Citing instances of patient steering, America’s Health Insurance Plans is calling on the federal government to put up guardrails to prevent inappropriate or financially motivated third-party premium payments.
Other researchers, however, argue the program that allows organizations to absorb premium costs for low-income patients helps stabilize the market while bringing down the uninsured rate.
It’s the latest in what has emerged as a somewhat divisive federal policy created under the Affordable Care Act that allows certain organizations to provide premium assistance for exchange plans. Although the Department of Health and Human Services (HHS) has issued an interim final rule outlining the circumstances in which third parties can provide assistance, ongoing litigation has held up implementation.
In a new brief, AHIP argues that the third-party payment program has led to higher premiums within exchange plans because organizations are steering patients to the individual market.
“It is critical to have guardrails in place to ensure that payments made by third-party entities are truly in the best interests of the patient, are not motivated by financial gain for the provider, and do not result in market destabilization,” AHIP wrote.
The group recommended that HHS prohibit direct and indirect premium payments by providers by incorporating rulemaking into Medicare and Medicaid Conditions of Participation. AHIP added that there should be clear guidelines about how a third party can market premium assistance, and those organizations should be required to report information to HHS to improve transparency.
Insurers have raised particular concerns about dialysis providers funneling payments through the American Kidney Fund in order to steer end-stage renal patients to commercial plans that reimburse at a higher rate than government plans. UnitedHealthcare has also sued American Renal Associates, claiming the provider paid premiums through the AKF.
The AKF has said insurers are guilty of steering patients toward government plans. Meanwhile, lawmakers have accused insurers of discriminating against people with chronic diseases by rejecting consumers that receive assistance from charity groups.
AHIP's concerns appear to go beyond dialysis coverage. The group says "issuers in the individual market have seen a rise in third-party payments" from organizations steering patients away from Medicare and Medicaid.
Amid these accusations, research released this month by the Commonwealth Fund found third-party payments that base their support on income rather than certain health conditions could improve affordability. After interviewing participants in five assistance programs in Washington state, Stan Dorn, a senior fellow with Families USA, found the program helped support more than 1,000 consumers that would have otherwise gone uninsured and helped cut down on uncompensated care costs.
"The affordability problems facing low-income consumers purchasing marketplace coverage are unlikely to be solved on a national scale without major policy changes,” Dorn wrote. “Until such changes are made, TPP programs could make a meaningful contribution.”