PSI: CMS Final Rule On Ryan White Premium Assistance & Other State/Federal Programs

The Centers for Medicare and Medicaid Services (CMS) has posted an interim final rule (IFR) with comment period requiring Qualified Health Plans (QHPs) to “accept premium and cost-sharing payments made on behalf of enrollees by the Ryan White HIV/AIDS Program, other Federal and State government programs that provide premium and cost sharing support for specific individuals, and Indian tribes, tribal organizations, and urban Indian organizations.” This also applies to standalone dental plans (SADPs). In its regulatory impact analysis, CMS says the “vast majority of issuers already accept such payments.”
The rule takes effect upon its release for public inspection today; it is scheduled to appear in the Federal Register on Wednesday, March 19. Comments are due in 60 days. In the IFR:

• The agency notes that “we have become aware that, despite related policy clarifications, some QHP issuers continue to reject payments of premium and cost sharing by the Ryan White HIV/AIDS Program” and that “in particular, this QHP issuer practice is causing access problems for persons who rely on the Ryan White HIV/AIDS Program for assistance.”
•  In addition to new regulatory stipulation (§156.1250) that “QHP and SADPs must accept third party premium and cost sharing payments from the Ryan White HIV/AIDS Program,” CMS elaborates that it seeks to “ensure that individuals reliant on programs similar to the Ryan White HIV/AIDS Program are not being adversely affected by QHPs’ and SADPs’ refusal to accept third party premium and cost-sharing payments [and so] we are including within the new requirement that QHPs and SADPs must accept third party premium and cost-sharing payments from the following other entities in addition to the Ryan White HIV/AIDS Program: Indian tribes, tribal organizations, and urban Indian organizations; and state and federal government programs.”
• The standard “applies to all individual market QHPs and SADPs, regardless of whether they are offered through an [Federally Facilitated Exchange], an [State-Based Exchange], or outside of the Exchanges.”
• However, CMS says “our new standard does not prevent QHPs and SADPs from having contractual prohibitions on accepting payments of premium and cost sharing from third party payers other than those specified in this interim final regulation. In particular, as stated in our November FAQ, we remain concerned that third party payments of premium and cost sharing provided by hospitals, other healthcare providers, and other commercial entities could skew the insurance risk pool and create an unlevel competitive field in the insurance market. We continue to discourage such third party payments of premiums and cost sharing, and we encourage QHPs and SADPs to reject these payments.”

Even though CMS continues to discourage premium assistance from commercial entities and hospitals, CMS has already dealt with the issue of non-profit patient assistance foundations, such as PSI, in the frequently asked question document (FAQ) dated February 7th, 2014. This Q&A which clarified with regards to premium assistance, specifically stated:

• Q2: Does the November 4, 2013 FAQ apply to QHP premium and cost sharing payments on behalf of QHP enrollees from private, not-for-profit foundations?
• The concerns addressed in the November 4, 2013 FAQ would not apply to payments from private, not-for-profit foundation if: …(b) if they are made on behalf of QHP enrollees who satisfy defined criteria that are based on financial status and do not consider enrollees’ health status. In situations (b), CMS would expect that premium and any cost sharing payments cover the entire policy year.

PSI will continue to provide health insurance premium assistance according to our current PSI Program Parameters. We applaud the Department of Health and Human Services and the Centers for Medicare and Medicaid Services for developing this interim rule on such an important issue, so that individuals with chronic, rare and catastrophic illnesses are not adversely affected. PSI will be developing comments to CMS requesting that further clarification be issued regarding the PSI patient assistance model versus the for-profit model.