- CMS is asking for public comment on concerns raised about providers and other organizations directing Medicare or Medicaid-eligible people toward individual market plans, including marketplace plans, in order to get higher reimbursement rates for providing their care.
- The announcement responds to the the issue of third party groups that subsidize premiums for ACA plans for such purposes.
- The agency is looking at possible regulatory changes that could include prohibiting or limiting premium payments and the waiving of cost-sharing by healthcare providers.
CMS officials stressed that it is improper for providers or provider-affiliated organizations to influence people away from Medicare or Medicaid coverage for the sake of financial gain.
“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," CMS Deputy Administrator and Director of the Center for Program Integrity Shantanu Agrawal said in a statement.
Part of the issue, CMS said, is that steering patients away from their Medicare or Medicaid benefits can disrupt their care and care coordination through the changes to their network of providers. On the flip side, it can also affect the pool of people entering the ACA marketplace and impact the costs and integrity of the program.
“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," said CMS Acting Administrator Andy Slavitt.
For now, third-party premium payments are discouraged but the matter of whether to accept them is left to health insurance companies. CMS notes its guidance does not apply to certain federal, state, local government or tribal programs, or Ryan White HIV/AIDS programs expressly permitted to cover premiums under CMS regulations.