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By Sara Hansard
Feb. 18 — Thirty-eight House members Feb. 18 asked the CMS to take action to require health insurers to accept premium payments from some nonprofit charities for some beneficiaries.
“Our goal is to ensure that our most vulnerable patient populations have access to needed treatments and therapies through health insurance coverage,” said the letter to acting Centers for Medicare & Medicaid Services Administrator Andy Slavitt. The signers were five Republicans and 33 Democrats.
The 2017 Notice of Benefit and Payment Parameters (NBPP) proposed rule (CMS-9937-P), which was released in November 2015 , would expand the list of entities from which insurers are required to accept premium payments to nonprofit charitable organizations in future years, the letter said. The proposed rule, which was received by the Office of Management and Budget for review Feb. 2, is expected to be finalized in late February or early March.
“We request that CMS modify the final rule or take other regulatory action to include qualified nonprofit charitable organizations as a category of entities from whom insurers are required to accept third-party premiums,” including patient advocacy organizations, patient assistance organizations, places of worship and local civic groups, the letter said.
Health insurers have often opposed allowing nonprofit organizations such as hospitals to pay premiums for enrollees, arguing that it could lead to adverse selection if coverage is dropped after patients are treated. Hospitals, on the other hand, have pushed to be allowed to pay premiums, arguing that doing so would result in more coverage for many low-income people who need medical care.
“Non-profit charitable organizations provide a needed service to Americans who suffer from rare diseases, chronic illnesses and catastrophic conditions,” said the letter. The charities serve as a safety net for many families, it said.
However, the letter said, the population that receives premium assistance from nonprofit charities “is so low as to have no meaningful impact on the risk pool.” While there are more than 11 million Americans enrolled in Affordable Care Act marketplace qualified health plans (QHPs), two major nonprofit premium assistance programs, Patient Services Inc. and the American Kidney Fund, provide only 4,500 and 6,500 patients with premium assistance a year, respectively, it said.
“CMS should know that certain guardrails intended to minimize risk pool impacts may have the unintended consequence of excluding the very patient population it intends to protect,” the letter said. Limiting assistance to individuals not eligible for other minimum essential coverage “could be highly problematic,” because it could be “misinterpreted to disqualify end-stage renal disease (ESRD) patients who may qualify for Medicare if they voluntarily apply, but who instead choose a QHP.” Under Department of Health and Human Services guidance, people with ESRD are not required to sign up for Medicare, and the Internal Revenue Service has stated that ESRD patients who don't apply for Medicare coverage are eligible for marketplace tax credits, it said.
Similar to premium assistance made available through programs such as the Ryan White Care Act, the threshold question of eligibility is whether a prospective beneficiary has a qualifying medical condition, such as a rare or serious chronic disease, the letter said.
Most patients receiving premium assistance are not new insurance enrollees, the letter said. “The decision to seek premium assistance from non-profit charitable organizations is generally not triggered by a diagnosis; rather it is triggered by a change in employment or financial status necessitating third-party assistance,” it said.
More than 3 million adults are neither eligible for Medicaid nor eligible for marketplace premium tax credits, the letter said. “This leads to a crippling level of out-of-pocket cost exposure and financial hardship,” it said.
In addition, patients with rare and serious chronic diseases often face network adequacy issues with bronze and silver tier plans sold in the ACA marketplaces and sometimes need to select higher-tier plans with higher premiums, the letter said.
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