New rule seeks to stop dialysis providers from steering patients to higher-reimbursement ACA plans

In response to concerns that some dialysis facilities may be pushing patients toward higher-reimbursement health plans, CMS is tightening its regulations. (Getty/porpeller)

In response to concerns that some healthcare providers may be pushing patients to sign up for Affordable Care Act plans in order to reap higher reimbursement rates, the federal government is tightening its regulations.

The Centers for Medicare & Medicaid Services issued a request for information about the issue in August, noting it has received anecdotal reports that providers—particularly dialysis facilities—are directing individuals who are eligible for Medicare or Medicaid into ACA marketplace plans by offering to pay their premiums. In an interim final rule released Monday, CMS says its suspicions proved true.

Many of more than 800 comments that CMS received indicated that there is a “widespread” practice of dialysis facilities involving themselves in end-stage renal disease (ESRD) patients’ coverage decisions. That can harm patients’ chances of receiving a kidney transplant, expose them to additional costs for healthcare services and put them at “significant risk” for mid-year coverage disruptions, CMS notes.

ESRD patients are particularly vulnerable to the practice, CMS says, because nearly all have alternative public coverage options that have lower reimbursement rates than individual-market plans, and they require ongoing medical care that incentivizes providers to influence their coverage decisions.

Thus, CMS says it is establishing new “Conditions for Coverage” standards for dialysis facilities that make direct or indirect premium payments for individual market health plans. Those facilities will be required to “make patients aware of potential coverage options and educate them about the benefits of each to improve transparency for consumers,” according to the new rule.

The agency says it is also considering totally prohibiting third parties from paying the individual market plan premiums of people who have alternative coverage options. Some stakeholders, though, sent letters to CMS arguing that such charitable premium assistance supports patient choice and saves taxpayer money, the agency acknowledges.

CMS has not been the only entity to accuse dialysis providers of steering patients toward higher-reimbursement coverage. In July, UnitedHealth sued American Renal Associates Holdings Inc., saying it regularly convinced Medicare- and Medicaid-eligible patients with ESRD to obtain coverage with the insurer.