Healthcare Business News

Ryan White patients await CMS rule on third-party assistance

By Joe Carlson
Posted: March 12, 2014 - 6:30 pm ET

The CMS is slated to publish a rule, perhaps in the next few days that could clarify the complex legal controversy that caused hundreds of low-income HIV and AIDS patients in Louisiana to face losing their insurance because of the Affordable Care Act.

Word of the clarifying regulation came in the context of a courtroom showdown between the state's largest insurer, Blue Cross and Blue Shield of Louisiana, and John East, a Louisianan living with HIV who gets subsidies through the federal Ryan White program to pay for his insurance coverage. East's class-action lawsuit was put on hold by mutual agreement during a court hearing Monday because the forthcoming CMS regulations may solve the legal dispute without litigation.

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The Louisiana Blues announced earlier this year that the insurer would not accept payments for policies sold on insurance exchanges if the money came from anyone other than the insured person or their family. That ban included grants from HHS' Ryan White program, which benefits low-income Americans living with the expensive chronic condition.

Such “third-party” payments are seen as a financial risk by insurance companies because they may encourage hospitals, drug companies and government programs to add a disproportionate share of sicker and costlier patients to insurance pools. The Patient Protection and Affordable Care Act took away insurers' ability to reject patients with expensive pre-existing conditions, prompting fears among insurers that only sicker, more expensive patients would buy insurance.

Drug companies have long offered financial assistance to lower-income patients who need help affording expensive medications. Now hospitals have also expressed interest in offering financial help to community members who want to buy coverage on the exchanges.

The CMS last year urged insurers to reject these third-party payments. Since then, the agency has softened that position, clarifying that the policy should not apply to the Ryan White program or insurance-subsidy programs run by independent foundations. The mixed messages from CMS gave both sides of the debate ammunition for their arguments.

On March 4, the federal Office of Management and Budget within the Office of Information and Regulatory Affairs announced that it was analyzing a new interim final rule from CMS that would clarify its policy on third-party payments for health plans sold on the insurance exchanges. The text of the proposed rule has not been released.

The Louisiana Blues said it expects the text to be published in the Federal Register within the next few days. The stay on East's lawsuit will last until 60 days after the rule is published, or until Aug. 1. In the meantime, the insurer has suspended its ban on third-party payments and said it will accept such payments until Nov. 1, which is the first day of open enrollment for 2015 health coverage.

Follow Joe Carlson on Twitter: @MHJCarlson

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