CMS Issues Interim Final Rule to deal Third-Party Payment of Insurance Premium

CMS (Centers for Medicare and Medicaid Services) released an interim final rule with comment period on December 14, 2016 to modify and amend Medicare’s dialysis facility conditions for coverage to require few disclosures to sufferers and health insurance issuers to deal widespread uncertainties over unsuitable steerage of dialysis patients to individual market plans. CMS decided to concentrate on dialysis providers provided the “overwhelming majority of comments [got in response to the RFI] focused on sufferers with [end-stage renal disease (ESRD)]” and “the high charges and absolute necessity of transplantation or dialysis” for individuals with ESRD after releasing an RFI about “unsuitable steering of people eligible for Medicare or Medicaid into Marketplace plans” by third parties in August 2016.

In accordance to CMS, reimbursement rates for dialysis and other ESRD treatment are “tens or even hundreds of thousands of dollars more per patient when sufferers enroll in individual market coverage rather than public coverage.” As such, providers have powerful incentives to steer patients to private coverage and pay some thousand dollars in premiums on their behalf. But doing so places sufferers at substantial health and financial risks. Third-party payment of premiums to enroll a sufferer in individual market coverage might interfere with transplant readiness, expose the sufferer to substantial financial harm for services beyond dialysis, and might result in mid-year coverage disruption, CMS noted.
In order to address these concerns, the interim final rule needs Medicare-certified dialysis facilities to reveal the array of charges and coverage options available to a patient, involving the presence of Medicaid, Medicare ESRD coverage, and individual market plans, and to make sure that health insurance issuers are aware of and eager to accept a third-party’s payment of premiums on behalf of the patient. As explained by the Fact Sheet of CMS, providers must:

• Give a summary of short- and long-term cost estimates of several health coverage options for sufferers and information on enrollment periods for those health coverage options.
• Make up-front disclosures to sufferers regarding their health insurance coverage options, involving information about available individual market plans, Medicaid or Children’s Health Insurance Program (CHIP) coverage, and available options and charges of Medicare ESRD coverage.
• Inform issuers of the individual market plans for which they make payments of premiums for individual market policies.
• Get assurance from the issuer that it will accept these payments of premiums for individual market plans for the duration of the plan year, or else not make such payments.

Providers are not being precluded by the interim Final rule from making charitable donations that boost access to health care. Another thing was noted by CMS that it remains concerned about third-party payment of premiums for persons who are eligible for public coverage, like Medicaid or Medicare, and is considering whether to release a blanket prohibition on third-party payment of premiums for such persons. Centers for Medicare and Medicaid Services (CMS) has solicited comments on this and alternative approaches, like whether to permit third-party payments upon a proving that it was in the best interest of individual patient. For interim final rule, the comment period closes on the day of January 11, 2017 and the rule is effective on January 13, 2017.