CMS examines inappropriate steering of people eligible for Medicare or Medicaid into Marketplace plans

The Centers for Medicare & Medicaid Services (CMS) today issued a request for information seeking public comment on concerns that some health care providers and provider-affiliated organizations may be steering people eligible for, or receiving, Medicare and/or Medicaid benefits into Affordable Care Act-compliant individual market plans, including Health Insurance Marketplace plans, for the purpose of obtaining higher reimbursement rates. CMS also sent letters to all Medicare-enrolled dialysis facilities and centers informing them of this announcement.

The request for information and letters to providers 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. These actions reflect ongoing efforts by the CMS Center for Program Integrity to address possible issues in the Marketplace that could affect the integrity of the programs for both consumers and issuers, and the costs of the individual insurance market, while at the same time help ensure patients are enrolled in the right plan for them.

“Ensuring access to high quality patient care is a top priority for us. We are concerned about reports that some organizations may be engaging in enrollment activities that put their profit margins ahead of their patients’ needs,” said CMS Acting Administrator Andy Slavitt. “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.”

“It is improper to influence people away from Medicare or Medicaid coverage for the purpose of financial gain,” said Shantanu Agrawal, M.D., CMS Deputy Administrator and Director of the Center for Program Integrity. “Our goal is to protect patients from being unduly influenced in their decisions about their health insurance options, and to protect the integrity of all the programs we oversee.”

Currently, third-party payment of premiums and cost sharing of qualified health plans in the individual market by health care providers such as physicians, medical facilities or affiliated non-profit organizations are discouraged, but the ultimate decision about accepting those payments are left to health insurance companies. This guidance does not apply to certain federal, state, or local government programs, Ryan White HIV/AIDS programs or Indian tribes, tribal organizations and urban Indian organizations, which are expressly permitted to pay insurance premiums for consumers under CMS regulations. Recently, concerns have been raised that certain providers or organizations affiliated with specific providers may steer consumers into individual market plans, including Marketplace health plans, because they would receive higher payment rates under a private plan than under Medicare or Medicaid. 

In addition to asking for more information on instances of problematic steering of consumers to individual market plans, CMS is also 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, CMS is looking at authorities to impose 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.

Like reducing inappropriate use of special enrollment periods and other efforts, today’s steps are a part of the Administration’s ongoing work to strengthen and expand the Health Insurance Marketplace. 

The request for information can be found on the Federal Register website at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-20034.pdf

The letter to all dialysis providers can be found on the CMS website at: https://www.cms.gov/about-cms/components/cpi/downloads/rfi-medicare-dialysis.pdf

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