools."
But Blue Cross and Blue Shield of Louisiana says that beginning March 1 it won't accept third-party payments on behalf of enrollees and the payments must come directly from policyholders.
Citing concerns about fraud and abuse, the company says in a statement: "There have been instances here and elsewhere in which certain providers or medical equipment suppliers will steer people to a specific health plan and offer to pay those people's premiums so that the provider/supplier can bring in financial benefits through billing the insurance company for the member's covered services. This kind of activity can lead to improper use of services, wasted money and increased healthcare costs for everyone."
The Louisiana Blue plan adds that organizations helping patients with HIV/AIDS to pay their premiums can still provide financial support, but the members must actually make the payment to the insurer. The company's stance also affects other policyholders, not just HIV/AIDS patients, it said.
Separately, the Louisiana Health Cooperative, a Consumer Operated and Oriented Plan that was funded by the ACA, also says it only accepts payment from the named policyholder, according to documents obtained by Inside Health Policy. But a spokesperson for the Louisiana Health Cooperative declined comment on the insurer's position on accepting Ryan White payments on behalf of plan enrollees.
Patient group Lambda Legal has filed administrative complaints with HHS' Office of Civil Rights against BCBS of Louisiana, the Louisiana Health CO-OP and Vantage Health Plan, which also announced a similar policy regarding Ryan White programs making premium payments. The group argues that because the insurers are not taking those subsidies it effectively denies coverage to low-income people with HIV.
Patient advocates and other groups have argued that patient assistance programs that help pay premiums and cost-sharing on behalf of enrollees are essential to ensure individuals can afford high-cost medications and other expenses. But insurers and pharmaceutical benefit managers oppose such payments, arguing that they will only raise prices and harm consumers down the road.
Criticism of exchange plans' drug costs and plans' utilization management methods has escalated, and CMS recently indicated that it would bump up its scrutiny of QHP drug formularies as a part of the 2015 federally facilitated exchange plan certification process. In itsdraft 2015 letter, CMS said that to prevent discrimination in benefit design it intends to review plans that are outliers based on "an unusually large number of drugs subject to prior authorization and/or step therapy requirements."
Patient advocates, according to the sign-on letter they are circulating, also want HHS to require that all exchanges ensure QHPs provide complete and accurate drug formulary information in a standardized format. The essential health benefits rule should also be changed to require coverage of specialty drugs, when no generic exists, that are widely accepted in treatment guidelines or best practices, they say. This would include all HIV antiretroviral drugs, the letter adds. - Rachana Dixit ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it )
Andrea Weddle
HIV Medicine Association
Executive Director
1300 Wilson Blvd., Suite 300
Arlington, VA 22209
Ph 703.299.0915
F 703.299.2766

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